Anatomic Lung Resection Research Articles

Factors associated with postoperative costs following anatomic lung resections without major complications.

To detect factors associated with costs of anatomic lung resection without major complications. Two hundred and fifty consecutive patients submitted to anatomic lung resection (185 by VATS) in 1 fiscal year (1 April 2014–31 March 2015) were included. Thoracic Morbidity and Mortality (TMM) system was used to grade the severity of complications. Two hundred and ten patients who did not develop major complications (TMM < 3) were analysed. Postoperative costs were retrieved from the Financial Department through a Patient Level Information and Costing System. Multivariable regression and bootstrap analyses were used to test the association of several baseline patient characteristics with costs and obtain an aggregate scoring system to estimate postoperative costs. Among the 210 patients, 117 (56%) did not develop any complication and 93 (44%) had minor complications. Their average postoperative cost was 4040€, significantly lower than the one observed in patients with major complications (13 156€, P < 0.0001). Multivariable regression revealed that open thoracotomy (P = 0.01), carbon monoxide lung diffusion capacity (DLCO) < 60% (P = 0.001) and coronary artery disease (CAD) (P = 0.009) were associated with postoperative costs. Open thoracotomy would increase the cost by 648€, DLCO < 60% by 935€ and CAD by 1043€. If all three factors were present, they would cause an increase of postoperative costs from 3592€ to 6219€. We were able to identify clinical factors associated with postoperative costs in patients without major complications. Recognizing groups of increased cost may lead to specific process analyses aimed at optimising their pathways of care and ultimately saving money. Moreover, these findings may help administrators to tailor future individualized lung resection reimbursement tariffs based on patient characteristics.

European risk models for morbidity (EuroLung1) and mortality (EuroLung2) to predict outcome following anatomic lung resections: an analysis from the European Society of Thoracic Surgeons database.

To develop models of 30-day mortality and cardiopulmonary morbidity from data on anatomic lung resections deposited in the European Society of Thoracic Surgeons (ESTS) database. Retrospective analysis of 47 960 anatomic lung resections from the ESTS database (July 2007-August 2015) (36 376 lobectomies, 2296 bilobectomies, 5040 pneumonectomies and 4248 segmentectomies). Logistic regression analyses were used to test the association between baseline and surgical variables and morbidity or mortality. Bootstrap resampling was used for internal validation and to check predictors of stability. Variables that occurred in more than 50% of the bootstrap samples were deemed reliable. User-friendly aggregate scores were then created by assigning points to each variable in the model by proportionally weighting the regression coefficients. Patients were grouped in classes of incremental risk according to their scores. Cardiopulmonary morbidity and 30-day mortality rates were 18.4% (8805 patients) and 2.7% (1295 patients). The following variables were reliably associated with morbidity after logistic regression analysis (C-index 0.68): male sex ( P < 0.0001); age ( P < 0.0001); predicted postoperative forced expiratory volume in 1 s (ppoFEV1) ( P < 0.0001); coronary artery disease (CAD) ( P < 0.0001); cerebrovascular disease (CVD) ( P < 0.0001); chronic kidney disease ( P < 0.0001); thoracotomy approach ( P < 0.0001); and extended resections ( P < 0.0001). All variables occurred in more than 95% of the bootstrap samples. An aggregate score was created that stratified the patients into six classes of incremental morbidity risk ( P < 0.0001). The following variables were reliably associated with mortality after logistic regression analysis (C-index 0.74): male sex ( P < 0.0001); age ( P < 0.0001); ppoFEV1 ( P < 0.0001); CAD ( P = 0.003); CVD ( P < 0.0001); body mass index ( P < 0.0001); thoracotomy approach ( P < 0.0001); pneumonectomy ( P < 0.0001); and extended resections ( P = 0.002). All variables occurred in more than 80% of bootstrap samples. An aggregate score was created that stratified the patients into six classes of incremental mortality risk ( P < 0.0001). The updated ESTS morbidity and mortality models can be used to define risk-adjust outcome indicators for auditing quality of care and to counsel patients about their surgical risk.

