IV - Diagnostic Procedures
Editors: Shields, Thomas W.; LoCicero, Joseph; Ponn, Ronald B.; Rusch, Valerie W.
Title: General Thoracic Surgery, 6th Edition
Copyright 2005 Lippincott Williams & Wilkins
> Table of Contents > Volume I - The Lung, Pleura, Diaphragm, and Chest Wall > Section IV - Diagnostic Procedures > Chapter 18 - Video-Assisted Thoracic Surgery as a Diagnostic Tool
Chapter 18
Video-Assisted Thoracic Surgery as a Diagnostic Tool
Anthony P.C. Yim
Alan D.L. Sihoe
Many advances have been made in the field of video-assisted thoracic surgery (VATS) since the last edition of this book. The use of VATS as a diagnostic tool for pleural diseases, solitary pulmonary nodules, and interstitial lung diseases has now been well accepted into mainstream thoracic surgery. Its role as an adjunct in lung cancer staging and in selected cases of chest trauma is becoming increasingly appreciated. However, alongside this technologic advancement in surgery, we have also witnessed rapid development of various imaging modalities for diagnosis of a variety of chest diseases. The use of low-dose helical computed tomography (CT) of the thorax for lung cancer screening poses a challenge to the clinicians to best select patients for a surgical biopsy. Positron-emission tomography (PET) has already made an impact on tumor staging and patient selection for resection. Newer diagnostic modalities like monoclonal antibody scans, somatostatin receptor scans, and antisense imaging techniques are likely to enhance the physician's diagnostic ability further. Therefore, although surgical histology remains a cornerstone for diagnostic confirmation, readers are reminded that clinical management algorithms may need to be continually updated in the face of such rapid evolution in surgical, radiologic, and medical technology. The role of VATS in such algorithms similarly needs constant review and revision.
The objective of this chapter is to give an overview of the current applications of VATS in the diagnosis of chest disease and to define its role in modern thoracic investigative algorithms.
BACKGROUND
The human body contains two noncommunicating pleural spaces. In contrast, elephants are born with physiologic pleural symphysis and essentially no pleural space at all. Other mammals, such as horses and buffalos, have extensive communications between the right and left thoracic spaces, effectively rendering them with a single pleural cavity. It is fortuitous that the anatomy in humans allows for single-lung collapse using selective one-lung anesthesia, affording ample room in the pleural cavity for instrument maneuvering during surgery, as emphasized by Kirsch (2000). Because carbon dioxide insufflation is generally unnecessary for lung collapse, valved ports and dedicated endoscopic instruments are not mandatory. We are therefore blessed in having an ideal cavity for minimal-access thoracic surgery.
Many detailed reviews on the history and development of thoracoscopy have already been written, such as that by Braimbridge (2000), and we shall not duplicate them in detail here. It is perhaps sufficient to note that thoracoscopy itself is an established technique, used for more than a century for adhesiolysis (to complement collapse therapy in tuberculosis management) and for simple pleural biopsy. Although the birth of thoracoscopy is generally credited to Hans Christian Jacobeus, a Swedish internist in the early part of the 20th century, recent evidence as recorded by Hoksch and colleagues (2002) suggests that this technique may have existed even half a century earlier. Much of the early use of thoracoscopy was for the diagnosis of intrathoracic diseases. However, it was the introduction of high-resolution video-endoscopic systems in the 1980s and of modern techniques of selective single-lung ventilation that revolutionized thoracic surgery. The fusion of these newer elements greatly enhanced the application of the old technique of thoracoscopy in the management of chest disease, evolving into VATS as we know it today. The role of VATS as a diagnostic tool for chest diseases is now well established in modern clinical practice.
BASIC TECHNIQUE
For general VATS diagnostic procedures, we prefer general anesthesia with selective one-lung ventilation using a double-lumen endotracheal tube. A single-lumen endotracheal
P.315
tube with a bronchial blocker is an acceptable alternative, particularly for a patient with a small trachea. In young children for whom no suitably sized double-lumen tube is available, we use a single-lumen tube with the tip placed into the contralateral main-stem bronchus.
We have recently begun employing a novel method of highly selective lobar lung collapse for VATS in selected adult patients with compromised respiratory function.* A similar technique using balloon catheter blockade of a targeted lobar bronchus was described by Takahashi and associates (2001) for children, and later by Morikawa and colleagues (2002) for adults. Our method uses a fiberoptic bronchoscope to guide placement of a standard nasogastric feeding tube to the bronchial orifice of the target lobe (Fig. 18-1; see Color Fig. 18-1). The tube is left open to air or connected intermittently to low suction to expedite lobar collapse.
The patient is turned to a full lateral decubitus position and the table flexed to widen the rib spaces on the operation side, the senior author (APCY) emphasized in 1995. The positions of the surgeon and assistant depend on the site of the pathology as suggested by preoperative imaging. The surgeon stands facing the site of the pathology with the camera-holding assistant on the same side. The television monitor is positioned so that the surgeon, the site of pathology, and the monitor are aligned to allow the surgeon to look straight ahead when operating. Five- or 10-mm thoracoscopes are used with a 0- or 30-degree lens, and a three-chip CCD video camera. Prewarming the thoracoscope with a sterile hot-water bath effectively prevents fogging of the lens (which can result from temperature differences when it is first inserted into the chest).
Intercostal port placement is described by Landreneau and colleagues (1992). This baseball-diamond pattern allows the comfortable triangulation of the instruments to target the lesion site from either side. For general exploration, the first (camera) port is often made in the midaxillary to anterior axillary line at the seventh or eighth intercostal space. This first port is always made bluntly, and digital exploration is performed to detect and release adhesions around the port site before camera insertion. Generally, a 10-mm camera is used for adults and a 5-mm camera for children. The remaining two instrument ports are made under video guidance.
The authors prefer the use of standard conventional instruments, such as sponge-holding forceps, for nontraumatic lung manipulation. Rotation or tilting of the operating table can facilitate visualization by allowing the lung to drop away from the area to be examined. Pulmonary biopsies are taken using standard endoscopic staplers. An alternative technique is the enucleative precision cautery resection first described by Perelman and later advocated by Cooper and colleagues (1986).
 |
Fig. 18-1. Novel technique for selective lobar lung collapse. A. A suction catheter in situ after insertion through a standard endotracheal tube to the target lobar bronchus under guidance of fiberoptic bronchoscopy. B. Needlescopic video-assisted thoracic surgery (VATS) view of selective collapse of the right upper lobe (arrow), with the right lower lobe (foreground) still ventilated. (See Color Fig. 18-1.) |
One recent development in this regard is the technology of saline-enhanced thermal sealing, which employs a continuous flow of electrically conductive saline between the tissue and the diathermy electrode to translate the electrical
P.316
energy of the diathermy into thermal energy in the tissue, has been reported by one of us (APCY) and associates (2002a). This achieves hemostasis and pneumostasis in the tissue, but the peak temperatures involved are significantly less than with direct conventional diathermy, resulting in less char formation, smoke generation, and lateral thermal damage to the adjacent tissue (hence reducing the potential for blood vessel perforation). The technology has been incorporated into a floating-ball device to allow nodulectomy by a modified Perelman's technique (Fig. 18-2A). The technology has also been used in a bipolar sealing forceps, which functions similarly to an endoscopic stapling device for wedge resections (Fig. 18-2B), with the advantage of minimizing the consumable costs of reloadable cartridges for the stapler. Randomized studies comparing this technology with conventional staples are underway.
At the end of the procedure, the authors normally leave in a single chest tube (20 to 24F) overnight. Some authors, such as Russo and colleagues (1998), advocate even sooner removal of the chest tube.
