Video-assisted thoracic surgery: Risks and benefits

Summary: Background: Thoracoscopy has been used throughout this century, especially in the treatment of pleural disease. The introduction of video-assistance and especially designed instruments such as stapling devices in 1992 led to a worldwide and enthusiastic application for the treatment of a variety of thoracic pathologies. Methods: This report summarizes our experience gained from 1013 consecutive VATS procedures performed since 1990 for various indications in order to clarify its role for surgery of thoracic pathologies. Results: 234 patients underwent VATS for pleural biopsy, 154 for talcage, 163 for pulmonary wedge resections in order to clarify interstitial diseasee or indetermined nodules, 126 for spontaneous pneumothorax, 91 for decortication of empyema, 63 for symphatectomy, 55 for biopsy of mediastinal lesions, 29 for pericardial effusions (fenestration), 25 for lung volume reduction surgery, 17 for excision of mediastinal cysts and 12 for excision of neurogenic tumors of the posterior mediastinum. Conclusions: Our results demonstrate that VATS has gained established acceptance for several indications, however, caution in application of VATS is clearly indicated for some diseases, especially for thoracic malignancie

Video thoracoscopic surgery used to manage tuberculosis in thoracic surgery

Background: The aim of this study was to evaluate the indications and results of video-assisted thoracic surgery (VATS) for the management of tuberculosis in 10 patients with unusual clinical and radiologic presentation for the disease. Methods: From March 2000 to March 2002, 96 diagnostic VATS operations for unclear thoracic lesions were performed at the authors' institution. Their final diagnosis for 10 (10.4%) of these patients was tuberculosis. The suspected preoperative diagnoses were pancoast tumour (n = 1), pericardial effusion (n = 1), pleural mesothelioma (n = 1), pleural empyema (n = 2), mediastinal lymphoma (n = l), and lung cancer (n = 4). Results: For all the patients, the diagnosis of tuberculosis was achieved by VATS. The duration of drainage was 2.5 days. There have been neither morbidity nor mortality since surgery. The hospital stay was 3 to 5 days. Conclusion: Thoracoscopy is a safe and effective procedure for the management of tuberculosis. Tuberculosis should be kept in mind during the differential diagnosis of unknown thoracic lesions, and also for patients who live in economically well developed countries and are not immune compromise

Pulmonary function testing after operative stabilisation of the chest wall for flail chest

Objective: This is a prospective evaluation of chest wall integrity and pulmonary function in patients with operative stabilisation for flail chest injuries. Methods: From 1990 to 1999, 66 patients (56 men, 10 women; mean age 52.6 years) with antero-lateral flail chest (≧4 ribs fractured at ≧2 sites) underwent surgical stabilisation using reconstruction plates. Clinical assessment and pulmonary function testing were performed at 6 months following surgery. Results: Fifty-five (83%) patients had various combinations of injuries of the thorax, head, abdomen and extremities. Sixty-three (95.5%) patients underwent unilateral and 3 (4.5%) patients bilateral stabilisation with a median delay of 2.8 days (range 0-21 days) from admission. The 30-day mortality was 11% (seven of 66 patients). Immediate postoperative extubation was feasible in 31 of 66 patients (47%) and extubation within 7 days following stabilisation in 56 of 66 patients (85%). No plate dislocation was observed during the follow-up. The shoulder girdle function was intact in 51 of 57 patients (90%). Chest wall complaints were noted in 6 of 57 (11%) patients, requiring removal of implants in three cases. All patients returned to work within a mean period of 8 (range 3-16) weeks following discharge. Pulmonary function testing (n=50) at 6 months after the operation revealed a significant difference of predicted vs. recorded vital capacity (VC) and forced expiratory volume in 1s (FEV1) (P=0.04 and P=0.0001, respectively; Wilcoxon signed-rank test). The median ratio of the recorded and predicted total lung capacity (TLC) was shown to be significantly higher than 0.85 (P=0.0002; Wilcoxon signed-rank test), indicating prevention of pulmonary restriction. Conclusion: Antero-lateral flail chest injuries accompanied by respiratory insufficiency can be effectively stabilised using reconstruction plates. Early restoration of the chest wall integrity and respiratory pump function may be cost effective through the prevention of prolonged mechanical ventilation and restriction-related working incapacit

Heritability of lifetime milk yield and productive life and their relationship with produc- tion and type traits in the Simmental, Swiss Fleckvieh and Red Holstein populations in Switzerland

Abstract Costs of milk production can be reduced through lower replacement rate by increasing productive life of cows. Lifetime production (LP, production to 6 th lactation) and productive life (PL, number of completed lactations) of 112,850 daughters of 766 test AI bulls were used to obtain daughter averages and to estimate heritabilities. Bulls belonged to three sections of the Swiss Simmental and Red&White cattle herd book, differing in percentage of Red Holstein genes. Correlations of daughter average LP and PL with sire EBVs for production, functional and type traits and with composite indices differed among herd book sections and, in some instances, changed signs (e.g., for correlations with EBV for linearly scored muscling) due to different breeding objectives. The strongest correlations of LP were found with EBV milk (>0.69), of PL with total merit index (0.44 to 0.52) and the composite fitness index (0.32 to 0.56). Heritabilities were estimated using two sire models (without or with including a fixed effect of herd book section). They were around 0.19 and 0.13 for LP, and 0.111 and 0.097 for PL from the two models. Estimates obtained from the first model may be more appropriate because breeding objectives differ among herd book sections

The bmi-1 oncoprotein is differentially expressed in non-small cell lung cancer and correlates with INK4A-ARF locus expression

