Invasive Thoracoscopic Surgery Research Articles

P2.17A.07 Impact of Preoperative Anxiety on Postoperative Outcomes in Patients Undergoing Minimally Invasive Thoracoscopic Surgery

P2.17A.07 Impact of Preoperative Anxiety on Postoperative Outcomes in Patients Undergoing Minimally Invasive Thoracoscopic Surgery

Impact of preoperative anxiety on postoperative outcomes in patients undergoing minimally invasive thoracoscopic surgery: A prospective cohort study

BackgroundPreoperative anxiety is a common preoperative psychological state in patients with cancer and associated with worsening perioperative outcomes. However, high-quality prospective studies on preoperative anxiety in patients undergoing lung surgery are scarce. MethodsWe conducted a prospective cohort study, enrolling a total of 540 patients. Preoperative anxiety in patients undergoing thoracic surgery was measured using the Hospitalization Anxiety Scale. Patients were grouped according to the Hospitalization Anxiety Scale scores as follows: no anxiety (score <8) and anxiety (score ≥8). The association of preoperative anxiety with postoperative complications and non-complicated adverse events was determined by univariate regression and polynomial regression analyses. ResultsA total of 121 patients (22.4 %) experienced preoperative anxiety. The anxiety group had a longer average hospital stay (4.33 vs. 3.85 days). Postoperative complications were similar between groups, but the anxiety group reported worse sleep quality (measured by the Athens Insomnia Scale). Regarding postoperative pain, both groups had comparable rates of mild and severe pain on postoperative day 1. However, the anxiety group experienced significantly higher rates of severe pain on postoperative day 2 and mild pain on postoperative day 3. Additionally, the incidence of postoperative nausea and vomiting was significantly higher in the anxiety group on postoperative day 1. ConclusionsPreoperative anxiety may not increase the rates of postoperative complications in patients undergoing lung surgery. However, it may be associated with postoperative sleep disturbances, pain, nausea, and vomiting, as well as prolong the length of postoperative hospitalization.

Minimally Invasive Thoracoscopic Surgery of Lung Adenocarcinoma in Old Age People

Minimally Invasive Thoracoscopic Surgery of Lung Adenocarcinoma in Old Age People

A New Index for the Quantitative Evaluation of Surgical Invasiveness Based on Perioperative Patients' Behavior Patterns: Machine Learning Approach Using Triaxial Acceleration.

The minimally invasive nature of thoracoscopic surgery is well recognized; however, the absence of a reliable evaluation method remains challenging. We hypothesized that the postoperative recovery speed is closely linked to surgical invasiveness, where recovery signifies the patient's behavior transition back to their preoperative state during the perioperative period. This study aims to determine whether machine learning using triaxial acceleration data can effectively capture perioperative behavior changes and establish a quantitative index for quantifying variations in surgical invasiveness. We trained 7 distinct machine learning models using a publicly available human acceleration data set as supervised data. The 3 top-performing models were selected to predict patient actions, as determined by the Matthews correlation coefficient scores. Two patients who underwent different levels of invasive thoracoscopic surgery were selected as participants. Acceleration data were collected via chest sensors for 8 hours during the preoperative and postoperative hospitalization days. These data were categorized into 4 actions (walking, standing, sitting, and lying down) using the selected models. The actions predicted by the model with intermediate results were adopted as the actions of the participants. The daily appearance probability was calculated for each action. The 2 differences between 2 appearance probabilities (sitting vs standing and lying down vs walking) were calculated using 2 coordinates on the x- and y-axes. A 2D vector composed of coordinate values was defined as the index of behavior pattern (iBP) for the day. All daily iBPs were graphed, and the enclosed area and distance between points were calculated and compared between participants to assess the relationship between changes in the indices and invasiveness. Patients 1 and 2 underwent lung lobectomy and incisional tumor biopsy, respectively. The selected predictive model was a light-gradient boosting model (mean Matthews correlation coefficient 0.98, SD 0.0027; accuracy: 0.98). The acceleration data yielded 548,466 points for patient 1 and 466,407 points for patient 2. The iBPs of patient 1 were [(0.32, 0.19), (-0.098, 0.46), (-0.15, 0.13), (-0.049, 0.22)] and those of patient 2 were [(0.55, 0.30), (0.77, 0.21), (0.60, 0.25), (0.61, 0.31)]. The enclosed areas were 0.077 and 0.0036 for patients 1 and 2, respectively. Notably, the distances for patient 1 were greater than those for patient 2 ({0.44, 0.46, 0.37, 0.26} vs {0.23, 0.0065, 0.059}; P=.03 [Mann-Whitney U test]). The selected machine learning model effectively predicted the actions of the surgical patients with high accuracy. The temporal distribution of action times revealed changes in behavior patterns during the perioperative phase. The proposed index may facilitate the recognition and visualization of perioperative changes in patients and differences in surgical invasiveness.