There is a trend toward the use of ever-smaller thoracoscopes for simpler procedures to minimize access trauma further. Thoracoscopes and instruments of 2-mm diameter (i.e., needlescopic instruments) have been used for thoracodorsal sympathectomies for many years at the authors' institution, and their use in thoracic diagnostic procedures is being explored, as noted by the senior author (APCY) and coinvestigators (2000a, 2000b). Lazopoulos and colleagues (2002) demonstrated 100% diagnostic accuracy with 0% mortality and morbidity when using 2-mm mini-VATS for intrathoracic diagnosis in 54 patients. Such needlescopic VATS procedures offer less pain and even better cosmesis than classic VATS. The authors use a simple underwater seal technique to detect air leaks on-table after our needlescopic VATS procedures, obviating the need for routine chest tube insertions, as described by the senior author (APCY) and his colleagues (2002b). However, the 2-mm fiberoptic lens generally offers an inferior video image quality compared with that of a 3-mm Hopkins rod lens. Some surgeons also report poorer control and feel through the 2-mm endoscopic instruments because of their flexibility. Hence, more experience on the part of the surgeon is demanded.
 |
Fig. 18-2. Endoscopic instruments incorporating the saline enhanced thermal sealing technology. A. Floating ball device. B. Bipolar sealing forceps (TissueLink Medical Inc., Dover, NH). |
A related but totally different technique is pleuroscopy (sometimes referred to as medical pleuroscopy ), which can be performed using a sterile fiberoptic bronchoscope. The bronchoscope is usually inserted under local anesthesia through a chest drain tract into the pleural cavity, or through a small chest incision. The scope can be placed through a truncated chest tube, which can then guide the tip of the endoscope to the area of interest, as suggested by one of us (APCY) (1996a). The application of this technique is very limited, and we would reserve this procedure for the occasional frail or debilitated patient who cannot tolerate general anesthesia but for whom an accurate tissue diagnosis (usually a pleural biopsy) is nonetheless required.
USE OF VIDEO-ASSISTED THORACOSCOPIC SURGERY AS A DIAGNOSTIC MODALITY
Pleural Disease
Effusion
The normal human pleural space is a closed potential space containing only a minimal volume of fluid (usually less than 5 mL) similar in composition to tissue fluid. This pleural fluid normally allows the lung to glide smoothly on the chest wall during respiration. Under certain abnormal circumstances, the amount of this fluid can increase, giving rise to a pleural effusion (Table 18-1).
Table 18-1. Common Causes of an Indeterminate Pleural Effusion | |
|---|---|
|
P.317
Conventional methods of diagnosing the pathology underlying an abnormal pleural effusion include imaging, thoracocentesis, and percutaneous pleural biopsy. However, each of these has its specific drawbacks and limitations. Imaging (including chest radiography, ultrasonography, or CT) is useful in detecting and localizing the effusion but cannot diagnose the underlying etiology. Imaging can, however, guide thoracocentesis or insertion of drainage catheters. Thoracocentesis provides biochemical, microbiological, and cytologic information regarding the effusion. A precise histologic diagnosis is rarely indicated for a transudative effusion as determined by Light's criteria (1983); on the other hand, an exudative effusion calls for further investigation to exclude malignancy and tuberculosis, among others. This can be performed blindly as a bedside percutaneous procedure, or with radiologic guidance for targeting loculated effusions. It has been estimated by Collins and Sahn (1987) that up to 75% of diseases presenting with pleural effusion can be diagnosed by analysis of the fluid tapped by thoracocentesis. It has been suggested that a positive diagnosis is more likely with diseases such as empyema thoracis, chylothoraces, and hemothoraces, which do not require a precise cytologic diagnosis. However, for diseases for which cytology is essential for diagnosis, such as malignant pleural disease, the yield is much lower. Menzies and Charbonneau (1991) reported positive cytologic diagnosis rates from thoracocentesis of 45% to 80%, with rates for malignant mesothelioma as low as 20%.
Percutaneous pleural biopsy is typically performed using an Abrams needle. Using this technique to detect malignant disease, Rao (1965) and Canto (1977) and their colleagues reported positive diagnosis rates of only 38% to 67%. Tomlinson and Sahn (1987) reported only 54% to 75% positive diagnosis rates for tuberculosis using the Abrams needle. These relatively low sensitivity rates are not surprising given that many pleural lesions may be located on the mediastinal, diaphragmatic, or visceral pleural surfaces, which are inaccessible to the percutaneous approach.
The problem, therefore, is that at least 15% to 25% of pleural effusions may remain undiagnosed using the aforementioned nonsurgical techniques. Boutin and co-workers (1981) reported that 215 in a series of 1,000 pleural effusions remained undiagnosed using only the former techniques. Repeating thoracocentesis for those 215 patients with indeterminate effusions only marginally increased the yield. However, in the same 215 patients, thoracoscopy gave 96% diagnostic accuracy, suggesting that thoracoscopy and VATS may indeed be the ideal investigative tools for such situations.
VATS not only offers bigger, more representative biopsies to be undertaken, but also allows for all of the pleural surfaces (including the mediastinal, diaphragmatic, and visceral pleura) to be fully visualized and accessible for biopsy. A large volume of literature has already been published during the past 15 to 20 years confirming that VATS consistently achieves positive diagnosis rates for indeterminate pleural effusions in 95% to 100% of case. A 1991 metaanalysis by Menzies and Charbonneau of 1,500 cases of indeterminate pleural effusions worldwide confirmed that VATS gave 90% diagnostic accuracy with only a 3% morbidity. The diagnostic effectiveness of VATS in pleural disease is perhaps even greater than that of an exploration by thoracotomy given the superior ability of VATS to visualize the entire lateral chest wall.
The senior author (APCY) and associates (1996a) previously demonstrated that more than half of all indeterminate pleural effusions may be related to an underlying malignant disease. This relatively high incidence highlights the importance of thorough investigation of all such effusions. With the proven efficacy and low morbidity of VATS, there is a strong case for early aggressive investigation of such effusions surgically should nonsurgical techniques prove inconclusive. Using VATS enables the surgeon to diagnose less common causes of indeterminate pleural effusions without difficulty. These include the location and repair of sources of persistent chylothorax and the close pleuroperitoneal fistulae associated with peritoneal dialysis as reported by the senior author (APYC) and colleagues (2002c).
For the diagnosis of pleural effusions of unknown origin, the basic three-port VATS technique described is used earlier. Representative parietal pleural biopsies can be undertaken with endoscopic biopsy forceps inserted through the instrument ports. Should dedicated biopsy forceps not be available, an acceptable alternative method is to circumscribe with a generous margin the suspected pleural lesion, then to peel off the disc of pleura, containing it with forceps. If it can immediately be determined that the effusion was due to malignant disease, one can elect to apply chemical pleurodesis by talc insufflation. Talc insufflation, as noted by the senior author (APCY) and associates (1996b), can be given by blowing in talc through a wide-bore suction catheter placed into the pleural space using a 50-mL bladder syringe.
For the experienced VATS surgeon, the use of two ports (one for the camera, one for biopsy forceps), or even one port, can be sufficient to obtain adequate pleural biopsy specimens should there be no major adhesions. For the one-port technique, the biopsy forceps can be inserted alongside the video-thoracoscope through the same port to reach the target lesion. An alternative is the use of an operating telescope with an offset eyepiece plus a central working channel for the insertion of the biopsy forceps. In patients coming to an operation with a chest drain already in situ, the drain site wound can be used as the single port, avoiding extra incisions.
Pleural Space Infections
The natural history of a parapneumonic effusion follows a well-described sequence, classically progressing through exudative, fibrinopurulent, and then organized phases. The management of pleural space infections and parapneumonic effusions is consequently very dependent on timing, with early parapneumonic effusions responding well to drainage alone, whereas full-blown lung entrapment would
P.318
require extensive decortication procedures as described by the senior author (APCY, 1999).
The major role of VATS in such clinical situations is therapeutic. Breaking down loculations in the fibrinopurulent phase to allows for adequate drainage of a unified cavity. VATS may have a minor secondary role as a diagnostic adjunct in these cases, yielding a greater mass of pleural fluid, pleural exudative tissue, pleural cortical peel, and even lung tissue for microbiological study than is produced by other nonsurgical investigations.
