Objective: Chronic lung infection is the main indication for lobectomy in benign pulmonary disease and may be technically demanding due to inflammatory changes such as adhesions, lymph node enlargement and neovascularization. The role of the thoracoscopic operation in these indications is yet ill-defined. Methods: We retrospectively analyzed the results of patients who underwent thoracoscopic lobectomy (TL) between 1992 and June 1999 and compared this study group with patients who underwent open lobectomy (OL), all for benign disease. Data were not normally distributed, therefore, the median and range is given and nonparametric statistical analysis was applied. Results: A total of 117 lobectomies for benign disease (64 TL) were analyzed. Indications included bronchiectasis (36 TL; 18 OL), chronic infections (13 TL; eight OL), tuberculosis (five TL; 15 OL), emphysema (five TL; one OL), AV-malformations (two TL; one OL), severe haemoptysis (four OL), and others (three TL; six OL). Twelve conversions to thoracotomy were necessary due to severe adhesions. One patient in the open lobectomy group died within 30 days postoperative. Drainage time was 5.0 (1-32) days in TL and 6.0 (3-21) days in OL, hospital stay was 8.5 (4-41) days and 10.0 (5-52) days, respectively. Blood loss was 0 (0-2000) ml in TL and 300 (0-6000) ml in OL. Operation time for thoracoscopic lobectomies significantly decreased from 2.5 (1-6) h for cases between 1992 and 1997 (n = 49) to 1.5 (0.5-2.5) h for recent cases (n = 15) (P < 0.01). In addition, a trend towards less blood loss was noted (100 (0-2000) ml vs. 0 (0-400) ml; P = 0.06). Drainage time and hospital stay did not differ significantly. Conclusions: Thoracoscopic lobectomy in chronic inflammatory disease can be performed safely in selected patients, especially with bronchiectasis. Conversion rate to thoracotomy is low. Operation time with this approach declined significantly over time. (C) 2001 Elsevier Science B.V. All rights reserved.

Objective: This is a prospective evaluation of chest wall integrity and pulmonary function in patients with operative stabilisation for flail chest injuries. Methods: prom 1990 to 1999, 66 patients (56 men, 10 women; mean age 52.6 years) with antero-lateral flail chest (greater than or equal to4 ribs fractured at greater than or equal to2 sites) underwent surgical stabilisation using reconstruction plates. Clinical assessment and pulmonary function testing were performed at 6 months following surgery. Results: Fifty-five (83%) patients had various combinations of injuries of the thorax, head, abdomen and extremities. Sixty-three (95.5%) patients underwent unilateral and 3 (4.5%) patients bilateral stabilisation with a median delay of 2.8 days (range 0-21 days) from admission. The 30-day mortality was 11% (seven of 66 patients). Immediate postoperative extubation was feasible in 31 of 66 patients (47%) and extubation within 7 days following stabilisation in 56 of 66 patients (85%). No plate dislocation was observed during the follow-up. The shoulder girdle function was intact in 51 of 57 patients (90%). Chest wall complaints were noted in 6 of 57 (11%) patients, requiring removal of implants in three cases. All patients returned to work within a mean period of 8 (range 3-16) weeks following discharge. Pulmonary function testing (n=50) at 6 months after the operation revealed a significant difference of predicted vs. recorded vital capacity (VC) and forced expiratory volume in 1 s (FEV1) (P=0.04 and P=0.0001, respectively; WiIcoxon signed-rank test). The median ratio of the recorded and predicted total lung capacity (TLC) was shown to be significantly higher than 0.85 (P=0.0002; Wilcoxon signed-rank test), indicating prevention of pulmonary restriction. Conclusion: Antero-lateral flail chest injuries accompanied by respiratory insufficiency can be effectively stabilised using reconstruction plates. Early restoration of the chest wall integrity and respiratory pump function may be cost effective through the prevention of prolonged mechanical ventilation and restriction-related working incapacity. (C) 2001 Elsevier Science B.V. All rights reserved.

