[show abstract][hide abstract] ABSTRACT: Cyclosporine (CsA), a calcineurin inhibitor, has been associated with endothelial dysfunction in transplant patients. Human and in vitro studies suggest that CsA produces endothelial dysfunction by impairing vascular endothelium-dependent relaxation. However, little is know about the CsA effects to modulate the vasorelaxation after prolonged graft preservation. In this study using a protocol designed to eliminate the influences of infusion pressure and shear stress, we evaluated the effect of CsA on vasorelaxation of coronary and pulmonary arteries after 16-hour University of Wisconsin (UW) solution preservation.
[show abstract][hide abstract] ABSTRACT: Empyema frequently complicates the hospitalization of children; and in advanced stages, it often requires surgical intervention. In this study, we investigated the use of video-assisted thoracic surgery (VATS) for the management of postpneumonic empyema in children who have had an unsatisfactory medical response.
We did a retrospective review of the medical records of 51 consecutive patients with loculated empyema (mean age, 5 years; range, 2 months to 15 years) hospitalized at Chang Gung Memorial Hospital between 1995 and 2000. All patients underwent debridement of the necrotic lung tissue and evacuation of the loculated empyema cavity using a VATS approach.
The mean operating time for the 51 patients was 90 min (range, 50-210); mean blood loss was 70 cc. Fever subsided within 72 h postoperatively in all patients. On average, chest tubing was removed on the 7th postoperative day (range, 4-18 days). However, in one patient who suffered from a prolonged air leak, the chest tube was not removed until day 18. The mean postoperative stay for all patients was 13.7 days (range, 9-23). No deaths occurred, and all of the children made a good recovery. A follow-up revealed that one of the 51 children patient suffered a left upper lung abscess 7 months after discharge. Left upper lobectomy was performed in this case, and the patient was discharged uneventfully 10 days after the operation.
VATS is a safe and effective treatment for pediatric empyema. Thoracoscopic-assisted surgery facilitates visualization, evacuation, and debridement of the necrotizing lung tissue. Early surgical intervention can avoid lengthy hospitalization and prolonged intravenous antibiotic therapy, and it can accelerate clinical recovery.
[show abstract][hide abstract] ABSTRACT: How to optimally treat deep sternal wound infection after open wound infection remains controversial. Biomaterial advances have made local antibiotics-releasing systems a promising alternative for treating deep sternal wound infection. Two patients with deep sternal wound complications were treated with radical wound debridement, sternal refixation, retrosternal suction drainage, bilateral pectoralis major muscle flaps and placement of collagenous drug carriers loaded with vancomycin underneath, above and between the sternal edges. No treatment failure and death occurred in these patients. There were no side effects, treatment failures or deaths after adjuvant treatment with collagenous vancomycin. Preliminary results of these 2 case studies demonstrate the feasibility of successfully treating deep sternal wound infections with collagenous vancomycin in combination with surgical debridement. This technique is easily performed, reliable and safe.
[show abstract][hide abstract] ABSTRACT: Thoracoscopy has been used for both diagnostic and therapeutic purposes. Its use in the trauma field is rapidly increasing. Here, we present a case of chest trauma that was successfully treated using the thoracoscopic approach. A 43-year-old male patient was brought to our emergency room with a severe right chest wall-penetrating metal-rod injury, which had occurred after falling from a height. The chest X-ray showed an upper right lung lobe injury. Video-assisted thoracoscopic surgery (VATS) was performed for diagnosis of any other associated injury and for management of the penetrating injury. The prognosis was good. We believe that minimal thoracoscopic surgery is an alternative way that provides a more rapid diagnosis, and a less-invasive and safe operation for acute chest trauma patients.
