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Ann Thorac Surg 1996;61:538-541
© 1996 The Society of Thoracic Surgeons

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Original Article: General Thoracic

Complications and Failures of Video-Assisted Thoracic Surgery: Experience From Two Centers in Asia

Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong, and Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Republic of China

Accepted for publication October 30, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. There have been few specific reports on negative outcomes after video-assisted thoracic surgery. We report our combined experience from two centers in Asia.

Methods. From September 1992 to April 1995, 1,337 patients were operated on with the video-assisted thoracic surgical approach. All the patients were prospectively studied.

Results. There was one death (mortality rate, 0.07%) and 56 nonfatal complications: persistent air leaks (21), bleeding (6), wound infection (13), empyema (2), cerebrovascular accident (1), reexpansion pulmonary edema (2), deep vein thrombosis (1), prolonged ventilatory support (4), intercostal neuralgia (5), and port-site recurrence (1), giving rise to an overall nonfatal complication rate of 4.26%. Procedure failures consisted of 7 recurrences of spontaneous pneumothorax (of 407 cases or 1.7%); 2 recurrences of malignant pleural effusion (of 39 cases or 5.1%), and 2 local recurrences after resections for stage I lung cancers (of 41 cases or 4.9%).

Conclusions. We conclude that video-assisted thoracic surgery is safe and effective for a wide range of procedures. A learning curve is present, and careful patient selection and attention to details are essential in optimizing surgical results.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Within a relatively short time, video-assisted thoracic surgery (VATS) has been widely used in the diagnosis and treatment of many thoracic conditions. Despite the wealth of literature on the subject, studies designed to specifically address VATS complications and failures are few [1, 2]. We reviewed our combined experience from 2 teaching centers in Asia (Prince of Wales Hospital, Hong Kong, and Chang Gung Memorial Hospital, Republic of China) focusing on complications and procedure failures. The two centers are geographically and ethnically close together and the patients were almost exclusively Chinese. Our results and discussion on how some of these complications and failures may be minimized form the basis of this article.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
From September 1992 to April 1995, a total of 1,337 cases of VATS were performed at the two centers:

There were 767 male and 570 female patients with age ranging from 22 days to 86 years. Some patients had more than one procedure performed under the same or separate anesthesia sessions, but they were grouped only under their most major procedures. Nearly all the procedures were performed under general anesthesia with selective one-lung ventilation using a double-lumen endobronchial tube in adults or main bronchial intubation with a single-lumen tube in infants and young children [3]. On four occasions we performed the procedure under local anesthesia or general anesthesia with double-lung ventilation in very poor risk patients with secondary pneumothorax (2) or malignant pleural effusion (2) for talc insufflation. Our techniques for the management of spontaneous pneumothorax [4, 5], pleural effusion [6], peripheral lung nodules [7], lobectomy [8–10], thymectomy [11], pericardial effusion [12], esophagectomies [13], and others [14–16] have been previously reported and will not be repeated here. During the same period VATS was attempted on 15 patients but abandoned because of pleural symphysis (7), inability of the patient to tolerate one-lung ventilation (5), or failure of the surgeon to accurately localize lung nodules (3). These patients were excluded from our study.

All the patients in our study have been followed up prospectively. Specifically, we paid attention to chest drain durations, hospital stays, perioperative complications, and procedure failures. Complications were classified according to a system originally proposed by Clavien, and associates [17]. There are a total of five grades:

• Grade I
  
• Minor, non–life-threatening complications
  
• No residual disability
  
• Grade IIa
  
• Potentially life-threatening
  
• No residual disability
  
• Operation not required to manage complications.
  
• Grade IIb
  
• Potentially life-threatening (include intraoperative complications)
  
• No residual disability
  
• Operation required to manage complications.
  
• Grade III
  
• Associated with residual disability
  
• Grade IV
  
• Death as a result of a complication
  

We modified the system (which was primarily designed for postoperative complications) to include major intraoperative mishaps under grade IIb. Also, the length of hospital stay alone was not used to stratify complications as we are dealing with many procedures here and what constitutes ``prolonged hospital stay'' is difficult to define. These complications were further stratified between two time periods: the first 16 months (September 1992 to December 1993) versus the second 16 months (January 1994 to April 1995) for comparison.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Perioperative complications and procedure failures after VATS stratified temporally under the two time periods are listed in Tables 1 and 2. The overall mortality rate was 0.07%, and the nonfatal complication rate was 4.26%. There were proportionally more nonfatal complications and procedure failures over the first 16 months compared with the subsequent 16 months, despite more technically advanced procedures such as anatomic lung resections, thymectomies, and esophagectomies being performed in the latter period. We believe that careful attention to patient positioning and operative techniques [18] is important in minimizing short-term and long-term postoperative pain. The overall median chest drainage was 2 days (range, 0 to 25 days), and median postoperative hospital stay was 4 days (range, 1 to 37 days) for the entire group.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

Our data from two teaching centers in Asia over a 32-month period represent the combined efforts of two individuals who share similar philosophy on patient selection, surgical techniques, and postoperative care. The patient populations are also ethnically homogeneous and are representative of the spectrum of ``VATS diseases'' we encounter in this part of the world. The introduction of any new surgical approach brings along its own problems and complications. Some of these are immediately obvious, whereas others are only apparent later as more experience is gained. Our results are in agreement and compare favorably with the previous reports [1, 2] in that VATS can be safely performed: both the mortality and morbidity figures were acceptably low, considering the magnitude of surgical procedures on a wide range of intrathoracic pathology.