Photodynamic therapy (PDT) following surgical tumor resection is leading to improved local tumor control and might be useful for selected intrathoracic malignancies. However, optimal tumor selectivity of PDT is mandatory to avoid injury of adjacent normal tissues. (1) PDT was applied on human tumor xenografts (malignant mesothelioma, squamous cell carcinoma of the neck, adenocarcinoma of the colon). M-tetrahydroxyphenylchlorin (mTHPC) and polyethylene glycol-derived mTHPC (MD-mTHPC) were administered i.p. The tumor and normal tissue of the hind leg were irradiated with 652 nm laser-light. Drug and light doses and drug-light intervals were varied. The extent of necrosis was assessed histologically. (2) Intrathoracic PDT was performed in minipigs with drug-light doses optimized in nude mice. After administration of the sensitizers i.v., intrathoracic structures were irradiated and analyzed histologically. The tumor selectivity of PDT increased in the xenograft model by: (1) choosing an appropriate drug light interval; (2) decreasing the drug dose while increasing the light dose; and (3) applying MD-mTHPC instead of mTHPC. In the minipig model, the extent of injury of intrathoracic structures was equally related to modulation of treatment conditions. The modification of chlorins and the modulation of the drug-light conditions improved the tissue selectivity of PDT. Nevertheless, further methodological optimizations are prerequisites for clinical use of PDT, especially for intraoperative application in thoracic surgery.

Isolated limb perfusion therapy (ILP) is beneficial in the treatment of recurrent melanoma of the extremities where 73% of all cases perfused for in-transit metastasis have shown complete or partial remission lasting for a minimum of 4 months and for periods of 2 years and more. 5-year survival for this patient subgroup is 50%. The same therapeutic modality has a very promising place in the treatment of hypervascularized soft tissue sarcomas and is shown to offer definitive cure for recurrent carcinomas of the lower limbs that have defied successful response to repeated localized surgical interventions. It is therefore concluded that the role of isolated perfusion for progressive soft tissue tumors is important and unquestionable.

Pleural empyema is a disease which is not always recognized. Despite consecutive treatment and antibiotics its mortality rate is still high, especially in older patients with concomitant disease or in the case of delayed treatment. We report our experience with early video-assisted thoracoscopic surgery of pleural empyema in 13 patients, where chest tube drainage had failed. The clinical symptoms of empyema did not exceed 14 days, bacteriologic cultures were positive in 62%. In all patients the fever disappeared within 1 to 5 days (mean 3.5) postoperatively and they remained in hospital for an average of 11.5 days after video-assisted thoracoscopic surgery. Pulmonary function tests 6 months later revealed normal values without a substantial loss of lung volumes. No relapse of empyema occurred.

The technique of minimal invasive surgery has SucCeSSfUlly been introduced into the area of thoracic surgery. Surgery of the intrathoracic organs may now be performed without compromise of respiratory mechanics, thus allowing the operative treatment of an ever widening range of pathological conditions. An analysis of our experience (287 thoracoscopic interventions in the last three years) reveals that the diverse procedures performed on the pleura (pleurectomy and pleurodesis). on the lung (wedge resection, fistula closure and ligature of parenchymatous leaks) and on other defined anatomical structures such as the sympathetic nerves or the thoracic duct, are effective in the therapy of intrathoracic disease. The most important pathological conditions which may be treated by thoracoscopy are listed. The range of complications and their causes, which developed in 8 % of all procedures, are discussed. The current limitations of this method are defined in the context of the situations where thoracoscopy was discontinued (9 times), a thoracotomy performed (17 times) or a further procedure became necessary (14 times). Current developments and innovations are summarized by a short review of the literature.

We report the case of a patient who had a spontaneous hemarthrosis of the ankle secondary to a false aneurysm of the dorsalis pedis artery that was caused by an osteophyte