In developing countries, VATS may still play an important diagnostic role in patients with suspected pulmonary tuberculosis, as discussed by the senior author (APCY, 1996b). Mycobacteria are notoriously difficult to culture, and positive diagnosis often requires sizable specimens for microbiological study. VATS can prove useful in obtaining generous quantities of tissue for tuberculosis microscopy and culture. Such biopsies can be performed in a dedicated diagnostic VATS procedure, or more commonly as part of a therapeutic VATS decortication procedure for an established empyema.
For cases of pleural space infections, the same basic three-port technique as described previously is used. For empyema thoracis, the authors prefer siting ports close enough together that fingers passed through any two ports can touch inside the chest. Using this bidigital technique, dense adhesions and loculations can be broken down around the ports, allowing greater room for exploration by the video-thoracoscope. This is the same VATS technique employed in reoperated chests, as described by one of us (APCY) and colleagues (1998). For diagnostic purposes, pleural fluid aspirated and exudative peel from the parietal or visceral pleural surfaces are submitted for microbiological and pathologic studies. In areas where tuberculosis is still endemic, microbiological studies to exclude acid-fast bacilli are also mandatory.
Mesothelioma
Malignant mesothelioma can be notoriously difficult to diagnose. In its early stages, it may not be detectable even on CT scanning. Even if pleural thickening is seen on CT, it is often situated on the mediastinal, diaphragmatic, or costophrenic angle parietal pleura, which are not amenable for percutaneous needle biopsy. Any such biopsy would still be a blind procedure, yielding only small quantities of tissue, which may be insufficient for the histopathologist to make the difficult distinction between a malignant mesothelioma and metastatic adenocarcinoma. In cases in which a fluid effusion is present, the diagnostic yield of fluid cytology from a diagnostic tap can be as low as 4% to 20%.
VATS is able to access all parts of the pleura, yielding generous biopsy specimens with high diagnostic yield. In 1979, Boutin and colleagues reported that thoracoscopy could yield a 94% positive diagnosis rate in cases of mesothelioma, compared with only 40% with percutaneous biopsies. In 1991, Sgro and co-workers achieved an 85.7% positive diagnosis rate. Grossebner and colleagues (1999) used VATS to confirm malignant mesothelioma in 23 of 25 patients suspected of having the disease clinically.
Diffuse Interstitial Lung Disease
The appearance of diffuse pulmonary infiltrates on radiologic imaging presents a diagnostic challenge for most clinicians given the great variety of possible etiologies with similar radiologic appearances.
Sputum analysis and bronchoalveolar lavage can yield positive cytologic and microbiological results. However, in more than half of all cases, the diagnosis remains elusive, as noted by Gaensler and Carrington (1980). Percutaneous biopsy techniques are of limited value in this group of patients, owing to the small specimen size they generally obtain. In particular, some pathologies (such as pulmonary lymphoma) require special staining and cellular architectural analysis for identification and cannot be diagnosed from the small biopsy specimens these techniques provide.
Traditionally, the diagnostic procedure of choice was the open lung biopsy. This can be performed through a limited thoracotomy without video assistance. Several studies have reported a positive diagnosis rate of more than 90% for diffuse lung infiltrative disease with open lung biopsy. Nonetheless, before the advent of VATS, the morbidity and pain of a thoracotomy often deterred many clinicians from performing lung biopsies until late in the course of the disease.
In modern practice, VATS has gradually replaced open lung biopsy in most cases by virtue of its lower morbidity, giving reduced postoperative morbidity and pain to the patient. It has also been shown in many studies that the size and quality of the biopsy from VATS is not inferior to that obtained by the open procedure. Rena and associates (1999), for example, achieved 100% diagnostic accuracy using VATS for 58 patients with diffuse interstitial lung disease, with only two complications (both prolonged air leaks) and only one conversion to minithoracotomy because of pleural symphysis. Caccavale and Lewis' (1999) review of 61 patients undergoing VATS biopsy for diffuse lung infiltrates achieved a 100% diagnostic rate at a cost of only two complications (both prolonged air leaks).
Numerous studies during the past decade have also compared VATS favorably to the open lung biopsy for the diagnosis of diffuse pulmonary infiltrates in terms of relative patient morbidity. Ferguson (1993) reported that VATS gave significantly shorter hospital stays when used for diagnosis of diffuse lung disease compared with open biopsy. Bensard and coauthors (1993) conducted a retrospective study comparing 21 patients undergoing open lung biopsy with 22 undergoing VATS biopsy. Diagnostic accuracy was essentially the same in both groups, but the VATS patients enjoyed a lower complication rate (2 of 22 vs. 4 of 21), shorter mean duration of chest drainage (1.4 days vs. 3.2 days), and shorter hospital stay (2.6 days vs. 5.7 days).
P.319
Ferson and associates (1993) also demonstrated that, compared with open lung biopsy, VATS lung biopsy offered significantly shorter hospital stays and fewer complications. A 1995 study by Kadokura and colleagues also concluded that VATS offered similar, if not better, results as compared with open lung biopsy, with comparable complication rates, and that VATS was thus a satisfactory alternative. In 1998, Ravini and colleagues retrospectively compared 65 patients who underwent VATS biopsy for diffuse lung disease with 68 who underwent open lung biopsy. Specimen adequacy and diagnostic accuracy were equivalent in both groups, but the VATS patients enjoyed significantly less blood loss, reduced postoperative analgesic requirements, and shorter postoperative stays. A prospective, randomized trial by Ayed and Raghunathan (2000) compared 32 patients having VATS biopsy for diffuse lung disease to 29 patients undergoing open biopsy. The diagnostic yield in the two groups was comparable, but the VATS procedure gave significantly shorter operating times, reduced postoperative analgesic requirement, and reduced duration of hospital stay. There was also a trend for VATS patients to have a lower complication rate.
The same basic three-port technique as described previously with port sites are placed to target the site of suspected maximal pathology as suggested by preoperative imaging. If all other factors are equal in bilateral disease, the authors prefer the right-sided approach because the extra fissure and lobe edges give more possibilities for an easy biopsy at a lung edge.
The actual region of lung biopsied is determined based on imaging findings, intraoperative appearance, and finger palpation. We do stress that finger palpation is an important step because the tactile qualities of the lung are as important an indicator of abnormality as the visual appearances.
Gaensler and Carrington (1980) have previously reported that the lingula and right middle lobe made poor biopsy sites, given their alleged propensity for inflammation, scarring, and congestion that can affect histologic diagnosis. However, others, such as Miller and associates (1987) and Wetstein (1986), have not found this to be the case, and we certainly do not deliberately avoid biopsy at these sites should they appear representative. Pego-Fernandes and associates (1998) describe the ideal site for biopsy as the intermediate zone between frankly diseased and relatively normal-looking lung, which reportedly gives greater histologic yield.
Regardless of the site chosen, a wedge excision biopsy technique is preferred, and studies by Miller (1992) and Rena (1999) and their colleagues have shown that such a wedge technique can give up to 100% diagnostic accuracy. The wedge is taken using an endoscopic stapler gun device. Should wound protection be required in cases of suspected malignancy, a small specimen can be delivered through a plastic or metal endoscopy trocar port, whereas larger resections can be placed in a sterile plastic bag inside the chest before delivery. The number of biopsy specimens is dependent on the surgeon's preference, but Chechani and co-workers (1992) found that taking a second biopsy specimen never yielded a different result from the first in their series of 20 patients. Flint and co-workers (1995) have shown that a single large biopsy specimen (2-cm diameter or more) from a well-selected site is sufficient for reliable diagnosis, with any further specimens failing to augment the histopathologic findings of the first. Most recently, Stamenkovic and associates (2002) demonstrated a 98% diagnostic yield using only a single targeted VATS lung biopsy for interstitial lung disease.
Preventza and colleagues (2002) demonstrated that about 87% of patients undergoing VATS wedge lung biopsies could be safely discharged after an overnight hospital stay only.