Pediatric Thoracoscopy: Ten Years Experience in Tertiary Hospital

Purpose: A minimally invasive Thoracoscopic Surgery (TS) offers several options in diagnosis and surgical treatment in pediatric surgery. This study evaluates experience and outcome of thoracoscopic surgery in pediatrics during 10 years period in tertiary hospital. Patients and methods: This retrospective study conducted at King Faisal Hospital and Research Center, Jeddah, Saudi Arabia from 2012 to 2022. Data of 43 patients who underwent TS were enrolled. Data include patient’s demographic characteristics, co-morbidity, diagnosis, type of thoracoscopic procedures, time of intervention, length of hospital stay, post-operative complications. Results: Mean age of patients was 4.99 years. Females were more than males (55.8 vs. 44.2%). Sixteen (37.2%) patients had comorbidities. Thoracoscopic proce- dures were feasible in 43 children and adolescents with chest diseases including lung empyema (20.9%), congenital lobar emphysema (14.0%), interstitial lung disease (14.0%), congenital pulmonary airway malformation (11.6%), mediastinal mass (9.3%), lung metastasis (11.6%), lymphoma (4.7%), chronic inflamma- tions (7.0%), hemothorax (2.3%), bronchogenic cyst (2.3%), pleural effusion (2.3%) and pulmonary sequestration and right diaphragmatic hernia (2.3%). Proce- dures were made mostly for lung biopsy (25.0%), lobectomy (22.7%), decortication (20.9%), mediastinum mass resection (6.8%), lung metastasectomy (6.8%), lymph node biopsy (4.5%), diagnostic (4.6%), cyst excision (4.6%), diaphragmatic hernia repair (2.3%) and thymectomy (2.3%). Duration of hospital stay ranged from 2-180 days. All of the cases had chest drain (100.0%) and some of them required post-operative intubations (30.2%). Conversion rate to open was (4.7%). Complications were pneumothorax (7.0%), bleeding (2.3%) and air leak (2.3%). Conclusions: Thoracoscopic approach is a challenging method for diagnosis and treatment in pediatrics. However, complications were reported as pneumo- thorax, bleeding and air leak. In order to improve results, conversion rates, and the capacity to handle thoracoscopic complications, proper training is crucial.

Imaging and pathological characteristics, treatment, and prognosis of pulmonary sequestration-A retrospective study of 13 cases.

This study aimed to summarize and analyze the characteristics of pulmonary sequestration to improve our understanding of this disease. Between January 2019 and April 2023, the clinical data of 13 patients with pulmonary sequestration underwent surgical treatment at the First Affiliated Hospital of Gannan Medical University. The male-to-female ratio was 4:9, the age was 0.5 to 60 years, and the average age was 38 ± 19 years. There were 10 and 3 cases of intralobar and extralobar pulmonary sequestration, respectively. Chest enhanced computed tomography (CT) and three-dimensional vascular reconstruction showed that the abnormal blood vessels were derived from the descending thoracic aorta in nine cases and from other blood vessels in four cases. Three patients underwent thoracoscopic lobectomy, two underwent thoracoscopic segmentectomy, and eight underwent thoracoscopic wedge resection. All the patients successfully completed the surgery and were discharged postoperatively. Some patients with pulmonary sequestration exhibit no obvious symptoms. Patients with clinical symptoms are easily confused for pneumonia, bronchial cysts, lung abscesses, and lung tumors; therefore, patients with pulmonary sequestration are prone to missed diagnosis and misdiagnosis. Currently, enhanced chest CT combined with three-dimensional vascular reconstruction can accurately show the course, branches, and relationship with the mass of the feeding artery. Routine pathological examination is helpful to further clarify the diagnosis of pulmonary sequestration. Minimally invasive thoracoscopic surgery is the preferred treatment for patients with pulmonary sequestration. Surgical resection is safe and feasible, and satisfactory results are typically obtained.