P1.31: Pleural Empyema and Broncho Pleural Fistula After Lung Resection: Analyses of 29 Patients Treated in our Clinic

Broncho pleural fistula (BPF) and pleural empyema are seriously complications after anatomical and non anatomical lung resection although is rare. But with high mortality rate particularly after radical pneumonectomy. a BPF may arise either from dehiscience or disruption of a bronchial closure after anatomical lung resection (segmentectomy, lobectomy; bilobectomy, pneumonectomy)or bronchoplastic sleeve resection and nonanatomical lung resection (wedge resection).Postoperative bronchopleural fistula is classified based in time of onset after surgery; as early (within first week); Intermediate (between 7 and 30 days);and late after (30 days). Malnutrition, imunosuppressive steroids therapies, prior thoracic radiation therapy, poorly controlled lung and pleural infection, active smokers, and the use of induction of chemotherapy are a number of predisposing factors that may developing bronchial fistula and subsecuent pleural empyema. Also others factors related with technical side are, long bronchial stump, large diameter bronchial stump, positive resection margin of bronchial stump, devascularisation of bronchial stump from cauter or unappropriate sutures during bronchial closure. Also risk factors for bronchopleural fistula are right Pneumonectomy, Diabetes, Completion Pneumonectomy, Active TB, Extrapleural Pneumonectomy, COPD, positive pressure ventilation, large postoperative fluid requirement, benign diagnosis prolonged chest tube utiliz. Empyema and BPF are extremely uncommon after lobetomy in contemporary series, particularly after thoracoscopic lobectomy. Empyema is seen in less than 2% of cases, and BPF in less than 1%. Post-pneumonectomy BPF and empyema are associated with mortality rates that vary from 5% up to nearly 50%. We are analysing our patients treated with pleural empyema and bronchopleural fistula, treated previously with lung resection,anatomical und non anatomical for malignant und benignen lung disease.Its retrospective study for period of time 2005-2015.The number of patients treated during 2005-2016 with pulmonary rezexion is 560.Mean age of patients 58±5.6 years (ranging from 13-87 years old).Male 420 patients and female 140 patients. Realized of kind Interventi are 47 patients pneumonectomy, 448 patiens anatomical lobectomy, 12 patients segmentectomy, 18 patients bilobectomy, 35 patients non anatomical resection (wedge lung resection). Bronchial fistula as a major complication occurred in 29 patients after lobectomy in 16 patients, after pneumonectomy in 8 patients, in 5 patients after right pneumonectotmise and 3 after left pneumonectomy, in 3 patients after segmentectomy, in 2 patients after wedge lung resection. Fistul bronchial pulmonary without pleural empyema 3 patients. Treated only pleural dranage for a long time 11 patients. In 2 patients are treated by using of fibrin glue bronchoscopicaly in bronchial fistulae under 5 mm and without infection. By open window are treated 18 patients according Elosser and Clagett –Virculla. Mean time hospital stay of patients treated with bronchial fistula et pleural empyema is 25 ± 5 days (average 5-90 days). 90 days mortality was in 5 patients in 2 patents post after lower bilobectomy and in 2 patients after right and left pneumonectomy, 1 patient after wedge lung resection. Cause of deaths, respiratory failure, sepsis, toxic shock. The diagnosis and management of bronchopleural fistula (BPF) remain a major therapeutic challenge for clinicians and surgeons. It is associated with significant morbidity and mortality.

From biportal to uniportal video-assisted thoracoscopic anatomical lung resection: A single-institute experience.

Our study sought to review our experience from biportal to uniportal video-assisted thoracoscopic surgery (VATS) major lung resection. Lessons we learned from the evolution regarding technical aspects were also discussed.We retrospectively reviewed patients who underwent VATS lobectomy or segmentectomies in Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi, Taiwan, during January 2012 and December 2014. Patient clinical profiles, surgical indications and procedures, postoperative course, and oncological parameters were analyzed and compared between the biportal and uniportal groups.A total of 121 patients were enrolled in this study with median follow-up of 19.5 ± 11.6 months for all patients and 22.5 ± 11.5 months for primary lung cancer patients. Operation time (146.1 ± 31.9–158.7 ± 40.5 minutes; P = 0.077), chest drainage time (3.8 ± 3.3–4.4 ± 2.4 days; P = 0.309), conversion to thoracotomy rate (2.2%–2.6%; P = 0.889), and complication rate (15.6%–19.7%; P = 0.564) were equal between the groups, whereas blood loss (96.7 ± 193.2–263.6 ± 367; P = 0.006) was lower in the uniportal group. For lung cancer cases, there were no statistical differences in the histology, cancer staging, mediastinal lymph node dissection stations, numbers of dissected N1, N2, and overall lymph nodes between uniportal and biportal groups.Our preliminary data showed that uniportal VATS anatomical lung resection is as feasible, equally safe, and of comparative oncological clearance efficacy to biportal VATS.

