Page 51 - World Association of Laparoscopic Surgeons - Journal

Atul Soni et al

somewhat less effective: Recurrence rates are reportedly lesions were resected and each had a tumor-free margin of
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5 to 10% vs only 1 to 3% after open thoracotomy. Talc at least 1 cm. The mean duration of chest tube placement
insufflation for pleurodesis may also be effective. 27 and hospital stay were 2.1 and 4.1 days respectively. Seven
Although most operators perform these procedures using patients (10%) experienced a complication (three patients
general anesthesia, thoracoscopic wedge resection of blebs had prolonged air leaks).
and bulla using local anesthesia has been reported. 28 There are several limitations to the VATS approach.
Endoscopic photocoagulation by argon or neodymium: First, only peripheral lesions are accessible by this
Yttrium-aluminum-gamet (ND:YAG) lasers can be used as technique. Second, the operator cannot perform careful
curative therapy for pneumothorax. Torre et al coagulated bimanual palpation of the lungs; thus, resection may be
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blebs and partially scarred parietal pleura through the incomplete. In a retrospective study, Roth et al noted that
thoracoscope in 85 patients with spontaneous 45% of patients with unflateral metastases present on
pneumothorax. There were no complications despite the use preoperative chest computed tomography were found to
of general anesthesia. The average hospital stay was 5 days. have bilateral metastases present at median stemotomy.
Eighty (94%) patients were treated successfully by Confirmation of equivalent survival by randomized trials
thoracoscopy and laser follow-up, 5 to 86 months. among the various surgical approaches for metastasectomy
Thoracoscopy and laser failed early in two patients; both is required before the reported reduced morbidity and length
patients had lesions larger than 2 cm. Three other patients of stay afforded by the thoracoscopic technique can be of
developed a later recurrance of pneumothorax. Each significant benefit to the patient.
required thoracotomy. Emphysematous bullae that compromise aerating
Thoracoscopy, with its various modalities, is successful adjacent lung can adversely affect patients with limited
with a low recurrence rate for spontaneous pneumothorax. pulmonary reserve. Although some authors advocate
Some argue that the indications for operative intervention surgical management of diffuse emphysematous disease, 11,62
in the patient with a spontaneous pneumothorax have the main indication for operation in patients with bullous
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changed since the advent of the VATS technique. Some emphysema is the presence of giant bullae. 9 Bullectomy
surgeons now perform VATS sooner if chest tube may benefit selected patients if the bullae occupy a
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thoracostomy is not effective by 72 hours. We have been significant portion of the hemithorax, and the structure and
advocating, for various reasons, earlier surgical intervention function of the remaining lung parenchyma are preserved.
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for persistent air leak irrespective of which technique is Wakabayashi et al described 22 patients who underwent
employed. Nevertheless, it is still not clear that thoracoscopy thoracoscopic ablative bullectomies with the carbon dioxide
is justified in patients presenting with a first episode of (CO ) laser technique. Patients in this study had advanced
2
pneumothorax. It is clear that thoracoscopy is best suited emphysema with poor lung mechanics (mean forced
for pneumothorax from small, visible blebs, whereas expiratory volume in 1 second = 26% predicted). Two
thoracotomy is still the surgical treatment of choice for the patients died postoperatively (one myocardial infarction,
patient with known substantial bullous disease. 57 one pneumonia); thus, the perioperative mortality was nearly
Pulmonary metastasectomy may favorably influence 10%. Three (14%) patients required subsequent
survival in selected patients with certain tumors. 58,59 There thoracotomies for complications but did well. All patients
are two patient populations that are considered for reported improved dyspnea postoperatively. Postoperative
metastasectomy. The first group consists of patients who pulmonary function tests were available at up to 3 months
will not achieve a survival benefit from resection but in in 11 patients. FEV , FVC, and exercise treadmill times
1
whom a diagnosis of metastatic disease is needed. The increased significantly indicating objective improvement.
second group consists of those patients with a limited tumor Nevertheless, an ill-defined patient selection, prolonged air
burden who may achieve a survival benefit from leaks (mean 13 days), insufficient follow-up data, and the
metastasectomy. Currently, thoracotomy or median high perioperative surgical mortality in this series make
sternotomy are the standard surgical approaches for thoracoscopic CO laser bullectomy very controversial.
2
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pulmonary metastasectomy. The operative morbidity varies Kaiser performed 23 consecutive VATS bullectomies
from 5 to 14% and the hospital stay from 8 to 10 days for giant bullae and had no mortality. All patients reported
in recent series using these open approaches. 58,60 functional improvement. Long-term outcome remains to be
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Dowling et al successfully performed VATS resection of determined, however, the best candidates for bullectomy
select peripheral lesions in 72 patients by the use of an are those patients with a striking progression in the size of
endostapler, laser, or both. The mean diameter of the the bullae with a concurrent decrement in pulmonary
resected lesions was 1.6 cm (range, 0.2 to 4.3 cm). The function over a relatively short period of time. 39 Larger,

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