A Systematic Review of Short-Term Outcomes of Minimally Invasive Thoracoscopic Surgery for Lung Cancer after Neoadjuvant Systemic Therapy.

Minimally invasive surgeries for non-small cell lung cancers (NSCLCs) such as video-assisted thoracoscopic surgeries (VATSs) and robotic-assisted thoracoscopic surgeries (RATSs) have become standard of care for patients needing surgical resection in early stages. The role for neoadjuvant systemic therapy has increased with patients receiving neoadjuvant systemic chemotherapy and immunotherapy. However, there has been some equipoise over the intraoperative and overall outcomes for these patients. Here, we review the current data regarding outcomes of patients undergoing minimally invasive thoracic surgical resection after systemic chemotherapy, immunotherapy, or both. A systematic literature review of randomized controlled trials and observational studies presenting data on patients with NSCLC that underwent neoadjuvant systemic therapy followed by minimally invasive surgery was performed assessing complications, conversion rates, and lymph node yield. Our search strategy and review of references resulted in 239 publications to screen with 88 full texts assessed and 21 studies included in our final review. VATS had a statistically significant higher lymph node yield in five studies. The reported conversion rates ranged from 0 to 54%. Dense adhesions, bleeding, and difficult anatomy were the most common reported reasons for conversion to open surgeries. The most common complications between both groups were prolonged air leak, arrythmia, and pneumonia. VATS was found to have significantly fewer complications in three papers. The current literature supports VATS as safe and feasible for patients with NSCLC after neoadjuvant systemic treatment. Surgeons should remain prepared to convert to open surgeries in those patients with dense adhesions and bleeding risk.

Ultrasound-Guided Selective Bronchial Intubation: A Feasibility Study in Pediatric Animal Model.

ObjectiveSelective one-lung ventilation used to optimize neonatal and pediatric surgical conditions is always a demanding task for anesthesiologists, especially during minimally invasive thoracoscopic surgery. This study aims to introduce an ultrasound-guided bronchial intubation and exclusion technique in a pediatric animal model.MethodsSeven rabbits were anesthetized and airway ultrasound acquisitions were done.ResultsTracheal tube progression along the trachea to the right bronchus and positioning of the bronchial blocker in the left bronchus were successfully done with consistent ultrasound identification of relevant anatomical structures.ConclusionThe study provided a new application of ultrasound in airway management. More advanced experimental studies are needed since this technique has the potential for translation to pediatric anesthesia.

Treatment of Siewert type II adenocarcinoma of the esophagogastric junction: the perspectives from thoracic surgery

A greater controversy remains in clinical diagnosis and treatment of Siewert type II adenocarcinoma of esophagogastric junction (AEG), compared with Siewert type I and III AEG. In 2018, the first edition of Chinese Expert Consensus on the Surgical Treatment for Adenocarcinoma of Esophagogastric Junction was published in the Chinese Journal of Gastrointestinal Surgery. In the past few years, the advance in minimally invasive thoracoscopic surgery has been proven to reduce thoracic trauma in Siewert type II AEG. Meanwhile, distal thoracic esophagectomy can achieve more complete resection, and upper abdomen-right thoracic approach can ensure the mediastinal lymph node dissection and improve long-term survival. The concept and practice of endoscopic surgery and the comprehensive treatment also give new supplements to the treatment regimen of Siewert type II AEG. More clinical researches should be conducted to address the surgical residual safety and lymph node dissection issues.