Impact of intercostal paravertebral neurectomy on post thoracotomy pain syndrome after thoracotomy in lung cancer patients: a randomized controlled trial.

Thoracotomy leads to chronic neuropathic pain in up to 50% of patients and is responsible for an impaired quality of life. Intercostal nerve injury has been suggested to be responsible for this pain. In the present study the impact of paravertebral intercostal neurectomy on post thoracotomy pain was assessed. In this single center parallel-group randomized controlled trial patients underwent muscle sparing anterolateral thoracotomy and anatomical lung resection for lung cancer. A subcostal approach was used for thoracotomy with single paravertebral neurectomy being performed at the beginning of the procedure at the level of the retracted intercostal space. For documentation of neuropathic pain the Leeds Assessment Score for Neuropathic Symptoms and Signs (LANSS) was used postoperatively. The primary endpoint was defined as LANSS ≥12 points on day 120. In addition, the numeric pain rating scale (NRS) was used to score pain intensity. Out of 172 patients initially randomized 161 patients were investigated following intraoperative and postoperative drop-out criteria. All patients required anatomical lung resection via thoracotomy. Five patients were lost for follow up. For the remaining 156 patients there was no difference between the two groups with regard to LANSS ≥12: 26.6% in patients with neurectomy and 28.8% in control-subjects (P=0.78). In addition, the NSR score at day 120 did not differ significantly at rest and during activity between the two groups (at rest: 21.7% vs. 15.8% P=0.439; activity: 24.5% vs. 21.9% P=0.735). Neurectomy was not shown to reduce the post thoracotomy pain syndrome in patients with anatomical lung resection following anterolateral muscle sparing thoracotomy.

Pulmonary Resection for a Residual Tumor after Definitive Radiation in Locally Advanced Non-Small Cell Lung Cancer.

To clarify the benefits of surgery for a persistent tumor following definitive radiation in locally advanced non-small cell lung cancer, five patients were retrospectively reviewed. All patients received definitive radiation, and three received concurrent chemotherapy followed by anatomical lung resection for a residual local tumor. The median time from the radiation to surgery was 8.2 weeks. There were no postoperative mortalities. Four patients developed distant metastasis with a mean recurrence-free interval of 7.5 months. Distant metastasis frequently occurred within a relatively short period after surgery. Further studies with a larger sample size are needed.

The evolution of intraoperative conversion in video assisted thoracoscopic lobectomy.

INTRODUCTION Unplanned conversion to thoracotomy remains a major concern in video assisted thoracoscopic surgery (VATS) lobectomy. This study aimed to investigate the development of a VATS lobectomy programme over a five-year period, with a focus on the causes and consequences of unplanned conversions. METHODS A single centre retrospective review was performed of patients who underwent complete anatomical lung resection initiated by VATS between January 2010 and April 2015. RESULTS In total, 1,270 patients underwent a lobectomy in the study period and 684 (53.9%) of these were commenced thoracoscopically. There were 75 cases (10.9%) with unplanned conversion. The proportion of lobectomies started as VATS was significantly higher in the second half of the study period (2010-2012: 277/713 [38.8%], 2013-2015: 407/557 [73.1%], p<0.001). The conversion rate dropped initially from 20.4% (11/54) in 2010 to 9.9% (15/151) in 2013 and then remained consistently under 10% until 2015. Conversions were most commonly secondary to vascular injury (26/75, 34.7%). Patients undergoing unplanned conversion had a longer length of stay than VATS completed patients (9 vs 6 days, p<0.001). There was a higher incidence of respiratory failure (10/75 [14.1%] vs 23/607 [3.8%], p<0.001) and 30-day mortality (7/75 [9.3%] vs 6/607 [1.0%], p=0.003) in patients with unplanned conversion than in those with completed VATS. CONCLUSIONS As our VATS lobectomy programme developed, the unplanned conversion rate dropped initially and then remained constant at approximately 10%. With increasing unit experience, it is both safe and technically possible to complete the majority of lobectomy procedures thoracoscopically.

Anatomic lung resections for benign pulmonary diseases by video-assisted thoracoscopic surgery (VATS).