It should be pointed out that a patient with diffuse lung infiltrates might present with acute respiratory failure (often requiring ventilatory support). In such cases, the clinical deterioration may have been so rapid that no firm diagnosis has yet been made. Wedge lung biopsy is indicated for an urgent diagnosis, but the patient may not to be able to tolerate the one-lung ventilation required for VATS. Ferson and Landreneau (1998) warned that the attempt to change from a single-lumen to a double-lumen endotracheal tube can be very dangerous in such situations. Furthermore, the acutely congested lungs of such a patient can tear easily when standard endoscopic staple guns are applied. For such severely ill patients, it would be preferable to offer an open lung biopsy through a limited anterior thoracotomy. With such a technique, one-lung ventilation is not essential, the lung can be repaired by open suturing, and the entire procedure may be performed using local anesthesia by the bedside if necessary.
Surgeons have to be cognizant that lung biopsy in this group of patients is associated with significant operative risks. In a series of 80 such patients undergoing open lung biopsy, Warner and coauthors (1988) reported a positive diagnosis in only 66% of those patients, and the results altered management in only 70%. On the other hand, 15 of those patients suffered biopsy-related complications, and only 24 survived to be discharged from hospital. In 1995, Lachapelle and Morin reported that in a series of 31 patients with such acute respiratory failure, a positive diagnosis was achieved in 68%. In 58% of these patients, management was altered as a result of the biopsy findings, but their survival was no better than that of the other 42%. Clinical judgment is therefore critical in selecting patients of this category for a surgical procedure.
Solitary Lung Nodules
The solitary lung nodule is typically described as a single intrapulmonary mass lesion, which is well circumscribed and measures 3 cm in diameter or less. Thus defined, there is an incidence of 150,000 detected each year in the United States. Lillington reported in 1991 that 40% of such nodules were malignant, with most being primary lung tumors. Given that early-stage lung cancer is potentially curable, it is therefore imperative that an accurate diagnosis be made
P.320
accurately and promptly when such solitary lung nodules are found. Clinical and radiologic clues are of only limited use in diagnosis, and an accurate tissue diagnosis should remain crucial for virtually all patients with a solitary lung nodule. Whereas the risk is low for those nodules that have shown no change for 2 years or more, as Mack and associates (1993) as well as numerous other investigators have noted. If any nodule is new or has grown in size since the last chest radiograph, it must be assumed to be malignant until proved otherwise. Fiberoptic bronchoscopy is a readily available, low-morbidity procedure that can be offered. However, even with bronchoalveolar lavage, bronchial brushings, or transbronchial biopsy, the likelihood of obtaining a specific tissue diagnosis remains disappointingly low in many cases.
Percutaneous transthoracic fine-needle aspiration (FNA) for a cytologic diagnosis can be performed with imaging guidance by fluoroscopy, ultrasound, or CT. Lesions as small as 5 mm in diameter can be successfully targeted by the interventional radiologist. Sensitivity for diagnosing malignant disease has been reported in the range of 70% to 95%. There are, however, drawbacks. Patients with underlying pulmonary or airways disease may find it difficult to hold their breath for long durations as required during the procedure. Pneumothorax complicates 8% to 61% of cases of pulmonary FNA and often requires intervention, as reported by Shantaveerappa and associates (2002). Diagnostic accuracy is also to some extent dependent on sampling errors, the degree of necrosis within the tumour, and the skill of the operator. Disappointingly, however, it has been reported by Westcott (1980) that 5% to 23% of lesions reported as benign are eventually shown to be malignant.
PET represents an exciting new investigative tool, but its diagnostic efficacy remains to be convincingly validated. Worsley and coauthors (1997) provide a discussion of the early use of PET scanning for pulmonary nodules, but one cannot escape the conclusion that PET can provide only a probability of malignancy, not an accurate histologic diagnosis. The same is true with the use of technetium 99m (99mTc)-labeled peptide depreotide single photon emission computed tomography (SPECT), as reviewed by Goldsmith and Kostakoglu (2000).
Should the aforementioned methods not yield a positive result, a surgical diagnostic procedure is normally offered. Comparing transbronchial biopsy, CT-guided FNA, and surgical biopsy, Goldberg-Kahn and colleagues (1997) concluded that a surgical procedure was in fact the most cost effective. For surgical biopsy of the solitary lung nodule, VATS has now largely replaced open thoracotomy as the approach of choice. VATS not only offers an accurate tissue diagnosis in virtually all cases but also allows staging of the malignancy at the same time. Should the surgeon choose, the biopsy can be sent for frozen section, and if malignancy is confirmed, a curative resection can be performed in the same sitting.
Many studies have confirmed the diagnostic accuracy of VATS for lung nodules to be consistently in the vicinity of 95%. Mack and associates (1993) reported a virtually 100% diagnostic rate in a series of 242 patients with VATS lung wedge biopsies for indeterminate lung nodules, with a 3.6% complication rate. Fifty-two percent turned out to be benign lesions, and the other 48% were malignant. A review by Caccavale and Lewis (1999) of 142 of their patients also found a 100% diagnostic rate (38% benign, 62% malignant) with a 6.3% morbidity rate (mostly air leaks). Mitruka and colleagues (1995) achieved a positive specific tissue diagnosis in 96% of 613 patients undergoing VATS biopsy of solitary pulmonary nodules. Murasugi and associates (2001) achieved a 100% positive diagnostic rate with no mortality or morbidity in a series of 81 patients with small peripheral solitary lung nodules undergoing VATS wedge excisional biopsies.
Besides giving high diagnostic accuracy, the use of VATS for biopsy of solitary lung nodules gives remarkably low morbidity. Allen and co-workers (1993) compared a cohort of 64 patients who underwent VATS wedge excision biopsy of solitary lung nodules with 64 who underwent thoracotomy for the same biopsy. They found that the patients in the VATS group had lower postoperative analgesia requirements and could be discharged from hospital a median of 3 days earlier. Only four patients in the VATS group developed complications (two pneumothorax, one atrial fibrillation, and one persistent air leak). Such is the proven ability of VATS to obtain positive diagnoses with low morbidity that the threshold for surgical investigation for indeterminate solitary lung nodules today should be very low.
We again use the already described three-port VATS technique with ports arranged in diamond pattern aimed at the lesion as visualized by preoperative CT scanning. Because the lesion may often not be readily visible after the lung is deflated, palpation is an essential step in almost all cases. This can be done by use of instruments, but we strongly advocate the use of digital palpation for its superior feel, as noted by the senior author (APCY) and Ho (1995a). The part of the lung explored can be brought up to the fingertip for palpation using sponge-holding forceps. It may often be necessary to release any pleural adhesions and the pulmonary ligament to mobilize the entire lung for thorough palpation.
In some cases, the lesion may be so small or so deep within the lung parenchyma that it can elude all attempts at localization intraoperatively. Should such a situation be suspected from preoperative CT appearance, the surgeon is advised to have the lesion marked preoperatively by means of imaging-guided methylene blue injection or by guide-wire insertion. These and other strategies for preoperative and intraoperative localization have been reviewed by Mack (2000). Suzuki and colleagues (1999) report that if the lung nodule seen on CT is 10 mm or smaller in diameter and is situated more than 5 mm beneath the pleural surface, the probability of failing to detect the nodule intraoperatively is 63%, and preoperative marking should be considered. However, a lesion that appears at first glance to be deep seated on CT may actually be situated adjacent to an
P.321
interlobar fissure. In this case, the lesion may actually be readily detected and resected intraoperatively (Fig. 18-3; see Color Fig. 18-3B).
 |
Fig. 18-3. A solitary lung nodule. A. On computed tomography, the nodule at first glance appears to be deep seated, but closer inspection reveals that it is located close to the major fissure (arrow), making resection by VATS eminently feasible. B. VATS exploration confirms the nodule to be sited close to the fissure. (See Color Fig. 18-3B.) |
The authors' preferred method of biopsy is by a wedge resection using an endoscopic stapler gun device. Preferably, a 1-cm margin should be maintained around the lesion in the wedge. The ideal lesion for wedge excision would be on the lateral aspects of the lung close to the interlobar fissures. Care is taken to avoid cutting off perfusion and ventilation to the unresected parts of the lung lobe during staple resection of a deep-seated nodule. Should a particularly large wedge be excised (essentially a hemilobectomy), it may also be necessary to release the pulmonary ligament to ensure adequate filling of the pleural cavity by the lung after the operative procedure.
