Videothoracoscopy in the diagnosis and treatment of lung and ... medica Lituanica/0504...VATS...

Dainius Amerigas Piðèikas, Saulius Cicënas, Arnoldas Krasauskas30

Objective. To evaluate the efficacy of videothoracoscopic operations in the diagno-sis and treatment of lung and pleural diseases, complications and outcome.

Materials and methods. In 1997–2004, at the Department of Thoracic Surgery andOncology of Institute of Oncology, Vilnius University, 322 operations were performedusing videothoracoscopic devices of them 86 were resections: 6 (7%) lobectomies, 9(10.5%) wedge resections of lungs tissue due to I°. NSCLC performed for the elderly,30 (35%) metastases removal, 17 (19.8%) hamartomas, 3 (3.5%) pericardial cystecto-mies, 7 (8%) sympatectomies, 5 (5.8%) intrathoracal lipomectomies, 2 (2.4%) calcifi-cate removal, 3 (3.5%) resections of pericardium. 236 diagnostic procedures wereperformed in patients with various lung and pleural diseases: 76 (32%) biopsies oflungs and pleural tissue and 160 (68%) biopsies with chemopleurodesis. During tho-racoscopies we confirmed the diagnoses morphologically: tumour extention 41% (90pts from 219), pleural mesothelioma 19% (42 pts), inflammation 27% (59 pts), tuber-culosis 5% (11 pts), benign tumour 8% (17 pts). We performed chemopleurodesis inmesothelioma – 18 (11%) pts, malignant lesion – 69 (43%) pts, benign pleural effusion– 51 (32%) pts, TBC pleuritis – 11 (7%) pts, chylothorax – 11 (7%) pts.

Results. From the oncological point of view, videothoracoscopic operations are con-firmed. These operations shorten hospitalisation and combined treatment starts earlier.The mean period of hospitalization is 5 days. The complication rate was 13.7%: 32 casesof (10%) postoperative pneumonia, 8 (2.5%) cases of short-lasting pneumothorax, 2(0.6%) bleedings, 1 (0.3%) pleural empyema, 1 (0.3%) drop of the lung. We had noperioperative mortality. One patient (0.32%) died. All other patients (99%) recovered.Pleurodesis by talc insufflation (also known as talc poudrage) results in short- and long-term success (92%, 147 pts from 160). After resection, the margins were free of tumorinvasion. The diagnostic efficiency of thoracoscopy was 97% (322 of 333 cases).

Conclusions. VATS surgery is an effective and safe diagnostic and treatment met-hod for lung and pleural diseases. The diagnoses were confirmed in 93% of cases.Sometimes VATS surgery is the only way to remove tumours, and it shortens hospitalstay to 5 days. This method should be used for elderly patients with limited pulmonaryfunction (FEV1 < 1.0 litre, or <35% predicted; DLCO <40%, age >75 years; noendobronchial lesions) or for patients with significant co-morbid diseases. Early stageNSCLC may be effectively treated by anatomic resection with a good two year survival(83%, 5 pts from 6). The use of VATS techniques for wedge resection may be neededin highly selected patients such as those with a poor lung function and co-morbiddiseases, or those with clinical T1N0 or T2N0 disease in whom a muscle sparingthoracotomy carries more risk than VATS. After this resection the two-year survivalwas 80% (8pts from 10). Insufflation of talc powder during thoracoscopy is the bestconservative method of pleurodesis in malignant and recurrent benign effusions, inc-luding chylothorax. Success rate was 92% (147 pts from 160).

Key words: VATS, biopsy of lungs tissue and pleura, wedge resections, lobectomy,chempleurodesis

Dainius Amerigas Piðèikas,

Saulius Cicënas,

Arnoldas Krasauskas

Vilnius University Institute ofOncology, Department of ThoracicSurgery and Oncology, Lithuania

Videothoracoscopy in the diagnosis and treatment oflung and pleural diseases

ACTA MEDICA LITUANICA. 2005. VOLUME 12 No. 4. P. 30–37© Lietuvos mokslø akademija, 2005© Lietuvos mokslø akademijos leidykla, 2005

Adress for correspondence: Dainius Amerigas Piðèikas, Vilnius University Institute of Oncology, Thoracic SurgeryDepartment, Santariskiø 1, LT-08660 Vilnius, Lithuania. Tel.: +370 5 278 67 64. E-mail: [email protected]