Based on increasing evidence of its benefits regarding perioperative and oncologic outcome, video-assisted thoracoscopic surgery (VATS) has gained increasing acceptance in the surgical treatment of early stage non-small cell lung cancer (NSCLC). However, the evidence for a VATS approach in anatomic lung resection for benign pulmonary diseases is still limited. Between March 2011 and May 2014, data from 33 and 63 patients who received VATS anatomic lung resection for benign diseases (VATS-B) and early stage NSCLC (VATS-N), respectively, were analyzed retrospectively. For subgroup analyses, VATS-B was subdivided by operation time and underlying diseases. Subgroups were compared to VATS-N. Three patients from VATS-B and four from VATS-N experienced conversion to open surgery. Causes of conversion in VATS-B were intraoperative complications, whereas conversions in VATS-N were elective for oncological concerns (p<0.05). Operation time and duration of postoperative mechanical ventilation were longer by tendency; postoperative stay on intensive care unit and chest tube duration were significantly longer in VATS-B. Subgroup analyses showed a longer operation time as a predictor for worse perioperative outcome regarding postoperative mechanical ventilation, postoperative stay on intensive care unit, chest tube duration, and length of hospital stay. Patients with longer operation time suffered from more postoperative complications. Differences in perioperative outcome data were not significantly dependent on the underlying benign diseases compared to VATS-N. VATS is feasible and safe in anatomic lung resection for benign pulmonary diseases. Not the underlying disease, but a longer operation time is a factor for worse postoperative outcome.

Video-assisted thoracoscopic anatomic lung resections in Germany-a nationwide survey.

Video-assisted thoracoscopic surgery (VATS) is an accepted alternative to thoracotomy for anatomic lung resection (AR) and literature suggests benefits over the conventional open approach. However, it's routine clinical application is still low and varies within different countries. Nationwide survey among thoracic surgical units in Germany, evaluating the departmental structure, volume of the VATS program, experience with VATS-AR (lobectomies and other-than-lobectomies-anatomic-resections), surgical technique and learning curve data. Response rate among the 269 surgical units practicing thoracic surgery in Germany was 84.4% (n=227). One hundred twenty-two (53.7%) units do have experience with any type of VATS-AR. The majority of units started the VATS program only within the last 5years and 17.2% (n=21) of the units have performed more than 100 procedures by now. In 2013, 78.7% of the units performed less than 25% of their institutional AR via a VATS approach. Indications for VATS-AR were non-small cell lung cancer in 93.4% (up to UICC-stage IA, IB, IIA, IIB, IIIA in 7%, 22.8%, 33.3%, 17.5%, 7%, respectively), benign diseases in 57.4%, and pulmonary metastases in 50.8%. 43.4% of the departments had experience with extended VATS-AR and 28.7% performed VATS-AR after induction-therapy. Every second thoracic surgical unit in Germany does have experience in VATS-AR though only about 20% of them perform it routinely and also in extended procedures.

Efficacy and safety of Innoseal for air leak after pulmonary resection: a case-control study

BackgroundProlonged air leak is one of the most common complications after lung surgery and the cause of prolonged hospital stay frequently associated with major postoperative morbidity and thus responsible for even higher hospital costs. This case-control study was designed to test the sealing efficacy and safety of Enable-Innoseal TP4 in patients undergoing pulmonary resection for lung cancer. MethodsThis was a case-control trial enrolling patients with primary or single site metastatic lung cancer scheduled for elective anatomic or nonanatomic pulmonary resection presenting intraoperative grade 1 or 2 air leak at water submersion test; the study group population was then matched 1:1 according to surgical procedure, male/female ratio, preoperative FEV1, and age. ResultsIn the study population, 21 patients (70.0%) presented intraoperative grade 1 air leak and 9 patients grade 2 (30.0%) air leak; after comparison with the control group, we observed a significant shorter time for chest drain removal in the study population (P = 0.0050), whereas no difference was registered in terms of number of days needing for discharge (P = 0.0762). ConclusionsEnable-Innoseal TP4 was effective in treating limited intraoperative air leaks after pulmonary resection and preventing prolonged postoperative air leaks in patients receiving either anatomic or nonanatomic lung resections. Further randomized double-arm studies are required to confirm the efficacy of Enable-Innoseal TP4 demonstrated by this pilot study.

Rebuttal from Dr. Decaluwé and Dr. Dooms.

We congratulate Drs. Obiols and Call for their excellent argumentations to consider a preoperative exploration of the mediastinal lymph nodes in order to avoid futile anatomical lung resections. As they rightly pointed out, preoperative invasive mediastinal nodal staging is not routinely indicated in clinical stage IA non-small cell lung cancer (cStage-IA NSCLC). Nevertheless, the authors suggested specific indications in which preoperative invasive mediastinal nodal staging might be indicated for cStage-IA NSCLC: centrally located tumor; adenocarcinoma histology; high FDG-uptake on PET; tumor size (≤2 cm vs . 2.1–3.0 cm); or a combination of these factors.