In some instances, a deeply seated lesion may not be amenable to simple wedge excision. The authors have in many cases resorted to using the precision cautery resection technique described by Perelman and published by Cooper and colleagues (1986). The resulting defect can be closed by endoscopic suturing. The new saline enhanced thermal sealing technology described earlier is also applicable here. Landreneau and co-workers (1992) have also described using a neodymium:yttrium-aluminum-garnet (Nd:YAG) laser to thin out the parenchyma overlying a deep nodule, bringing it closer to the surface for stapled resection.
The resected wedge can be retrieved through any of the VATS ports. The anterior port may need to be enlarged slightly to allow the extraction of a large wedge. For specimen retrieval, the ports must also be protected against possible tumour seeding.
Lung Cancer Staging
The practical aim of lung cancer staging is to identify those patients with advanced disease, excluding them from an unnecessary, noncurative major lung resection. Traditional methods of staging include imaging (such as by CT scanning and even PET scanning) and operative staging by mediastinoscopy or thoracotomy.
CT scanning is now an essential component of lung cancer staging but has a well-known inability to distinguish benign enlarged lymph nodes from malignant ones. Staples and associates (1988) reported that CT sensitivity for mediastinal lymphadenopathy in lung cancer is 79%, but specificity only 65%. CT is also inadequate in diagnosing malignant pleural effusions and in detecting small, flat pleural metastases. PET scanning has revolutionized lung cancer staging, with strong evidence proving its superiority to CT for mediastinal staging of non small cell lung cancer (NSCLC) as reported by Dwamena and co-workers (1999) in a metaanalysis of the use of either PET or CT in the 1990s. However, even PET scanning is not infallible it is often unable to differentiate between metastatic and inflammatory lung lesions (such as tuberculosis granulomata), or between pleural metastases and recent chest wounds, with absolute confidence.
Traditional operative staging by mediastinoscopy remains important and allows exploration of the anterosuperior mediastinal lymph node stations bilaterally. Nevertheless, mediastinoscopy cannot reach all lymph node stations (e.g., the postcarinal, pulmonary ligament, or aortopulmonary window nodes). There have been attempts at transesophageal ultrasound-guided needle biopsy of N2 station lymph nodes, but results so far have been unconvincing in our view, with the small sample sizes yielded giving relatively high rates of inconclusive diagnoses.
In comparison, VATS offers direct visual assessment of the entire pleural space (including lateral chest wall and mediastinal surfaces), detection of pulmonary metastases, evaluation of chest wall involvement by tumor, and exploration of every ipsilateral lymph node station, and it allows
P.322
generous biopsy specimens of suspected metastatic lesions. In our unit, VATS has essentially replaced anterior mediastinotomy for anteroposterior window lymph node biopsy.
Much evidence points to the usefulness of VATS in detecting pleural metastases. As early as 1976, Deslauriers and coauthors suggested that thoracoscopy can be performed at the same sitting as mediastinoscopy to exclude pleural metastasis, and indeed early efforts at using VATS in lung cancer focused on suspected malignant pleural effusion when thoracocentesis has not yielded positive cytology. In 1997, Asamura and colleagues used VATS to explore 116 patients with confirmed lung cancer. They found effusions in 53 patients (46.7%), of which five proved to be malignant effusions on cytologic examination. Four of these five patients did not undergo subsequent thoracotomy. Roviaro and co-workers (1995), in a series of 154 lung cancer patients undergoing VATS exploration, found 7 (5%) with evidence of pleural metastasis but without effusion. In 1996, we reported that the diagnostic accuracy for VATS determination of pleural metastases in prethoracotomy lung cancer staging can be as high as 100%. In our study, 3.3% of 63 patients with known potentially resectable lung cancer were found to be inoperable as a result of their VATS staging findings. From these and other studies, it would appear that VATS can detect a small but important proportion of patients with lung cancer who have pleural metastases. Lack of a clinically detectable effusion in a patient with lung cancer cannot preclude existence of pleural metastases, but where an effusion is present, the likelihood of malignant pleural deposits is considerable. Given that VATS is quick to perform and has low associated morbidity, the senior author (APCY) (1996c) routinely performs a VATS assessment of the pleura in all lung cancer patients before thoracotomy for intended curative resection.
Should the tumor directly invade the chest wall, VATS can help to evaluate any such invasion and guide the level of the thoracotomy and extent of chest wall resection for a resection of the tumor en bloc with the invaded chest wall. On the other hand, VATS evaluation of the proximal extension of the tumor has not been so widely reported, but one interesting new development is the use of VATS for intrapericardial examination to determine proximal involvement and resectability of very central (suspected T4) tumors. Loscertales and associates (2002) used VATS for lung cancer staging routinely in 620 patients, of which 27 were found to have pericardial involvement on VATS. In 12 of these patients, preoperative imaging did not identify the pericardial invasion. Each of those 27 patients underwent VATS intrapericardial exploration to assess the feasibility of intrapericardial lung resection, and 21 were found to have respectable disease.
Many studies have demonstrated the efficacy of VATS for lymph node staging in lung cancer. Caccavale and Lewis (1999) reported that in a series of 231 receiving VATS staging for known or suspected lung cancer, 18 were proved to have N2 lymph node metastases. In the 1997 study of 116 lung cancer patients by Asamura and co-workers, N2 nodal metastases were found using VATS in two patients. In a study by Sagawa and associates (2002), VATS lung resection was performed with hilar and mediastinal lymph node dissection for 29 clinically stage I lung cancer patients. At the completion of the curative VATS procedure, another surgeon performed a standard thoracotomy with complete systematic nodal dissection. It was found that on average the thoracotomy could only produce 2% to 3% more lymph node tissue that had been missed by the VATS dissection. VATS lymph node dissection in experienced hands is equivalent to that achieved by an open procedure.
In our practice, cervical mediastinoscopy still remains an essential staging tool for patients with primary lung cancer, and we use VATS as an adjunctive modality.
Mediastinal Disease
Many common pathologies can present as mediastinal masses; hence, the need for a tissue diagnosis is important (Table 18-2). Mediastinal masses can often undergo biopsy by percutaneous FNA or TruCut under radiologic imaging guidance. The use of ultrasound-guided transesophageal FNA biopsy of mediastinal lesions has been described. These approaches are unfortunately often limited by the small volumes of tissue resected. In particular, mediastinal lymphoma may be difficult to diagnose accurately from the small tissue samples yielded. Diagnostic radiologists may also be hesitant to biopsy deeper mediastinal lesions for
P.323
fear of injuring surrounding structures despite the imaging guidance.
Table 18-2. Common Pathologies Presenting as Mediastinal Masses | |
|---|---|
|
The role of operative biopsy in the mediastinum by traditional procedures (mediastinoscopy, anterior mediastinotomy, sternotomy, or thoracotomy) is discussed in detail elsewhere. Suffice it to say that these techniques all have potential drawbacks, including limited view and reach, access-related morbidity, and so on.
In contrast, VATS offers a panoramic view of the entire hemithorax, allowing better definition of the pathology and surrounding structures. It gives more generous biopsy specimens than percutaneous and transesophageal approaches, and greater surgical versatility. In addition, VATS can also allow for the complete excision of the lesion in the same sitting.