[show abstract][hide abstract] ABSTRACT: Paradoxical cerebral air embolization through a residual tract after the removal of a central venous catheter is a serious complication of central venous cannulation. Air embolisms resulting from residual catheter tracts in general patients and in single lung transplant patients have been reported. The generally accepted mechanism of this complication is failure of a spontaneous collapse or thrombotic obliteration of a well-formed catheter tract. It may be related to the duration of catheter insertion, the patient's nutritional status, the diameter of the indwelling catheter, the upright position of the patient, deep inspiration or coughing, and improper wound dressing and catheter removal. Cardiovascular collapse, pulmonary or neurologic sequelae, and even death, are commonly noted in patients with air embolism. In this article, we report on cerebral air embolization as a complication with the removal with a central venous catheter in a patient with bullous emphysema. A high degree of suspicion and a prompt diagnosis are required for successful application of established therapy. Simple prophylactic procedures and constant awareness of the unusual mechanism of air embolism remain the best treatment.
Chang Gung medical journal 12/2000; 23(11):706-10.
[show abstract][hide abstract] ABSTRACT: To review the surgical and clinical results of minimally invasive resection of intrathoracic neurogenic tumors using a video-assisted thoracoscopic technique.
Thoracoscopy has emerged as a possible means for diagnosing and managing various intrathoracic disorders. Benign intrathoracic tumors often are ideal lesions for resection using a video-assisted technique. The authors report on their combined experience with the thoracoscopic resection of 143 intrathoracic neurogenic tumors.
Between March 1992 and February 1999, 143 patients with intrathoracic neurogenic tumors were diagnosed and underwent resection using video-assisted thoracoscopic techniques in three teaching centers. Case selection, surgical technique, and clinical results were reviewed.
The average age of the patients was 40.8 years; 57.3% were male. Thirty-eight patients (27%) had symptoms attributable to the masses. Seventy-two masses were neurofibromas, 33 were neurilemmomas, 7 were paragangliomas, and 31 were ganglioneuromas. All but seven tumors were located in the posterior mediastinum. The masses were on average 3.5 cm in greatest diameter. The mean surgical time was 40 minutes, and the average hospital stay was 4.1 days. There were no major postoperative complications or recurrences to date. Nine patients reported paresthesias over the chest wall during a mean follow-up of 29 months.
Resection of intrathoracic neurogenic tumors using a thoracoscopic technique based on standard surgical indications would seem to be appropriate. Most of these masses are benign and readily removed. For dumbbell tumors, a combined thoracic and neurosurgical approach is mandatory.
Annals of Surgery 09/2000; 232(2):187-90. · 6.33 Impact Factor
[show abstract][hide abstract] ABSTRACT: Cost containment is the driving force behind current health care reform. While video-assisted thoracic surgery (VATS) permits a less invasive approach to surgical diseases of the chest, cost is one aspect that is seldom discussed. In Asia, cost-effectiveness essential for the survival of this approach. We present our cost-effective experience with VATS in 2300 patients over a 7-year period.
Between 1992 and 1999, 2300 patients underwent video-assisted thoracic surgery at Chang Gung Memorial Hospital. The mean age was 53.2 years (range, 22 days to 102 years); 67% (1541 patients) were men. The VATS technique was mainly performed based on traditional surgical principles. Conventional instruments and the fundamental surgical techniques of dissection, suturing, hemostasis, and tissue approximation that are familiar in the open setting were modified and used to enhance cost savings during VATS.
Surgery was performed on 41 patients on an emergency basis (24 with impending cardiac tamponade and 17 with hemothorax). The mean hospital stay of the patients treated by VATS was 4.5 days. The majority of the patients were operated on successfully using conventional instruments under video vision. The overall operative cost was decreased as compared to common VATS techniques. No delayed morbidity was noted in our patients after a mean follow-up period of 39 months (range, 1 to 68 months).
It is our experience that VATS procedures should be performed with the same expertise as open surgery. Conventional instruments similar to those used in open thoracotomy can be incorporated in VATS, and with a more natural hand manipulation. Only through stringent use of expensive endoscopic consumables and application of modified techniques based on traditional surgical principles can VATS be performed efficaciously and economically for a wide range of thoracic conditions.