Digital Drainage System Reduces Hospitalization After Video-Assisted Thoracoscopic Surgery Lung Resection

The purpose of this study was to assess the efficacy of a digital versus traditional drainage system on hospitalization for patients undergoing video-assisted thoracoscopic surgery (VATS) anatomic lung resection. Consecutive patients who underwent VATS anatomic lung resection (July 2014 through January 2015) for lung cancer were analyzed. Patients were managed with overnight suction (-20 cm H2O) followed by gravity drainage (water seal or-8 cm H2O) in both the traditional and digital drainage systems, respectively; the digital system also allowed for continuous monitoring of air leaks. Chest tubes were removed when the air leak was absent for 12 hours and pleural drainage was less than 300 mL/24 h; patient outcomes selected by propensity matching were compared. The VATS lung resections (lobectomy or segmentectomy) were performed in 108 patients during the 7-month study period. The pleural cavity was drained with the traditional system in 75 patients and with the digital system in 33 patients. By propensity score matching at a 2:1 ratio, 40 patients were placed in the traditional group and20 patients, in the digital group for analysis. Demographics, percent predicted forced expiratory volume in 1 second, tumor size, stage, and type of resection were similar between the groups. The majority of patients (85%) underwent a lobectomy. There were no operative deaths. Overall complications were fewer in the digital system group (22%) compared with the traditional system group (35%; p= 0.01). Median air leak days (-1.1), chest tube days (-1.6), and total hospital stay (-1.5) were significantly reduced in the digital drainage system group. Patients undergoing VATS lung resections who were managed postoperatively with a digital drainage system experienced less morbidity and decreased hospitalization. A digital drainage system appears to be a safe alternative for management of the pleural cavity after VATS anatomic lung resection.

Four years' experience in uniportal video-assisted thoracoscopic surgery for major lung resections: influence of silicosis in clinical outcomes.

Crystalline silica (CS) is one of the most common minerals and a common particulate air pollutant in both working and living environments. Lung cancer is considered one of the serious consequences of silica exposure. This paper gives an overview of the role of silicosis in results of perioperative and postoperative of lung resection surgery performed by the most up to date video-assisted thoracoscopic surgery (VATS) approach: the uniportal VATS. In January 2012 a program of video-assisted thoracoscopic anatomic pulmonary resections through a uniportal approach (no rib spreading) was started in our institution by a single surgeon experienced in postero-lateral open major resections and in other VATS procedures except lobectomies. We have retrospectively reviewed our first 4 years of experience in which 128 consecutive patients had undergone this approach, setting as a variable comparison of the results the presence of silicosis. Between January 2012 to December 2015, 128 anatomical resections where attempted. Of these attempted major resections, 115 (90%) were successfully completed. Out of 128 patients 21 (16%) had a diagnosis of complex silicosis. The most frequent resection was left upper lobectomy. The mean surgical time was 178±65 min. The median postoperative chest drain time was 3 days and the median postoperative hospital stay time was 3 days. There were 25 (19%) minor complications 17 (68%) of them in the first year of experience, and 3 (2.3%) had major complications. Preoperative forced expiratory volume in one second (FEV1) less than 60%, diagnosis of chronic obstructive pulmonary disease (COPD) and silicosis have been predictive of postoperative minor complications. The uniportal VATS for major anatomic lung resections is reproducible and safe with good results when performed by surgeons experienced in both open major resections (anterior or postero-lateral thoracotomy), and multiport VATS minor procedures, even in highly complex cases such as patients with silicosis. Presence of silicosis should be taken into account as a predictive factor for postoperative complications. Therefore, overestimation of the benefits of the procedure in the patient selection process especially in the initial part of the experience must be avoided.

A model for predicting prolonged length of stay in patients undergoing anatomical lung resection: a National Surgical Quality Improvement Program (NSQIP) database study.