A large body of literature has been published detailing the diagnostic accuracy of VATS for mediastinal disease. Typically, the rates of a positive diagnosis of mediastinal lesions investigated by VATS have been reported as 85% to 100% by Kern (1993), Cirino (2000), and Chen (2001) and their colleagues. In 1994, Rendina and associates compared VATS with mediastinoscopy and anterior mediastinotomy and concluded that VATS generally could yield greater quantities of tissue for diagnosis for almost all mediastinal lesions resected. Gossot and coauthors (1996) compared 52 patients undergoing mediastinoscopy with 62 receiving VATS in a prospective study for mediastinal lesions requiring biopsy, finding equivalent diagnostic yields in both groups.
For biopsy of anterior mediastinal masses, a modification of the basic three-port VATS technique is used as described by the senior author (APCY) (1996d). Using this technique allows complete resection of the lesion if required.
The pericardium is also readily accessible by VATS from either the left or right side, employing the same three-port approach as above. The target pericardial lesion is typically resected by circumscription with sharp scissors or diathermy. Care is paid not to traumatize the underlying myocardium and to protect the phrenic nerve. Should the lesion prove malignant, and should a pericardial effusion be evident, a palliative pericardial window procedure can be performed in the same sitting.
Caution should be exercised when operating on a patient with signs of cardiac tamponade from a pericardial effusion. It is preferable to have this relieved by pericardiocentesis before induction of general anesthesia. Should the patient remain in very ill condition, or otherwise be unfit for one-lung ventilation, we advise against persevering with a VATS procedure and suggest that the pericardial surgery be performed through a parasternal anterior mediastinotomy or a subxiphoid approach, as reported by the senior author (APCY) and Ho (1995b). These can be done under local anesthesia.
There is growing interest and experience in the use of VATS for diagnosis in the posterior mediastinal compartment. Divisi and associates (1998) are among those reporting the use of diagnostic VATS for posterior mediastinal masses, including neurilemomas, paragangliomas, neuroepitheliomas, neurogenic sarcoma, and esophageal duplication. Dusmet and co-workers (1999) have suggested that VATS may give greater diagnostic yield than FNA techniques for the diagnosis of tuberculosis affecting the thoracic spine. Vanichkachorn and Vaccaro (2000) have also reviewed the possibility of using VATS in the diagnosis and treatment of thoracic intervertebral disc disease.
Chest Trauma
The use of thoracoscopy for chest trauma has been gradually established over the latter half of the 20th century. Branco first described the use of thoracoscopy to evaluate penetrating chest injuries as early as 1946. Jackson and Ferreira (1976), and later Feliciano (1992) and colleagues (1989), described the use of thoracoscopy for the diagnosis of diaphragmatic injury. Jones and coauthors (1981) used a rigid thoracoscope to assess and treat patients with continuing moderate hemorrhage following chest trauma. Liu and co-workers (1997) reported the successful use of VATS in safely assessing 50 chest trauma patients, diagnosing 19 unresolved hematomata, 13 pleural tears, 6 diaphragmatic tears, 5 actively bleeding intercostal vessels, 4 pulmonary lacerations, 1 traumatic chylothorax, and 1 posttraumatic empyema. Villavicencio and colleagues in 1999 performed a metaanalysis of the use of thoracoscopy in more than 500 chest trauma patients. It was found that thoracoscopy had a diagnostic accuracy of 98% for diaphragmatic injuries, and obviated the need for exploratory thoracotomy or laparotomy in 62% of trauma patients.
Although VATS has been used in many situations after chest trauma (Table 18-3), its most established diagnostic role in trauma patients remains in the assessment of diaphragmatic injuries. Madden and coauthors (1989) suggest that about 30% of all diaphragmatic injuries can be missed using a combination of chest radiography, CT scan, and diagnostic peritoneal lavage alone. However, using VATS, Uribe and associates (1994) could identify nine diaphragmatic injuries in 28 patients with thoracoabdominal penetrating injuries. Similarly, Spann and colleagues (1995) successfully detected diaphragmatic injuries in 8 of 26 patients with penetrating chest injuries using VATS. Nel and Warren (1994) reported a diagnostic sensitivity of 100% and a specificity of 90% when using VATS to specifically
P.324
look for diaphragmatic injury in 55 patients with left lower chest stab wounds. In the largest published series to date, Freeman and coauthors (2001) reported finding diaphragmatic injury in 60 (35%) of 171 patients undergoing VATS for penetrating chest trauma. Five independent risk factors for diaphragmatic injury after such trauma were identified that should call for VATS exploration: abnormal chest radiograph, associated intraabdominal injuries, high-velocity mechanism of injury, entrance wound inferior to the nipple line or the scapular tip, and right-sided entrance wound.
Table 18-3. Common Indications for Video-Assisted Thoracic Surgery after Chest Trauma | |
|---|---|
|
In the authors' practice, VATS is offered to all cases of penetrating chest injury in which the wound is shown to have penetrated into the pleural space, and the patient is hemodynamically stable. Pons and associates (2002) are among many who have reported favorably on the diagnostic value of VATS in the management of patients with penetrating chest injuries. However, should the patient become unstable or develop any of the Advanced Trauma Life Support (ATLS) criteria for immediate thoracotomy at any time, we would have no hesitation in abandoning the VATS and converting immediately to a standard thoracotomy. We always create new wounds for use as VATS ports. Using any existing trauma or chest drain wounds as ports can obscure or distract from injuries at or underlying the wound and can potentially lead to introduction of microbes from a dirty wound into the pleural cavity during instrumentation. Unless the initial findings call for immediate thoracotomy, we proceed with a three-port technique to explore all parts of the pleura, lung, and mediastinum. The entire VATS inspection takes no more than a few minutes and can give invaluable information guiding the further management of the trauma. In many cases, repair of injuries can be conducted by VATS, including endoscopic suturing of pleuropulmonary and diaphragmatic tears. Residual blood clots can be removed using sponge-holding forceps and wide-bore suction tubes. Should a thoracotomy prove necessary, the VATS findings can also help guide the level for the thoracotomy.
For blunt chest trauma, VATS is useful in evaluating a persistent air leakage or high drain output, an incompletely drained hemothorax, or a suspected diaphragmatic injury. Given the low morbidity of VATS, we have a very low threshold for offering VATS exploration in cases of blunt chest trauma, but again have even lower thresholds to convert to an open procedure should the patient's condition be unstable. Frame (1997) advocated VATS exploration for all patients suffering blunt torso trauma requiring abdominal exploration to exclude damage of the diaphragm or structures at or near it.
CONCLUSION
The diagnostic role of VATS has now been firmly established for many conditions such as indeterminate pleural effusions, diffuse lung infiltrates, and solitary lung nodules. As the safety and efficacy of VATS attract earlier referrals for biopsy in these conditions, patients stand to gain from the earlier establishment of a diagnosis. In other conditions, such as for staging of lung cancer, controversy still exists, and it may take a greater body of evidence before most clinicians become convinced of the role of VATS. For many surgeons, however, the potential for detecting unsuspected pleural metastases, ease of use, and low morbidity associated with VATS are already sufficient to warrant its routine use for all lung cancer cases.
Advancements in medical imaging modalities would certainly affect the patient selection process for VATS. Nonetheless, no imaging technique, however advanced, can provide a definitive histological diagnosis. On the other hand, although cytologic and histologic diagnoses could be provided by bronchoscopic, percutaneous, or transesophageal biopsies, these approaches tend to yield small specimens that are often inadequate for a detailed diagnosis. In comparison, VATS holds many key advantages. As experience is gained, it is anticipated that VATS will become the diagnostic tool of choice for increasingly more clinical situations.
REFERENCES
Allen MS, et al: Video-assisted thoracoscopic stapled wedge excision for indeterminate pulmonary nodules. J Thorac Cardiovasc Surg 106:1048, 1993.
Asamura H, et al: Thoracoscopic evaluation of histologically/cytologically proven or suspected lung cancer: a VATS exploration. Lung Cancer 16:183, 1997.
Ayed AK, Raghunathan R: Thoracoscopy versus open lung biopsy in the diagnosis of interstitial lung disease: a randomised controlled trial. J R Coll Surg Edinb 45:159, 2000.