VATS suregery in treatment of lung and pleural diseases 31

INTRODUCTION

Methods of clinical minimal invasive surgery appea-red in the 20th century. H. C. Jacobeus in 1910used a cystoscope to observe the pleural cavity (1).VATS surgery flowers in Europe after treatment ofpneumothorax for TB patients, lung and pleural ma-lignant deseases and empyema, stopping cancer spre-ad into the pleural space (2). From 1960, due tosuccessfull conservative treatment of TB patients,VATS surgery was forgotten. Some centres in Euro-pe used VATS for the diagnosis and treatment ofpleural deseases (3). From 1990, with the introduc-tion of fibrooptic cables in thoracic surgery, manu-facturing anesthesia devices, creating new endosutu-re staplers, VATS surgery was renovated and manyoperations could be done with VATS.

Thoracoscopy is today primarily a diagnostic pro-cedure, but it can also be applied for therapeuticpurposes. Pleural effusions are by far the leadingindication for medical thoracoscopy both for diagno-sis, mainly in exudates of unknown etiology, for sta-ging diffuse malignant mesothelioma or lung cancer,and for treatment by talc pleurodesis malignant orother recurent effusions, or in cases of empyema.Spontaneous pneumothorax for staging and, in stageI and II, for local treatment is also an excellent in-dication. For those who are familiar with the tech-nique, other (mainly diagnostic) indications are biop-sies from the diaphragm, the lung, the mediastinumand the pericardium. In addition, medical thoraco-scopy offers a remarkable tool for research as a “goldstandard” in the study of pleural effusions.

Due to technical improvements and a trend to-wards less invasive procedures, thoracoscopy was re-discovered by thoracic surgeons at the beginning ofthis decade, and named “surgical” thoracoscopy,which is more precisely known as video-assisted tho-racic surgery (VATS). This revival has also suppor-ted the introduction of “medical” thoracoscopy intothe scope of respiratory physicians, particularly inthe USA where, according to a national survey in1994, already more than 5% of all pulmonologistswere applying medical thoracoscopy.

In 1997, VATS surgery was introduced at the De-partament of Thoracic Surgery of Institute of Onco-logy, Vilnius University. Our objective was to evalu-ate the efficacy of videothoracoscopic operations inthe diagnosis and treatment of lung and pleural di-seases, complication rates, outcome.

MATERIALS AND METHODS

In 1997–2004 at the Vilnius University Institute ofOncology we performed 322 videothoracoscopies (Fig.1).

Preoperative evaluation included chest radiogra-phy, thoracentesis (when indicated), respiratory func-

tion tests, and ECG. Flexible bronchoscopy and chestCT were performed when clinically indicated.

Thoracoscopy is usually performed through oneor several small, <2-cm skin incisions made alongthe intercostal spaces. Patients are placed in the la-teral decubitus position, involved side up, althoughsome procedures, such as thoracic sympathectomy,are performed with patients in the supine position.Pleural trocars can also be safely placed in the axil-la, so that axillary thoracoscopy can potentially pre-cede an axillary toracotomy. We used general anest-hesia with single- or double-lumen endotracheal in-tubation performed in an operating suite. Many pro-cedures limited to removal of pleural fluid, visualiza-tion, and biopsy of parietal pleura can be performedthrough a single skin incision made in approximatelythe fifth to seventh intercostal space along the late-ral chest wall of the involved hemithorax. When a 5-to 10-mm pleural trocar and cannula are insertedthrough the incision, the parietal pleura, diaphragm,and lung are well visualized. Pleural fluid evacuatedand parietal pleural biopsy specimens are obtainedfrom both normal- and abnormal-appearing areas. Achest tube is placed through incision site and con-nected to a suction device, and the lung is gentlyreexpanded.

The mean age of the patients was 61 ± 15 years.We have performed 86 resections and 236 diagnosticprocedures in patients with various lung and pleuraldiseases, which included 76 (32%) biopsies of pleuratissue and 160 (68%) biopsies with chemopleurodesis.

The endoscopic view of a metastatic pleural cavityand endoscopic pleural biopsy are shown in Fig. 2.

Removed pleural metastases according to prima-ry tumour site are characterized in Fig. 3.