[show abstract][hide abstract] ABSTRACT: Catamenial hemoptysis is a rare form of hemoptysis. It is a term for the condition of hemoptysis associated with menses. Few cases have been reported in the literature. Only one case, treated by video-assisted thoracoscopic wedge resection, has been described. We report the case of a 26-year-old woman who suffered from catamenial hemoptysis for 7 months and was treated successfully with a video-assisted thoracoscopic (VATS) wedge resection of the lesion. No evidence of recurrence was noted in the postoperative follow-up period of 48 months. We suggest that VATS is the good choice for single focus catamenial hemoptysis.
[show abstract][hide abstract] ABSTRACT: Woven graft tera is a very rare complication after aortic root replacement using Cabrol's technique. In this report, we present a 40-year-old man with aortic annular ectasia and severe aortic regurgitation who underwent four revisional aortic valve operations because of recurrent paravalvular leakage after valve repair and/or replacement. The Bentall operation with translocated aortic valve and Cabrol's coronary artery anastomosis were performed in the fifth operation, because of progressive dilatation of the aortic root and ascending aorta. Unfortunately, aortico-ventricular tunnel developed 2 years after aortic root replacement using Cabrol's technique. Graft tear and proximal anastomotic leakage were found to be the cause of the tunnel during the sixth operation. The patient died of myocardial failure 8 days after the seventh aortic root replacement operation. The devastating result of this complication should alert cardiovascular surgeons to the possibility of graft failure after the Bentall operation.
Journal of the Formosan Medical Association 03/2000; 99(2):170-3. · 1.00 Impact Factor
[show abstract][hide abstract] ABSTRACT: We report the case of a 54-year-old male motorcyclist with an apparent grade IV liver injury and life-threatening hemomediastinum and right hemothorax following blunt deceleration trauma. Massive hemothorax and an unstable hemodynamic status even under copious blood volume replacement made emergent surgical intervention mandatory. A midline laparotomy was performed at first to rule out abdominal bleeding accompanied by a diaphragmatic tear, but the procedure was soon converted to a thoracotomy after finding an intact diaphragm and persistent bleeding from the chest tube. An isolated internal thoracic artery (ITA) transection was identified. It was actively bleeding and causing a huge anterior mediastinal hematoma and had ruptured into the right pleural cavity. The bleeder was controlled with suture ligation and the hemodynamic status was soon stabilized. The patient recovered without significant sequelae. The rarity of this kind of presentation is discussed, including both the ITA injury mechanism and the problems posed in making an early and correct diagnosis.
Changgeng yi xue za zhi / Changgeng ji nian yi yuan = Chang Gung medical journal / Chang Gung Memorial Hospital. 01/2000; 22(4):666-70.
[show abstract][hide abstract] ABSTRACT: The best management of pacemaker lead related endocarditis is complete surgical or percutaneous removal of the pacemaker system. Although the traditional surgical approach is via median sternotomy, we present two cases in which the lead and vegetations were removed using a video-assisted endoscopic technique through a limited right submammary incision. In each case the patient was supported by partial extracorporeal perfusion. Additional tricuspid valve repair and atrial septal defect closure was performed in one case. The postoperative courses were uneventful, illustrating that, when compared to the conventional open heart surgical approach, the less invasive approach can be a safe and effective way to remove an infected foreign body from the right heart with increased comfort, fast recovery, and a better cosmetic result.