There are currently no studies that have specifically delineated the risk factors for a prolonged length of hospitalization in patients undergoing anatomical lung resection. Knowing these risk factors is important in terms of risk stratification and improving outcomes in the high-risk population. The goal of this study was to identify risk factors associated with a prolonged length of stay (≥14 days) in patients undergoing an anatomical lung resection and to further create a model for predicting the probability of a prolonged length of stay in these patients. The NSQIP database (2005-2013) was culled for data on 45 distinct preoperative, intraoperative and postoperative variables among patients undergoing anatomical pulmonary resections. Univariate and multivariate logistic regression analyses were used to determine variables that contributed to a prolonged length of stay. A scoring system was created based on these results and applied to internal and external (a single institution database) validation groups to test for the adequacy of the model through the comparison of receiver operating characteristic curves. Fifteen factors were found to be significant for prolonged length of stay; six were preoperative (age >70 years [P < 0.0001], functional status-dependent [P = 0.0020], chronic obstructive pulmonary disease [P < 0.0001], serum sodium <135 mmol/l [P = 0.0200], ASA Class 3 [P = 0.0070] and ASA Class 4 or 5 [P = 0.0010]), one was intraoperative (open thoracotomy [P < 0.0001]) and eight were postoperative (pneumonia [P < 0.0001], unplanned reintubation [P < 0.0001], prolonged mechanical ventilation [P < 0.0001], urinary tract infection [P < 0.0001], stroke [P = 0.0020], transfusion [P = 0.0010], deep vein thrombosis/thrombophlebitis [P < 0.0001] and return to the operating room [P < 0.0001]). A simple model for predicting the probability of a prolonged length of stay in patients undergoing anatomical lung resection has been successfully created. This model can allow for better risk stratification of patients preoperatively based on certain existing comorbidities, and can help to predict the impact the development of various postoperative complications will have on overall patient outcomes.

Bipolar Sealing of Lung Veins with 5 mm and 10 mm Instruments - Bursting Pressures Measured in an Ex-Vivo Model

In every anatomic lung resection, lung veins need to be sealed and divided. If open surgery is performed, veins are usually treated with ligatures. In minimally-invasive procedures a vascular stapler is used. Blood vessels can be securely closed with modern bipolar sealing technology. Since this method has rarely been used in lung veins, we carried out the present study on an ex-vivo model to test whether satisfactory bursting pressures can be achieved using 5 mm and 10 mm MARSEAL® sealing instruments. The experimental investigations were carried out on heart-lung preparations (including both lungs) from freshly-slaughtered pigs (weight: 199 lbs). After the lung veins were dissected, three groups were formed according to size: group 1: 1-7 mm, group 2: 8-10 mm and group 3: > 10 mm. Bipolar sealing was performed with a 5 mm or 10 mm MARSEAL® sealing device and the special SealSafe® G5 electric current. Vessels closed by simple ligation served as a control group. A pressure sensor was implanted into the unsealed end of the blood vessel. Air was pumped into the blood vessel and the bursting pressure - the pressure (in mbar) at which the vessel began to leak - was determined digitally. The mean bursting pressures were compared using the non-parametric Mann Whitney U test (the level of significance was p < 0.05). In group 1 the mean bursting pressures for the 5 mm and 10 mm instruments were found to be 167.1 ± 38.7 mbar and 113.8 ± 23.3 mbar, respectively. Both were significantly inferior to the pressure of 178.8 ± 44.5 mbar achieved by the control group. In group 2 the bursting pressures were 122.7 ± 27.8 mbar with the 5 mm instrument and 93.5 ± 39.6 mbar with the 10 mm instrument. The mean bursting pressure for the control group was 180.7 ± 35.8.mbar. In group 3 the mean bursting pressures were 98.2 ± 28.8 mbar with the 5 mm instrument and 65.5 ± 19.7 mbar with the 10 mm instrument. All attempts to seal the entire left atrium failed. In our ex-vivo model of lung veins, acceptable bursting pressures were achieved in blood vessels with a maximum diameter of 10 mm. Bipolar impedance-controlled sealing may create an adequate seal on pulmonary veins up to a diameter of 10 mm. The use of a 10 mm instrument has no advantage compared to a 5 mm instrument. Secure sealing of the left atrium is not possible.

Thulium laser versus staplers for anatomic pulmonary resections with incomplete fissures: negative results of a randomized trial.