Bensard DD, et al: Comparison of video-thoracoscopic lung biopsy to open lung biopsy in the diagnosis of interstitial lung disease. Chest 103: 765, 1993.
Boutin C, et al: La thoracoscopie dans le mesotheliome pleural. Interet diagnostique, prognostique et therapeutique. [Thoracoscopy in pleural mesothelioma. Diagnostic, prognostic and therapeutic interest.] Rev Fr Mal Respir 7:680, 1979.
Boutin C, et al: Thoracoscopy in malignant pleural effusions. Am Rev Respir Dis 124:588, 1981.
Braimbridge MV: Thoracoscopy: a historical perspective. In: Yim APC, et al (eds): Minimal Access Cardiothoracic Surgery. Philadelphia: WB Saunders, 2000.
Branco JMC: Thoracoscopy as a method of exploration in penetrating injuries of the thorax. Dis Chest 12:330, 1946.
Caccavale RJ, Lewis RJ: Video-assisted thoracic surgery as a diagnostic tool. In: Shields TW, et al (eds): General Thoracic Surgery. 5th Ed. Philadelphia: Lippincott Williams & Wilkins, 1999.
Canto A, et al: Thoracoscopy in the diagnosis of pleural effusion. Thorax 32:550, 1977.
Chechani V, Landreneau RJ, Shaikh SS: Open lung biopsy for diffuse infiltrative lung disease. Ann Thorac Surg 54:296, 1992.
Chen JS, et al: Video-assisted thoracoscopic surgery for the diagnosis of patients with hilar and mediastinal lymphadenopathy. J Formos Med Assoc 100:213, 2001.
Cirino LMI, et al: Diagnosis and treatment of mediastinal tumors by thoracoscopy. Chest 117:1787, 2000.
Collins TR, Sahn SA: Thoracocentesis. Clinical value, complications, technical problems, and patient experience. Chest 91:817, 1987.
Cooper JD, et al: Precision cautery excision of pulmonary lesions. Ann Thorac Surg 41:51, 1986.
Deslauriers J, et al: Mediastinopleuroscopy: a new approach to the diagnosis of intrathoracic diseases. Ann Thorac Surg 22:265, 1976.
Divisi D, et al: Diagnostic and therapeutic approaches for masses in the posterior mediastinum. Acta Biomed Ateneo Parmese 69:123, 1998.
P.325
Dusmet M, Halkic N, Corpataux JM: Video-assisted thoracic surgery diagnosis of thoracic spinal tuberculosis. Chest 116:1471, 1999.
Dwamena BA, et al: Metastases from non-small cell lung cancer: mediastinal staging in the 1990s meta-analytic comparison of PET and CT. Radiology 213:530, 1999.
Feliciano DV, et al: Delayed diagnosis of injuries to the diaphragm after penetrating wounds. J Trauma 28:1135, 1989.
Feliciano DV: The diagnostic and therapeutic approach to chest trauma. Semin Thorac Cardiovasc Surg 4:156, 1992.
Ferguson MB: Thoracoscopy for diagnosis of diffuse lung disease. Ann Thorac Surg 56:694, 1993.
Ferson PF, et al: Comparison of open versus thoracoscopic lung biopsy for diffuse infiltrative pulmonary disease. J Thorac Cardiovasc Surg 106: 194, 1993.
Ferson PF, Landreneau RJ: Thoracoscopic lung biopsy or open lung biopsy for interstitial lung disease. Chest Surg Clin North Am 8:749, 1998.
Flint A, et al: Influence of sample number and biopsy site on the histologic diagnosis of diffuse lung disease. Ann Thorac Surg 60:1605, 1995.
Frame SB: Thoracoscopy for trauma. Int Surg 82:223, 1997.
Freeman RK, et al: Indications for using video-assisted thoracoscopic surgery to diagnose diaphragmatic injuries after penetrating chest trauma. Ann Thorac Surg 72:342, 2001.
Gaensler EA, Carrington CB: Open biopsy for chronic diffuse infiltrative lung disease: clinical, roentgenographic, and physiological correlations in 502 patients. Ann Thorac Surg 30:411, 1980.
Goldberg-Kahn B, Healy JC, Bishop JW: The cost of diagnosis: a comparison of four different strategies in the workup of solitary radiographic lung lesions. Chest 111:870, 1997.
Goldsmith SJ, Kostakoglu L: Nuclear medicine imaging of lung cancer. Radiol Clin North Am 38:511, 2000.
Gossot D, et al: Mediastinoscopy vs. thoracoscopy for mediastinal biopsy: results of a prospective nonrandomized study. Chest 110:1328, 1996.
Grossebner MW, et al: Mesothelioma VATS biopsy and lung mobilization improves diagnosis and palliation. Eur J Cardiothorac Surg 16:619, 1999.
Hoksch B, Birken-Bertsch H, Mueller JM: Thoracoscopy before Jacobaeus. Ann Thorac Surg 74:1288, 2002.
Jackson AM, Ferreira AA: Thoracoscopy as an aid to the diagnosis of diaphragmatic injury in penetrating wounds to the left lower chest: a preliminary report. Injury 7:213, 1976.
Jacobeus HC: Ueber die Moglichkeit die Zystoskopie bei Untersuchung seroser Hohlungen anzuwenden. Munchen Med Wochenschr 57:2090, 1910.
Jacobeus HC: The cauterization of adhesions in artificial pneumothorax treatment of pulmonary tuberculosis under thoracoscopic control. Proc R Soc Med 16:45, 1923.
Jones JW, et al: Emergency thoracoscopy: a logical approach to chest trauma management. J Trauma 21:280, 1981.
Kadokura M, et al: Pathologic comparison of video-assisted thoracic surgical lung biopsy with traditional open lung biopsy. J Thorac Cardiovasc Surg 109:494, 1995.
Kern JA, et al: Thoracoscopic diagnosis and treatment of mediastinal masses. Ann Thorac Surg 56:92, 1993.
Kirsch CM: Cirrhotic hydrothorax and the law of unintended consequences. Chest 118:2, 2000.
Lachapelle KJ, Morin JE: Benefit of open lung biopsy in patients with respiratory failure. Can J Surg 38:316, 1995.
Landreneau RJ, et al: Thoracoscopic resection of 85 pulmonary lesions. Ann Thorac Surg 54:415, 1992.
Lazopoulos G, et al: Diagnostic mini-video assisted thoracic surgery. Effectiveness and accuracy of new generation 2.0 mm instruments. Surg Endosc 16:1793, 2002.
Light RW: Pleural Diseases. Philadelphia: Lea & Febiger, 1983.
Lillington GA: Management of solitary pulmonary nodules. Dis Mon 37:271, 1991.
Liu DW, et al: Video-assisted thoracic surgery in treatment of chest trauma. J Trauma 42:670, 1997.
Loscertales J, et al: Usefulness of videothoracoscopic intrapericardial examination of pulmonary vessels to identify resectable clinical T4 lung cancer. Ann Thorac Surg 73:1563, 2002.
Mack MJ, et al: Thoracoscopy for the diagnosis of the indeterminate solitary pulmonary nodule. Ann Thorac Surg 56:825, 1993.
Mack MJ: Localization of pulmonary nodules. In: Yim APC, et al (eds): Minimal Access Cardiothoracic Surgery. Philadelphia: WB Saunders, 2000.
Madden MR, et al: Occult diaphragmatic injury from stab wounds to the lower chest and abdomen. J Trauma 29:292, 1989.
Menzies R, Charbonneau M: Thoracoscopy for the diagnosis of pleural disease. Ann Intern Med 114:271, 1991.
Miller D, et al: Video-thoracoscopic wedge excision for diffuse interstitial lung disease. Chest 102(Suppl):169s, 1992.
Miller RR, et al: Lingular and right middle lobe biopsy in the assessment of diffuse lung disease. Ann Thorac Surg 44:269, 1987.