The technical feasibility of video-assisted lobecto-my or thoracoscopic lobectomy has been aggresivelyassessed and confirmed in recent years. However, toadequately assess the value of this surgical technique,its feasibility also must be evaluated in more compro-mised patients, such as those with poor pulmonaryreserve and the eldery.

For 6 (7%) pts were performed lobectomies: 2upper and 4 lower. Four patients had IA – T1N0squamous cell CA and two patients had IB – T2N0

2637

40 35

48 4547 44

0

1 0

2 0

3 0

4 0

5 0

199 7 1 9 98 1 9 99 200 0 2 0 01 2 0 02 2 0 03 2 0 04

Fig. 1. The number of videothoracoseopies performed atVilnius University Institute of Oncology, 1997–2004


adenoCA. Lobectomy was performed with anatomicindividual ligation and separation of pulmonary veins,arteries, interlobar fissures, and bronchus with a stap-ler. The procedure was performed in the followingorder of stapling or ligation and division of anato-mic structures: for upper lobectomy (1) supperiorpulmonary vein; (2) superior trunk of the pulmonaryartery; (3) interlobar division; and (4) upper lobe

bronchus; for lower lo-bectomy (1) interlobar di-vision; (2) basal pulmo-nary artery (with separa-te ligation of A6); (3) lo-wer lobe bronchus; (4)interlobar fissures; (5) in-ferior pulmonary vein;and (6) pulmonary liga-ment. We resected allidentifiable nodes in theipsilateral thorax for ac-curate pathologic staging

to ensure an appropriate postoperative therapy. Thesubcarinal and the tracheal bifurcation were remo-ved to ensure an adequate resection of these nodes.

For patients with poor pulmonary reserve and theeldery we performed, 9 (10.5%) wedge resections oflung tissue to I°. NSCLC (T1 adenocarcinoma andT2 squamous cell carcinoma).

The lungs are the second most frequent site ofmetastases and often the only location of metastaticdisease. Most pulmonary metastases are located in thelung periphery and are immediately subpleural. Thislocation makes them particularly amenable to VATSresection. We removed lung metastases for 30 (35%)pts from primary sites (2 pts had double melastases):4 pts uterus carcinoma, 18 pts kidney carcinoma, 6pts breast carcinoma, 2 pts lung adenocarcinoma.VATS parenchymal-sparing wedge resection was per-formed with an endoscopic stapler. The endoscopicview of lung metastasis removal is shown in Fig. 4.

In cases of pleural effusion, we suggest that thefluid should not be evacuated just before the opera-tion. The patients with pleural effusion tolerated theprocedure extremely well, because they were used tofunctioning with a partial lung collapse. We used 4–8 g sterile talc powder which was blown graduallyon expanding the lung. The diseases for which weperformed pleurodesis and the diagnoses during tho-

Fig. 2. Endoscopic view of metastatic pleural cavity and endoscopic pleural biopsy

0 5 1 0 15 2 0 2 5 3 0 3 5 40 4 5

Uterus

Urinary bladder

Ovarian

Breast

Kidney

Lung

Fig. 3. Pleural metastases according to primary tumour

Fig. 4. Endoscopic view of lung metastasis removal


ments with endoscopic staplers or using the endos-copic suture technique were removed (Fig. 8).

For 5 (5.8%) pts we performed intrathoracal li-pomectomies. For their radiological and endoscopicview, see Fig. 9.

Seven (8%) sympatectomies were performed forpatients with Raynaud disease. In 6 (86%) patientsthere were no recurrences. For 7 (8%) pts resectionsof pericardium (5 cases were malignant wet pericar-ditis and 2 benignum pericarditis) were performed.Three (3.5%) pericardial cystectomies were perfor-med with electrocoagulation. All patients recovered.The endoscopic view of pericardium and pericardialcyst resection is shown in Figs. 10 and 11.

Postoperatively, a chest radiograph was obtaineddaily to ensure full lung expansion and to check forany pneumothorax or residual effusion. The intercos-tal underwater seal drainage was generally under suc-

tion for 24 to 48 h, and it wasremoved the day after the proce-dure or when the drainage was<100 ml/d.