This randomized trial evaluated the feasibility and safety of thulium 2010-nm laser to perform anatomic lung resections in patients with incomplete fissures, as compared to mechanical staplers with or without sealants. Seventy-two patients scheduled for segmentectomy or lobectomy were enrolled. After intraoperative confirmation of the extent of resection and incomplete fissures (Craig type 2, 3 or 4), they were randomized and allocated to one of the following arms: laser resection by thulium (group A) or standard resection with mechanical staplers with or without sealants (group B). The primary endpoints of the study included analysis of intraoperative and postoperative course, and costs. Thirty-eight patients were assigned to group A (32 lobectomies, 6 segmentectomies) and 34 to group B (31 lobectomies, 3 segmentectomies). No 30-day mortality was observed. Median operative times were 145.0 minutes (group A) and 142.5 minutes (group B, P = 0.83). The median time to drainage removal was 5 days (group A) and 4 days (group B), while the median length of hospital stay was the same (7 days). Prolonged air leaks >7 days were observed in 12 patients of group A (32%) and 10 patients of group B (29%, P = 0.46). Unpredictable late pneumothorax occurred in 3 patients of group A (2 readmissions, need for 1 repeat thoracotomy). Cost analysis demonstrated an intraoperative advantage for group A (mean 807 ± 212 euro) versus group B (mean 1,047+/-276 euro, P <0.0001), but the differences in total costs could be due to chance (P = 0.83). The use of laser to complete fissures can lead to late pneumothorax, even in the absence of postoperative air leaks. Moreover, the use of laser to complete fissures did not prove to reduce overall costs. Trial Registration Identification Number: 41/10 (IRB00001457 - FWA00001798 - IORG0001063).

Efficacy and hemodynamic response of pleural carbon dioxide insufflation during thoracoscopic surgery in a swine vessel injury model.

Thoracoscopic anatomical lung resection is a minimally invasive technique, but intraoperative massive bleeding is a critical complication. We investigated the hemostatic efficacy and safety of intrapleural carbon dioxide (CO2) insufflation in thoracoscopic surgery in a swine vessel injury model. Swines were assigned to one of four groups subjected to thoracoscopic surgery under target intrathoracic pressures of 0, 5, 10, or 15mmHg CO2 insufflation, respectively. A pin-hole injury of the right cranial lobe pulmonary vein was inflicted thoracoscopically and we compared the blood loss and hemodynamic changes in each group. There were no signs or echographic findings of air embolus. Both the blood loss per minute and total blood loss during the experiment were significantly lower in the 10 and 15mmHg groups than in the 0mmHg group (p>0.05, respectively). The hemodynamic signs, including heart rate, mean arterial pressure, and peripheral oxygen saturation, were not significantly different in the 0 and 10mmHg groups at most times, although they were significantly correlated with the insufflation pressure during the experiments (p<0.05). CO2 insufflation in thoracoscopic major lung resection appears to be safe, even in the short term, and can help to control vessel injury.

Robotic assisted thoracoscopic right upper lobectomy for post tuberculosis aspergilloma.

Minimally invasive techniques for non-oncologic lung resections especially fungal infections are not widely employed. Through this video we share our experience of one such case of a robotic resection of pulmonary aspergilloma. A 55-year-old male with recurrent hemoptysis underwent surgical resection of post tuberculosis aspergilloma of right upper lobe using a 4-arm DaVinci Robot. He received antituberculous drugs for 6 weeks pre-operatively. Systemic antifungals were given 2 weeks prior and continued for 3 months postoperatively. The operative time was 188 minutes and blood loss was 560 mL. Postoperative Chest X-rays showed complete lung expansion. Robotic resection of lung is technically possible with good clinical outcomes even in infective pathologies. Robotic technique allows excellent 3D visualisation and good dexterity for easier and safe dissection of adhesions, as well as effective and precise anatomical lung resections for pulmonary aspergilloma.

Single-port video-assisted thoracic surgery for early lung cancer: initial experience in Japan.

Single-port video-assisted thoracic surgery (SPVATS) emerged several years ago as a new, minimally invasive surgery for diseases in the field of respiratory surgery, and is increasingly becoming a subject of interest for some thoracic surgeons in Europe and Asia. However, the adoption rate of this procedure in the United States and Japan remains low. We herein reviewed our experience of SPVATS for early lung cancer in our center, and evaluated the safety and minimal invasiveness of this technique. We retrospectively analyzed patients who had undergone SPVATS for pathological stage I lung cancer in Nippon Medical School Chiba Hokusoh Hospital between September 2012 and October 2015. In SPVATS, an approximately 4-cm incision was made at the 4(th) or 5(th) intercostal space between the anterior and posterior axillary lines. A rib spreader was not used at the incision site, and surgical manipulation was performed very carefully in order to avoid contact between surgical instruments and the intercostal nerves. The same surgeon performed surgery on all patients, and analyzed laboratory data before and after surgery. Eighty-four patients underwent anatomical lung resection for postoperative pathological stage I lung cancer. The mean wound length was 4.2 cm. Eighty-four patients underwent lobectomy and segmentectomy, respectively. The mean preoperative forced expiratory volume in 1 second (FEV1%) was 1.85%±0.36%. Our patients consisted of 49 men (58.3%) and 35 women (41.7%), with 64, 18, 1, and 1 having adenocarcinoma, squamous cell carcinoma, adenosquamous carcinoma, and small-cell lung cancer, respectively. The mean operative time was 175±21 min, operative blood loss 92±18 mL, and duration of drain placement 1.9±0.6 days. The duration of the postoperative hospital stay was 7.1±1.7 days, numeric rating scale (NRS) 1 week after surgery 2.8±0.6, and occurrence rate of allodynia 1 month after surgery 10.7%. No patient developed serious complications, and no deaths occurred within 30 days of surgery. Two patients (2.4%) were converted to open thoracotomy. SPVATS is a safe and feasible technique, and is promising for next-generation thoracoscopic surgery. It may also reduce postoperative wound pain and contribute to improvements in the activities of daily living of patients.