Mitruka S, et al: Diagnosing the indeterminate pulmonary nodule: percutaneous biopsy versus thoracoscopy. Surgery 118:676, 1995.
Morikawa T, et al: Availability of lobe-selective bronchial blockade for video-assisted thoracic surgery: an initial experience with three cases. Surg Endosc 16:327, 2002.
Murasugi M, et al: The role of video-assisted thoracoscopic surgery in the diagnosis of the small peripheral pulmonary nodule. Surg Endosc 15: 734, 2001.
Nel JM, Warren BL: Thoracoscopic evaluation of the diaphragm in patients with knife wounds of the left lower chest. Br J Surg 81:713, 1994.
Pego-Fernandes PM, et al: Pulmonary biopsy by video-assisted thoracic surgery: experience of 76 cases. S Am J Thorac Surg 2:47, 1998.
Pons F, et al: The role of videothoracoscopy in management of precordial thoracic penetrating injuries. Eur J Cardiothorac Surg 22:7, 2002.
Preventza O, Hui HZ, Hramiec J: Fast track video-assisted thoracic surgery. Am Surg 68:309, 2002.
Rao NV, et al: Needle biopsy of parietal pleura in 124 cases. Arch Intern Med 115:34, 1965.
Ravini M, et al: Changing strategies of lung biopsies in diffuse lung diseases: the impact of video-assisted thoracoscopy. Eur Respir J 11:99, 1998.
Rena 0, et al: Videothoracoscopic lung biopsy in the diagnosis of interstitial lung disease. Eur J Cardiothorac Surg 16:624, 1999.
Rendina EA, et al: Comparative merits of thoracoscopy, mediastinoscopy, and mediastinotomy for mediastinal biopsy. Ann Thorac Surg 57:992, 1994.
Roviaro G, et al: Videothoracoscopic staging and treatment of lung cancer. Ann Thorac Surg 59:971, 1995.
Russo L, et al: Early chest tube removal after video-assisted thoracoscopic wedge resection of the lung. Ann Thorac Surg 66:1751, 1998.
Sagawa M, et al: A prospective trial of systematic nodal dissection for lung cancer by video-assisted thoracic surgery: can it be perfect? Ann Thorac Surg 73:900, 2002.
Sgro M, et al: Thoracoscopy in the diagnosis of pleural mesothelioma. Chir Ital 43:95, 1991.
Shantaveerappa H, et al: Intervention in patients with pneumothorax immediately following CT-guided fine needle aspiration of pulmonary nodules. Med Sci Monit 8:CR401, 2002.
Spann JC, Nwariaku FE, Wait M: Evaluation of video-assisted thoracoscopic surgery in the diagnosis of diaphragmatic injuries. Am J Surg 170:628, 1995.
Stamenkovic SA, et al: Are single targeted VAT lung biopsies accurate and cost-effective for interstitial lung disease? Presented at the 16th Annual Meeting of the European Association for Cardio-Thoracic Surgery, Monaco, September 22 25, 2002[abst].
Staples CA, et al: Mediastinal nodes in bronchogenic carcinoma: comparison between CT and mediastinoscopy. Radiology 167:367, 1988.
Suzuki K, et al: Video-assisted thoracoscopic surgery for small indeterminate pulmonary nodules: indications for preoperative marking. Chest 115:563, 1999.
Takahashi M, et al: Selective lobar-bronchial blocking for pediatric video-assisted thoracic surgery. Anesthesiology 94:170, 2001.
Tomlinson JR, Sahn SA: Invasive procedures in the diagnosis of pleural disease. Semin Respir Med 9:30, 1987.
Uribe RA, et al: A prospective evaluation of thoracoscopy for the diagnosis of penetrating thoracoabdominal trauma. J Trauma 37:650, 1994.
Vanichkachorn JS, Vaccaro AR: Thoracic disk disease: diagnosis and treatment. J Am Acad Orthop Surg 8:159, 2000.
Villavicencio RT, Aucar JA, Wall MJ Jr: Analysis of thoracoscopy in trauma. Surg Endosc 13:3, 1999.
Wakabayashi A: Expanded applications of diagnostic and therapeutic thoracoscopy. J Thorac Cardiovasc Surg 102:721, 1991.
Warner DO, Warner MA, Divertie MB: Open lung biopsy in patients with diffuse pulmonary infiltrates and acute respiratory failure. Am Rev Respir Dis 137:90, 1988.
Weissberg D, Kaufman M, Schwecher I: Pleuroscopy in clinical evaluation and staging of lung cancer. Poumon Coeur 37:241, 1981.
Westcott JL: Direct percutaneous needle aspiration of localized pulmonary lesions. Radiology 137(1 Pt 1):31, 1980.
P.326
Wetstein L: Sensitivity and specificity of lingular segmental biopsies of the lung. Chest 90:383, 1986.
Worsley DM, et al: Pulmonary nodules: differential diagnosis using 18F-fluorodeoxyglucose single-photon emission computed tomography. AJR Am J Roentgenol 168:771, 1997.
Yim APC: Minimizing chest wall trauma in video-assisted thoracic surgery. J Thorac Cardiovasc Surg 109:1255, 1995.
Yim APC: Improved technique for fiberoptic pleuroscopy [Letter]. Chest 109:1667, 1996a.
Yim APC: The role of video assisted thoracoscopic surgery in the management of pulmonary tuberculosis. Chest 110:829, 1996b.
Yim APC: Routine video-assisted thoracoscopy prior to thoracotomy. Chest 109:1099, 1996c.
Yim APC: Video-assisted thoracoscopic resection of anterior mediastinal masses. Int Surg 81:350, 1996d.
Yim APC: Paradigm shift in the management of empyema [Editorial]. Chest 115:611, 1999a.
Yim APC: Thoracoscopy and video-assisted thoracic surgery. Curr Opin Pulm Med 5:256, 1999b.
Yim APC, Ho JKS: Digital localization of peripheral lung nodules for video assisted thoracic surgery [letter]. Chest 107:886, 1995a.
Yim APC, Ho JKS: Video-assisted subxiphoid pericardiectomy. J Laparoendosc Surg 5:193, 1995b.
Yim APC, et al: Thoracoscopic management of malignant pleural effusions. Chest 109:1234, 1996a.
Yim APC, et al: Thoracoscopic talc insufflation versus talc slurry for symptomatic malignant pleural effusion. Ann Thorac Surg 62:1655, 1996b.
Yim APC, et al: Thoracoscopic operations on reoperated chests. Ann Thorac Surg 65:328, 1998.
Yim APC, et al (eds): Minimal Access Cardiothoracic Surgery. Philadelphia: WB Saunders, 2000a.
Yim APC, et al: Needlescopic VATS for palmar hyperhidrosis. Eur J Cardiothorac Surg 17:697, 2000b.
Yim APC, et al: A new technological approach to nonanatomical pulmonary resection: saline enhanced thermal sealing. Ann Thorac Surg 74: 1671, 2002a.
Yim APC, et al: A simple maneuver to detect air leak on-table following Needlescopic VATS Brief communication]. J Thorac Cardiovasc Surg 124:1029, 2002b.
Yim APC, et al: Pleuroperitoneal fistula. Ann Thorac Surg 73.1327, 2002c.
*The authors wish to thank Dr. KM Ho of the Department of Anesthesiology, North District Hospital, Hong Kong for allowing us to present his novel technique for selective lobar lung collapse using a nasogastric feeding tube. This technique has yet to be published but is already being used by Dr. Ho for selected patients undergoing VATS procedures performed by the authors.
EAN: 2147483647
Pages: 203
- Chapter II Information Search on the Internet: A Causal Model
- Chapter VII Objective and Perceived Complexity and Their Impacts on Internet Communication
- Chapter X Converting Browsers to Buyers: Key Considerations in Designing Business-to-Consumer Web Sites
- Chapter XIII Shopping Agent Web Sites: A Comparative Shopping Environment
- Chapter XVIII Web Systems Design, Litigation, and Online Consumer Behavior