Genes of the polycomb group function by silencing homeotic selector genes that regulate embryogenesis. In mice, downregulation of one of the polycomb genes, bmi-1, leads to neurological alterations and severe proliferative defects in lymphoid cells, whilst bmi-1 overexpression, together with upregulation of myc-1, induces lymphoma. An oncogenic function has been further supported in primary fibroblast studies where bmi-1 overexpression induces immortalization due to repression of p16/p19ARF, and where together with H-ras, it readily transforms MEFs. It was the aim of this study to assess the expression of bmi-1 in resectable non-small cell lung cancer (NSCLC) in association with p16 and p14ARF (=human p19ARF). Tumours (48 resectable NSCLC (32 squamous, 9 adeno-, 2 large cell, 4 undifferentiated carcinomas and 1 carcinoid); stage I, 29, II, 7, III, 12; T1, 18, T2, 30; differentiation: G1 12, G2 19, G3 17) were studied by immunohistochemistry for protein expression and by comparative multiplex PCR for gene amplification analysis. In tumour-free, normal lung tissue from patients, weak – moderate bmi-1 staining was seen in some epithelial cells, lymphocytes, glandular cells and in fibroblasts, whereas blood, endothelial, chondrocytes, muscle cells and adipocytes did not exhibit any bmi-1 expression. In tumours, malignant cells were negative/weakly, moderately and strongly positive in 20, 22 and 6 cases, respectively. As assessed by multiplex PCR, bmi-1 gene amplification was not the reason for high-level bmi-1 expression. Tumours with moderate or strong bmi-1 expression were more likely to have low levels of p16 and p14ARF (P = 0.02). Similarly, tumours negative for both, p16 and p14ARF, exhibit moderate–strong bmi-1 staining. 58% of resectable NSCLC exhibit moderate–high levels of bmi-1 protein. The inverse correlation of bmi-1 and the INK4 locus proteins expression (p16/p14ARF) supports a possible role for bmi-1 misregulation in lung carcinogenesis. © 2001 Cancer Research Campaign www.bjcancer.co

Morbidity and validity of the hemiclamshell approach for thoracic surgery.

OBJECTIVE: This is a prospective study to evaluate the indications and outcome of the hemiclamshell incision (longitudinal partial sternotomy combined with an antero-lateral thoracotomy) as used for a consecutive series of patients requiring surgery for various thoracic pathologies not ideally approached by postero-lateral thoracotomy, sternotomy or thoracoscopy. METHODS: All patients with a hemiclamshell incision performed between 1994 and 1998 were prospectively analyzed regarding indications, postoperative morbidity and outcome (clinical examination and pulmonary function testing) in order to validate this incision for thoracic surgery. RESULTS: 25 patients (15 men, 10 women) with an age ranging from 16 to 73 years (mean 43 years) underwent a hemiclamshell incision. The indications for the hemiclamshell approach were (1) chest trauma with massive hemorrhage requiring urgent access to the mediastinum and the ipsilateral pleural space (40%), (2) tumors of the anterior cervico-thoracic junction with suspicion of vascular involvement (28%) and (3) lesions involving both one chest cavity and the mediastinum (32%). The 30-day mortality was 8%. One patient suffered a sternal wound infection, mediastinitis and pleural empyema after a gun shot wound, whereas wound healing was uneventful in all other patients. Analgesic requirements for postoperative pain relief were not increased as compared to those following a standard thoracotomy. At 3 months normal sensitivity of the entire chest wall and intact shoulder girdle function was noted in 90% of the patients. Pulmonary function testing showed no restriction due to the hemiclamshell incision. CONCLUSIONS: The hemiclamshell incision is a useful approach in selected patients and does not cause more morbidity or long-term sequelae than a standard thoracotomy

Pulmonary function testing after operative stabilisation of the chest wall for flail chest.

OBJECTIVE: This is a prospective evaluation of chest wall integrity and pulmonary function in patients with operative stabilisation for flail chest injuries. METHODS: From 1990 to 1999, 66 patients (56 men, 10 women; mean age 52.6 years) with antero-lateral flail chest (> or =4 ribs fractured at > or =2 sites) underwent surgical stabilisation using reconstruction plates. Clinical assessment and pulmonary function testing were performed at 6 months following surgery. RESULTS: Fifty-five (83%) patients had various combinations of injuries of the thorax, head, abdomen and extremities. Sixty-three (95.5%) patients underwent unilateral and 3 (4.5%) patients bilateral stabilisation with a median delay of 2.8 days (range 0-21 days) from admission. The 30-day mortality was 11% (seven of 66 patients). Immediate postoperative extubation was feasible in 31 of 66 patients (47%) and extubation within 7 days following stabilisation in 56 of 66 patients (85%). No plate dislocation was observed during the follow-up. The shoulder girdle function was intact in 51 of 57 patients (90%). Chest wall complaints were noted in 6 of 57 (11%) patients, requiring removal of implants in three cases. All patients returned to work within a mean period of 8 (range 3-16) weeks following discharge. Pulmonary function testing (n=50) at 6 months after the operation revealed a significant difference of predicted vs. recorded vital capacity (VC) and forced expiratory volume in 1s (FEV1) (P=0.04 and P=0.0001, respectively; Wilcoxon signed-rank test). The median ratio of the recorded and predicted total lung capacity (TLC) was shown to be significantly higher than 0.85 (P=0.0002; Wilcoxon signed-rank test), indicating prevention of pulmonary restriction. CONCLUSION: Antero-lateral flail chest injuries accompanied by respiratory insufficiency can be effectively stabilised using reconstruction plates. Early restoration of the chest wall integrity and respiratory pump function may be cost effective through the prevention of prolonged mechanical ventilation and restriction-related working incapacity