RESULTS

After lung tissue wedge resec-tions all margins of tissue were“free” from tumours. After lo-bectomies, there were no meta-stases in removed lymph nodes(histological). In all 236 diagnos-tic procedures which were per-formed in patients with variouslung and pleura diseases thediagnosis was confirmed histo-

logically. The mean period of hospitalization aftervideothoracoscopies was 5 days (8 ± 3). Most ex-perts agree that when the initial evaluation of apleural effusion is nondiagnostic, especially whenneoplastic disease is suspected, thoracoscopic explo-

11%

32%

43%7%

7%

Mesothelioma Pleural effusionMalignant lesion Accumulation of lymphTBC pleuritis

Fig. 5. Diseases for which pleurodesis was performed

Extended tumour41%

Ple ural me s othe lioma

19%

Inflammation27%

Tuberculos is5%

Be nign tumour8%

Fig. 6. Clinical diagnoses confirmed by pathologist

Fig. 7. Endoscopic view of pleurodesis with sterile talc powder

racoscopies confirmed morphologically are shown inFigs. 5 and 6. The endoscopic view of pleurodesiswith sterile talc powder is shown in Fig. 7.

For 17 (19.8%) pts we removed hamartomas in 2(2.4%) pts calcificate, localised in marginal lung seg-


ration and parietal pleural biopsy should be consi-dered. The diagnostic accuracy of thoracoscopy isbetween 90 and 100%, compared with an approxi-mate sensitivity of 44% for closer needle pleuralbiopsy and 62% for fluid cytology; false negativesoccur most frequently in cases of early malignantmesothelioma. If the patient has a malignancy andnegative cytology on thoracocentesis, thoracoscopyis preferred over closer needle pleural biopsy, be-cause it will establish the diagnosis in >93% (219

pts from 236) of cases.The value of diagnosticmethods is shown inFig. 12.

In addition to diag-nosis, an important indi-cation for thoracoscopyin patients with malig-nant pleural effusions ispleurodesis. Completeevacuation of pleuralfluid, maximization oflung expandability by re-

moving adhesions, and pleurodesis by talc insuffla-tion (also known as talc poudrage) result in short-and long-term-success (92%, 147 pts from 160). Af-ter one year no pleural effusions were observed. Thedistribution of sterile, asbestos-free talc powder onall pleural surfaces is confirmed by thoracoscopic vi-sualiation. Following pleurodesis, low-grade feversshould be expected in up to 30% of patients, andhospitalization duration averages to 4.8 days. Pleuro-desis can also be achieved by pleurectomy using a

Fig. 8. Endoscopic hamartoma removal Fig. 9. Radiological and endoscopic view of intrathoracallipoma

Fig. 10. Endoscopic view of pericardium resectionFig. 11. View of pericardial cyst

0 10 20 30 40 50 60 70 80 90 100

Videothoracoscop y

Pleural biop s y

Cito logy

Fig. 12. The value of diagnostic methods


standard dissection technique or hydrodissection. Forrecurrent pleural effusions of benign etiology, theresults are usually excellent when talc is used, withsuccess rates varying from 65 to >90%.

The diagnostic efficiency of thoracoscopy was 97%(322 of 333 cases). In five cases thoracoscopy wasfollowed by thoracotomy because of extensive adhe-sions between the two pleural leaves. In six casesthere was bleeding.

The complication rate was 13.7% (Fig. 13). Wehad the following complications: 32 (10%) patientsdeveloped postoperative basal pneumonia (due to alow patients activity), 8 (2.5%) patients had a shortlasting pneumothorax (due to air leakage throughmechanical sutures), because emphysematous chan-ges in the lung parenchyma in elderly patients canmake mechanical stapling difficult and prolong po-stoperative air leakage. Two (0.6%) patients showedbleeding, 1 (0.3%) patient had pleural empyema and1 (0.3%) drop of the lung.

We had no perioperative mortality in our series of322 videothoracoscopic operations. One patient(0.32%) died on the 21st postoperative day becauseof empyema and later contralateral pneumonia. Allother patients (>99%) recovered.