Uniportal video-assisted thoracic surgery.

Even though the development of thoracoscopic procedures has a history of over a hundred years, it is only in the last two decades that interest in minimally invasive thoracic surgery has been renewed by two key technological improvements. These are the development of endoscopic cameras offering a panoramic view and the availability of new endoscopic instruments such as mechanical staplers. As a result of these advances, video-assisted thoracic surgery (VATS) was born. In 1992, there was a revolution in thoracic surgery when the first anatomic lung resection was performed by VATS through small incisions and with no rib spreading. In the following years, the progress of VATS was slow and accompanied by constant criticism until studies showing clear benefits of VATS over open surgery started to be published. From that point on, the technique spread throughout the world and variations of the technique regarding the number and placement of incisions, surgical approaches and new surgical instruments started to emerge. The information available on the Internet, live surgical events and experimental courses were important factors facilitating the rapid learning curve for minimally invasive surgery during the last decade. While initially slow to catch on, the traditional multi-port approach has evolved into a single-port (uniportal) approach that mimics open surgical vantage points while utilizing a non-rib-spreading, non-thoracotomy micro-incision. The early development of uniportal VATS was focused on minor procedures until the second phase of uniportal VATS started in 2010 with application of the technique to major pulmonary resections. In a period of only five to six years, experts have been able to apply the uniportal VATS technique to more complex procedures such as bronchial sleeve and carinal resections as well as vascular reconstructions. In contrast, non-intubated thoracic surgical techniques, described since the early history of thoracic surgery, peaked in the decades before the invention of the double-lumen endotracheal tube and have failed to gain widespread acceptance following their re-emergence over a decade ago thanks to improvements in video-assisted thoracoscopic techniques. In addition, experienced uniportal VATS surgeons are able to explore new and even less invasive approaches. Recently, the aim to avoid intercostal nerve damage by the transthoracic incision has led to the use of the technique through a single subxiphoid incision. It’s interesting to note that from the first thoracoscopic procedure performed more than a century ago, the biggest developments have taken place in the last five years. Several factors are responsible for this. The Internet has provided an invaluable platform to share knowledge. The development of specialized websites to which videos can be uploaded and scientific journals that include videos have contributed enormously to the dissemination and learning of minimally invasive techniques, especially uniportal VATS. The development of modern, narrowed and angulated endostaplers and other specialized surgical instruments have also been key factors contributing to the growing interest in uniportal video-assisted surgery in the last few years. At the same time, advances in the technology of ultra-high definition cameras, 3D technology and precise robotic systems have contributed to the progressive adoption of minimally invasive surgery throughout the globe. This special issue provides a summary of different aspects of uniportal VATS including several articles written by some of the best world experts in this technique. Areas covered range from the early experience of several groups to reports from the most experienced surgical teams, as well as emerging techniques such as uniportal non-intubated and subxiphoid approaches. Alongside medical and radiation oncology, which are advancing rapidly due to the development of more effective chemotherapeutic agents with less toxicity and novel radiation techniques such as stereotactic body radiation therapy (SBRT), the role of the surgeon is to offer the patient the best oncologic procedure with the least invasive approach possible. During the last couple of years, rapid progress in instrument design and technology have triggered the development of narrower and more angulated endostaplers, sealing devices for vessels and other refined thoracoscopic instruments. We truly believe in the use of the least invasive techniques such as the uniportal approach combined with modern ‘naked eye’ 3D image systems, wireless cameras and improved robotic technology to perform major pulmonary resections. Further advancements in technology will facilitate the adoption of single-incision minimally invasive techniques worldwide in the upcoming years. Video Uniportal video-assisted thoracic surgery.