Pacing and Clinical Electrophysiology 12/1999; 22(11):1700-3. · 1.75 Impact Factor
[show abstract][hide abstract] ABSTRACT: Spontaneous pneumothorax in apparently healthy individuals is a relatively common occurrence. The management of patients with spontaneous pneumothorax remains controversial. With the advances in thoracoscopic techniques and instrumentation, video-assisted thoracic surgery (VATS) is now accepted by many as the procedure of choice for surgical treatment of spontaneous pneumothorax. We report our combined experience with 757 patients who suffered from recurrent or persistent spontaneous pneumothorax treated by VATS over a 5-year period. Surgical indications included persistent air leak (n = 165), recurrence (n = 325), radiologically demonstrated huge bulla (n = 12), spontaneous hemopneumothorax (n = 13), incomplete expansion of the lung (n = 212), and bilateral involvement (n = 30). Several surgical procedures were undertaken, based on the thoracoscopic findings: endoscopic stapled bullectomy (n = 312), argon beam coagulation (n = 6), endoscopic suturing (n = 52), and endoloop ligation (n = 352). In 49 cases, mechanical or chemical pleurodesis was the only procedure performed. There were no mortalities or intraoperative hazards. Complications consisted of wound infections (n = 16), localized empyema (n = 2), chest wall bleeding (n = 1), and persistent air leaks (bulla type III) (n = 31). The median duration of the operation was 55 minutes (15-160 minutes), and the average postoperative hospital stay was 4.5 days (range 0-27 days). There were 16 recurrences (2.1%), after a mean follow-up of 30 months (range 1-60 months). Seven patients had recurrence from 9 to 17 months after stapled bullectomy. All the remaining patients had recurrence after failed pleurodesis. On the basis of our results, we conclude that video-assisted thoracoscopic management allows effective, safe performance of standard surgical procedures, avoiding a formal thoracotomy incision. We consider thoracoscopy the treatment of choice for patients with pneumothorax requiring surgical therapy.
World Journal of Surgery 12/1999; 23(11):1133-6. · 2.23 Impact Factor
[show abstract][hide abstract] ABSTRACT: Video-assisted thoracoscopic surgery (VATS) has emerged as an innovative and popular procedure for interruption of patent ductus arteriosus (PDA), while intraoperative transesophageal echocardiography (TEE) has proven to be an effective monitor in the evaluation of residual patency. Previous reports on the adequacy of surgical interruption of PDA under VATS and TEE are available for pediatric patients, but only limited information is available for adults with PDA. MATEIALS AND METHODS: Between August 1995 and October 1997, we monitored 35 adult patients undergoing PDA interruption via VATS with Hewlett-Packard color Doppler multiplane TEE throughout the procedure. The average PDA diameter was 10.2 +/- 1.8 mm. All the PDA were completely ligated.
Thirty-two patients showed no ductal flow after double ligation. In the other three patients, residual flow was detected intraoperatively after double ligation, but it was quickly abolished by the third ligation. One patient showed faint ductal flow by transthoracic echocardiography at postoperative follow-up, but no reintervention was needed.
Our study showed that, with the refinement of adult PDA interruption via VATS, intraoperative multiplane TEE provides higher resolution for direct evaluation of the entire course of PDA ligation without interrupting the surgical procedure and minimizes the incidence of complications.
[show abstract][hide abstract] ABSTRACT: To demonstrate the efficacy of using thoracoscopic endoloop ligation of bullae in patients with bullous emphysema.
From 1992 to 1997, 93 advanced age (mean age, 66 years) and oxygen dependency patients underwent thoracoscopic procedure using endoloop ligation for treatment of bullous emphysema. Clinical data were collected from chart review. Thoracoscopic loop ligation of bulla was carried out under general anesthesia with double lumen endotracheal tube and single lung ventilation.
Eighty-two patients (88%) exhibited subjective improvement in their symptom status at 3-month follow-up (from grade 2 or 3 to grade 1 or 2) according to the modified Medical Research Council dyspnea scale. The mean duration of chest drainage was 7.5 days (range, 4-19 days). Average hospital stay was 9.5 (range, 5-26) days. There was no post-operative death. A comparison of pre-operative and post-operative functional evaluation was available in 27 patients who showed an average increase in FEV1 (from 0.89 to 1.12 l) and declined in residual volume after operation. Complications include persistent airleak over 10 days in nine patients (9.7%), wound infection in three patients and localized empyema in five patients. There was no recurrent after a mean follow-up of 37 months.
Thoracoscopic loop ligation of bulla has proven to be a safe, reliable and cost effective means of technique for bullous emphysema.
European Journal of Cardio-Thoracic Surgery 10/1999; 16 Suppl 1:S40-3. · 2.67 Impact Factor
[show abstract][hide abstract] ABSTRACT: Minimally invasive surgical approaches have been applied recently in the management of valvular heart disease. In this report, we reviewed our preliminary experience of minimally invasive aortic valve replacement.