DISCUSSION

Many literature sources mention that radiologicaldiagnostics is not informative enough (4). The mainmethod of diagnostics is still lung and pleural biopsyand morphological diagnosis confirmation (5). UsingVATS, we could easily diagnose different pleural andlung diseases. J. Ginsberg, M. Goldberg in 1989 wroteabout VATS treatment of lung and pleural diseases.They indicated that this is a reliable and safe methodof diagnostics and treatment: with a 89% sensitivityand 100% indicated morphological diagnosis. Authorsunder live safety of VATS and complications ratewere 5–10% of all cases (6). This method should beused for elderly patients with limited pulmonary func-tion (FEV1 < 1.0 litre, or <35% predicted; DLCO<40%, age >75 years; no endobronchial lesions) orin patients with a significant co-morbid disease (7,8). Our results show that in 322 VATS surgery ca-ses, the complication rate was 13%, the diagnosiswas confirmed in 93% of cases. VATS surgery foundits place in treatment and diagnosis of pleural andlung diseases. VATS wedge resection for treatmentof non-small cell lung carcinoma (NSCLC), while not

specifically contraindicated,must be justified for the indivi-dual patient and may be con-traindicated in the psychologi-cally fit individual. Segmentec-tomy or wedge resection havebeen proposed for NSCLC. Inour cases, the two-year survival

after anatomic resection was 83% (5 pts from 6),and after wedge resection 80% (8 pts from 10). TheLung Cancer Study Group conducted a prospectivemulti-institutional trial comparing limited resectionwith lobectomy for patients with peripheral T1N0NSCLC (9). Both surgical techniques were perfor-med open, under direct vision. In limited resectionpatients, recurrence rates were increased, with localrecurrence rates triple that of the lobectomy group,and a worse survival: a 30% increase in overall de-ath rate and 50% in death with cancer. Limited pul-monary resection for NSCLC did not improve mor-bidity, mortality, or postoperative functions. With highlocal / regional recurrence rates and the higher de-ath rates with limited resection, lobectomy must beconsidered the standard approach for patients withperipherical T1N0 NSCLC. Therefore, the standardoperative approach for patients with a T1 or T2NSCLC remains thoracotomy, anatomic resection,and mediastinal lymph node staging / dissection. Theincision, whether open (standard) or closed, shouldnot compromise the surgeon’s ability to perform theneeded operation completely and safely (10). Overthe past 20 years, minimally invasive surgery techni-ques have been applied for the diagnosis, staging,and treatment of thoracic diseases (11, 12).

In metastatic pleural effusions, biopsies of the vis-ceral and diaphragmatic pleura are only possible un-der direct vision. Since the chest wall pleura is fre-quently (approximately in 30% of cases) not invol-ved, it is impossible in these cases to provide a diag-nosis by blind needle biopsy (13). Furthermore, be-cause of the large size of biopsies obtained at tho-racoscopy it may be much easier for the pathologistto suggest the organ from which the tumour origina-tes (14). In metastatic breast cancer, tissue can beobtained for determination of hormone receptors(15). Even with lymphomas, the diagnostic yield aswell as the morphological classification is improved.(16).

Therapeutically, several litres of fluid can be com-pletely and immediately removed during thoracosco-py with little risk of pulmonary oedema, because ofimmediate equilibration of pressures by direct en-trance of air into the pleural space (17). Furthermo-re, the re-expansion potential of the lung can beevaluated by visual inspection. In addition, the ex-tent of intrapleural tumour spread can be describedusing a scoring system which correlates quite closewith survival (18). The main advantage is certainly

86,3 13,7

W ithout complications C omplications

Fig. 13. Complication rate after VATS


that talc poudrage can be performed during medicalthoracoscopy, which today is the best conservativeoption for pleurodesis (19, 20), possibly because avery even distribution of the talc powder to all partsof the pleura is achieved. It has also been shown tobe very efficient in the treatment of lymphomatouschylothorax (21).

CONCLUSIONS

1. VATS surgery is an effective and safe method ofdiagnostics and treatment for lung and pleural dise-ases. The diagnoses were proved in 93% of cases.

2. Sometimes VATS surgery is the only way toremove tumours, and it shortens hospital stay till 5days. This method should be used for elderly pa-tients with a limited pulmonary function (FEV1 <1.0 litre, or <35% predicted; DLCO <40%, age >75years; no endobronchial lesions) or patients with sig-nificant co-morbid diseases.

3. Early stage NSCLC may be effectively treatedby anatomic resection with a good two-year survival(83%, or 5 from 6 patients).

4. The use of VATS techniques for wedge resec-tion may be needed in highly selected patients suchas those with a poor physiological status (poor lungfunction, co-morbid diseases) or those with clinicalT1N0 or T2N0 disease in whom a muscle sparingthoracotomy carries more risk than VATS. After thisresections, the two-year survival was 80% (8 pts from10).

5. The insufflation of talc powder during thora-coscopy is the best conservative method of pleuro-desis in malignant and recurrent benign effusions,including chylothorax. The success rate was 92% (in147 pts from 160).