Persistent air leaks remain the most common complication. Any definition of ``persistent air leaks'' is arbitrary [19]. Timing for further intervention depends on the suspected cause of the air leak and the expected hospital course if no further treatment is given. We normally would not consider further surgical intervention unless the leaks last for more than 10 days. Of our 21 patients with persistent air leaks, only 3 required reoperation (grade IIb). The majority of our patients with persistent leaks come from the pneumothorax group (18 of 21). Strategies to minimize this complication include the use of pericardial buttress to reinforce the staple line when transecting emphysematous lung [20], avoidance of argon beam coagulation on apical bullae, avoidance of endoscopic graspers on lung (the conventional sponge-holding forceps are ideal in handling lung tissue), and use of two or more endo-loops to ligate isolated small apical bullae to avoid slipping [4]. In 18 patients (grade I), air leak eventually stopped on its own or with the use of fibrin glue (Tisseel; Immuno AG, Vienna, Austria) applied over the area of leak under local anesthesia using a flexible bronchoscope placed through a truncated chest tube [4]. So far we have had 7 recurrences out of a total of 407 cases of thoracoscopically treated spontaneous pneumothoraces (recurrence rate, 1.7%). Possible explanations for the recurrence include inadequate pleural abrasion (4), use of argon beam coagulation for apical bullae (1), missed apical bullae (1), and slipping of an endoloop (1). Our experience was similar to that of Naunheim and associates [21] in that patients found on thoracoscopy to have no obvious bullae or those with multiple small bullae covering the entire lung are more likely to have recurrence. Whether partial pleurectomy or arbitrary excision of the lung apices should be performed for these patients, as suggested by Naunheim and associates [21], remains to be investigated.

Bleeding was the third most common complications in our series (following persistent air leaks and superficial wound infections) and occurred in 6 patients, 4 of whom required extension of the minithoracotomy for control or reoperation (grade IIb). This occurred in patients after decortication for trapped lungs (2), intercostal bleeding from a port site (1), left subclavian artery injury during adhesiolysis (1), segmental pulmonary artery injury during VATS lobectomy (1), and hilar bleeding due to vascular stapler failure (1). The intercostal bleeding was controlled on reoperation with VATS. The hilar bleeding was due to mechanical failure of the vascular stapler, which transected but did not staple the pulmonary vein during a lobectomy. Bleeding was slowed down with a ``sponge-stick'' followed by definitive control on conversion to an open procedure [22]. Bleeding of both the subclavian artery and pulmonary artery was controlled through extended wounds. In both cases of decortication, bleeding stopped on its own after the first 24 hours.

Port site recurrence is a known complication when VATS is applied to manage intrathoracic malignancy [23]. How one can best minimize this is uncertain, although gentle tissue handling during dissection and proper wound protection are likely to be important factors. Whether the use of tumoricidal agent can minimize this complication remains to be investigated. Patients with extensive pleural metastasis may be at higher risk for recurrence as in our case (malignant pleural effusion for talc insufflation). Both the surgeon and the patient should be aware of this potential complication.

We believe that careful patient selection and the experience of the surgical team remain the two most important factors in minimizing complications and procedure failures. Video-assisted thoracic surgery has an established role in the management of many thoracic conditions such as spontaneous pneumothorax and pulmonary nodules. However, its role in other procedures such as major lung resection and thymectomy remains unclear at present. Currently, this approach is contraindicated for resections of bronchogenic carcinoma beyond clinical stage I disease and established mediastinal malignancy. In fact, we continue to perform more thoracotomies than VATS for resections of intrathoracic malignancy.

Video-assisted thoracic surgery demands a different set of manual skills compared with conventional open surgical procedures, so special training is required for practicing thoracic surgeons who want to acquire this technique [24]. Video-assisted thoracic surgery is still in its evolution. However, for this approach to make a significant impact on healthcare in Asia, we need to show that it is not only safe and effective, but also economical and affordable even by developing countries here. An important part of our research in this field is therefore directed toward cost containment [25].

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Anthony P. C. Yim Hui-Ping Liu Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Yim, A. P. C. Articles by Liu, H.-P. Search for Related Content PubMed PubMed Citation Articles by Yim, A. P. C. Articles by Liu, H.-P.