Eighteen patients were operated on by means of an "I" ministernotomy, and 16 patients were operated on by means of a full median sternotomy during the same period. There was no difference between these two groups in term of age, sex, and preoperative left ventricular ejection fraction. In patients of the ministernotomy group, the operations were approached through an "I" median sternal split, from the second to the fifth intercostal space, 8 to 10 cm in length, with transverse division. Cardiopulmonary bypass was established through aorto-right atrial cannulation with aortic cross-clamping and antegrade or retrograde delivery of blood cardioplegia.
Under direct vision, aortic valve replacement was performed successfully in patients of both groups. The duration of cardiopulmonary bypass time and aortic cross-clamp time was significantly longer in the ministernotomy group than in the full sternotomy group. However, the length of incision, duration of endotracheal intubation, intensive care unit stay, pain score, postoperative length of stay, and return to normal activity interval were significantly shorter and lower in patients of the ministernotomy group than in those of the full sternotomy group. All patients recovered from the operation rapidly. Follow-up was complete in all patients with no late complications. Echocardiographic examination showed good function of aortic prostheses.
Our experience demonstrates that the "I" ministernotomy provides good exposure, reduced wound pain, enhanced recovery, shortened hospital stay, and good cosmetic healing. It may be a good alternative for surgical correction of aortic valve lesions.
The Annals of Thoracic Surgery 08/1999; 68(1):40-5. · 3.45 Impact Factor
[show abstract][hide abstract] ABSTRACT: Video-assisted thoracic surgery has proved to be valuable in many settings in thoracic surgery. The use of video-assisted thoracic surgery in trauma has recently rapidly increased. It is useful in acute or delayed management of patients with blunt and penetrating chest trauma. It is safe for removal of clotted hemothorax, treatment of thoracic empyema, treatment of persistent pneumothorax, treatment of chylothorax, and for diagnosis of diaphragmatic injury. We report two cases using thoracoscopy to remove intrathoracic metal fragments and avert the need for thoracotomy. In the first patient, a metal fragment injury was sustained via a penetrating wound from the supraclavicular notch to the right upper lung. The metal fragment was retrieved and the lung was repaired thoracoscopically using conventional suturing techniques. A second patient sustained a broken pin injury to the left upper mediastinum via a low neck wound. The pin was successfully removed under videothoracoscopy. Both patients recovered uneventfully and had shortened hospital stays. We feel that thoracoscopy offers a therapeutic as well as diagnostic benefit in stable patients with penetrating chest trauma.
Changgeng yi xue za zhi / Changgeng ji nian yi yuan = Chang Gung medical journal / Chang Gung Memorial Hospital. 04/1999; 22(1):117-22.
[show abstract][hide abstract] ABSTRACT: Minimal access surgery with video-assisted endoscopy has been applied to the correction of intracardiac lesions. We report our experience using this technique in surgical excision of left atrial myxoma in 3 patients.
From November 1995 to March 1997, 3 female patients, ages 45 to 80 years (mean, 62.7 years), received emergency operations for excision of left atrial myxoma. These operations were performed through a right anterior submammary minithoracotomy or right parasternal incision with the assistance of endoscopy during femoro-femoral cardiopulmonary bypass. The myocardium was protected by continuous coronary perfusion with fibrillatory arrest or cardioplegic arrest with aortic cross-clamping.
All the tumors were excised completely through the right atrial approach. The bypass time was 92 to 148 minutes (mean, 111 minutes). The operation time was 3.2 to 4.4 hours (mean, 3.7 hours). There were no hospital deaths. Follow-up, which ranged from 6 to 19 months (mean, 10.5 months), was complete in all patients. Transthoracic echocardiographic examination showed good ventricular function without any residual tumors. Patients were found to be in New York Heart Association functional class I or II. They were satisfied with the good cosmetic healing of the incision.
Our experience demonstrates that minimal access surgery is a technically feasible, safe, and effective procedure in surgical excision of left atrial myxoma.
The Annals of Thoracic Surgery 11/1998; 66(4):1301-5. · 3.45 Impact Factor