Received 16 June 2005Accepted 18 October 2005

References

1. Jacobaeus HC. Über die Möglichkeit der Zystoskopis-chen Untersuchung Serosser hohlunger enzuwenden.München Med Wochenschr 1910; 40: 2090.

2. Coba F. Atlas Thoracoscopicon. Heidelberg: Mailand,Springer and Kupfer, 1928.

3. Boutin C, Viallat JR, Cargnini P, Farisse P. Thoracos-copy and malignant pleural effusions. Am Rev RespirDis 1981: 124: 588–92.

4. Shields TW ed. General Thoracic Surgery. Baltimore:Wiliams & Wilkins, 1994.

5. Hazelrigg SR, Nuncshuk SK, Cicero J. Video-assistedThoracic Surgery Study Group, Video-assisted thoracicsurgery study data. Ann Thorac Surg 1993; 56: 1039–44.

6. Ginsberg RJ, Rice TW, Goldber M, Waters PF. Exten-ded cervical mediastinoscopy and VATS: a single sta-ging procedure for bronchogenic carcinoma of the left

upper lobe. J Thorac Cardiovasc Surg 1987; 94: 673–6.

7. Miller JI, Jr. VATS method in elderly patients. AnnThorac Surg 1993; 56: 769–71.

8. Shennib HA et al. Videothoracoscopy possibilieties forpatients with limited pulmonary function. Ann Surg1993; 218: 555–60.

9. Ginsberg RJ et al. (Lung Cancer Study Group). Aprospective multi-institutional trial. Ann Thorac Surg1995; 60: 615–23.

10. Yim AP et al. Videothoracoscopy or the standart ope-rative approach for the patient with a T1 or T2NSCLC. Chest 1996; 109: 13–7.

11. Naruke T et al. VATS and treatment of thoracic dise-ases. Ann Thorac Surg 1993; 56: 661–3.

12. Hau T et al. Minimally invasive surgery techniques forthe diagnosis and staging. Eur I Surg 1996; 162: 23–8.

13. Canto A, Rivas J, Saumench J, Morera R, Moya J.Points to consider when choosing a biopsy method incases of pleurisy of unknown origin. Chest 1983; 84:176–9.

14. Boutin C, Viallat JR, Cargnino P, Farisse P. Thoracos-copy in malignant pleural effusions. Am Rev RespirDis 1981; 124: 588–92.

15. Levine MN, Young JE, Ryan ED, Newhouse MT. Pleu-ral effusion in breast cancer. Thoracoscopy for hormo-ne receptor determination. Cancer 1986; 57: 324–7.

16. Celikoglu F, Teirstein AS, Krellenstein DJ, StrauchenJA. Pleural effusion in non-Hodgkin’s lymphoma. Chest1992; 101: 1357–60.

17. Brandth HJ, Loddenkemper R, Mai J. Atlas of Diag-nostic Thoracoscopy. New York, Thieme Stuttgart, Thie-me Inc., 1985.

18. Sanchez-Armengol A, Rodriguez-Panadero F. Survivaland talc pleurodesis in metastatic pleural carcinoma,revisited. Report of 125 cases. Chest 1993; 104:1482–5.

19. Kennedy L, Sahn SA. Talc pleurodesis for the treat-ment of pneumothorax and pleural effusion. Chest 1994;106: 1215–22.

20. Rodriguez-Panadero F, Antony VB. Pleurodesis. Stateof the art. Eur Pespir J 1997; 10: 1648–54.

21. Mares CC, Mathur PN. Thoracoscopic tale pleurodesisfor lymphoma induced chylothorax, a case series oftwenty two treated hemithoraces in eighteen patients.Am J Respir Crit Care Med 1997; 155: A481.

Dainius Amerigas Piðèikas, Saulius Cicënas,Arnoldas Krasauskas

VAIZDO TORAKOSKOPIJOS GALIMYBËSDIAGNOZUOJANT BEI GYDANT PLAUÈIØ IRPLEUROS LIGAS

S a n t r a u k aTikslas. Ávertinti vaizdo torakoskopiniø operacijø galimybesnustatant ir gydant plauèiø, pleuros ligas ir komplikacijas.

Medþiaga ir metodai. 1997–2004 m. Vilniaus universite-to Onkologijos instituto Torakalinës chirurgijos ir onkologi-


jos skyriuje naudojant vaizdo torakoskopà atliktos 322 ope-racijos. Ið jø 86 rezekcijos: 6 (7%) lobektomijos, 9 (10,5%)kylinës plauèio rezekcijos dël pirmos stadijos NSLPV senyvoamþiaus ligoniams, 30 (35%) ligoniø paðalintos metastazës,17 (19,8%) paðalintos hamartomos, 3 (3,5%) – perikardocistos, 7 (8%) – simpatektomijos, 7 (8%) – pleuros ertmëslipomos, 2 (2,4%) paðalinti kalcifikatai, 3 (3,5%) – perikar-do rezekcijos. Atliktos 236 diagnostinës procedûros ligo-niams, sergantiems ávairiomis plauèiø ir pleuros ligomis: 76(32%) – plaèiø ir pleuros audiniø biopsijos ir 160 (68%) –biopsijos su pleurodeze. Vaizdo torakoskopiniu bûdu mor-fologiðkai patvirtinome ðias ligas: iðplitæs navikinis procesas– 41% (90 ið 219), pleuros mezotelioma – 19% (42), uþde-giminës ligos – 27% (59), tuberkuliozë – 5% (11), nepikty-biniai augliai – 8% (17). Buvo atliktos pleurodezës ligo-niams, sergantiems: mezotelioma – 18 (11%), piktybiniupleuritu – 69 (43%), áprastu pleuritu – 51 (32%), TBCpleuritu – 11 (7%), dël limfos kaupimosi – 11 (7%).

Rezultatai. Onkologiniu poþiûriu vaizdo torakoskopinësoperacijos yra tikslingos, nes trumpina hospitalizacijos laikàir leidþia greièiau pradëti kombinuotà gydymà. Vidutinishospitalizacijos laikas – 5 dienos. Komplikacijø daþnis –13,7%. Stebëjome ðias komplikacijas: 32 (10%) pooperaci-nës pneumonijos, 8 (2,5%) trumpalaikiai oro prasiverþimaipro mechanines siûles, 2 (0,6%) kraujavimai, 1 (0,3%) pû-lingas pleuros uþdegimas, 1 (0,3%) plauèio kolapsas. Mirties

atvejø operacinëje nebuvo. 99% ligoniø pasveiko. Vienas li-gonis (0,32%) mirë 21 parà po operacijos. Pleurodezës, ápu-èiant talkà, efektyvumas – 92% (147 ligoniams ið 160 skys-tis pleuros ertmëje nebesikaupë). Po kyliniø plauèio audiniorezekcijø kraðtuose navikiniø làsteliø histologiðkai nerasta.Vaizdo torakoskopijos efektyvumas – 97% (322 atvejai ið333).

Išvados. 1. Vaizdo torakoskopinës operacijos yra efekty-vios ir saugios diagnozuojant bei gydant plauèiø ir pleuros li-gas. Diagnozë nustatyta 93% ligoniø. 2. Kai kuriais atvejaistai yra vienintelis bûdas paðalinti auglá ir sutrumpinti hospi-talizacijos laikà iki 5 dienø. Ðis bûdas taikomas senyvo am-þiaus ligoniams esant kvëpavimo nepakankamumui ar sergantgretutinëmis sunkiomis ligomis. 3. Ankstyvos NSLPV stadijosgali bûti efektyviai gydomos atliekant anatomines rezekcijas;geri dvejø metø iðgyvenimo rezultatai 83% (5 ligoniai ið 6).4. Vaizdo torakoskopinë plauèio audinio kylinë rezekcija ga-li bûti atliekama ir pasiteisina blogos fiziologinës bûklës ligo-niams ar kliniðkai sergantiems vëþiu su T1N0 ar T2N0 iðpli-timu, kuriems negalima atlikti tipinës torakotomijos. Po ðiørezekcijø dvejø metø iðgyvenimas – 80% (8 ligoniai ið 10). 5.Talko milteliø ápûtimas torakoskopijos metu yra geriausiaspleurodezës konservatyvaus gydymo bûdas sergant piktybi-niais ir uþsitæsusiais gerybiniais ðlapiais pleuritais ar esant lim-fos kaupimuisi pleuros ertmëje. 92% (147 ligoniams ið 160)po ðiø operacijø skystis daugiau nebesikaupë.

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