Progress in the esophagogastric anastomosis and the challenges of minimally invasive thoracoscopic surgery.

The esophagogastric anastomosis is most commonly performed to restore digestive tract continuity after esophagectomy for cancer. Despite a long history of clinical research and development of high-tech staplers, this procedure is still feared by most surgeons and associated with a 10% leakage rate. Among specific factors that may contribute to failure of the esophageal anastomosis are the absence of serosa layer, longitudinal orientation of muscle fibers, and ischemia of the gastric conduit. It has recently been suggested that the gut microbiome may influence the healing process of the anastomosis through the presence of collagenolytic bacterial strains, indicating that suture breakdown is not only a matter of collagen biosynthesis. The esophagogastric anastomosis can be performed either in the chest or neck, and can be completely hand-sewn, completely stapled (circular or linear stapler), or semi-mechanical (linear stapler posterior wall and hand-sewn anterior wall). Because of the lack of randomized clinical trials, no conclusive evidence is available, and the debate between the hand-sewn and the stapling technique is still ongoing even in the present era of robotic surgery. Centralization of care has improved the overall postoperative outcomes of esophagectomy, but the esophagogastric anastomosis remains the Achille’s heel of the procedure. More research and network collaboration of experts is needed to improve safety and clinical outcomes.

First clinical application of radiofrequency identification (RFID) marking system-Precise localization of a small lung nodule.

ObjectivesPrecise small lung nodule resection is challenging in minimally invasive thoracoscopic surgery. Various methods that help surgeons to locate the target nodule have been devised; however, the ideal way that satisfies the demand has not yet been realized. We have developed and applied a novel marking system to localize small lung nodules for the first time in humans.MethodsA radiofrequency identification tag (1.8 mm in diameter and 7 mm in length) that can communicate with a wand-shaped antenna (10 mm in diameter) from the distance of 3 cm was prepared. The tag was delivered adjacent to a 7-mm subsolid nodule in the right lower lobe of a patient under cone beam computed tomography guidance and video-assisted thoracoscopic surgery wedge resection was subsequently performed.ResultsThe delivery of the tag was smooth, and the tag was almost immediately detected by the antenna. Wedge resection was successfully performed with the guiding signal from the tag.ConclusionsWe have so far demonstrated that this technology could be applicable for small lung nodule detection in preclinical studies. In this first clinical experience, this system proved to provide accurate positional information of small lung nodules with depth.

Treatment of Spontaneous Pneumothorax by using the Video Assisted Thoracoscopic Surgery and Mini Invasive Thoracoscopic Surgery

Background and Aim: The temporizing treatment for spontaneous pneumothorax had been established methodically, but thoracoscopic surgical methods has been not yet. The objective of the study is to show the treatment effect of intra- and post-operation by using rational thoracoscopic surgery for the patients with spontaneous pneumothorax. Methods: We had performed Video Assisted Thoracoscopic Surgery (VATS) and Mini Invasive Thoracoscopic Surgery (MITS) for 322 patients with spontaneous pneumothorax and established rational surgery approach between January 2011 and December 2017. And then we evaluated the outcome of surgery compared to common thoracotomy. Results: Compared to common thoracotomy, VATS was an operation with large economic efficacy because of light operation associated injury, fast recovery and the ability to decrease temporary disability rate. And also it saved different drugs and provided Quality of life (QOL) because of low operative cicatrix. Conclusion: VATS not only gave light operative burden to patients but also decreased surgeons’ mental and physical fatigue. In the MITS automatic suture tool with expensive cost and limited indications was not used and the range of indications were wide and operating time was shortened because of procedure under direct visual field associated with thoracoscopy.

Mitral valve replacement via minimally invasive totally thoracoscopic surgery versus traditional median sternotomy: a propensity score matched comparative study.

To compare surgical outcomes after mitral valve replacement via either minimally invasive thoracoscopic (MIs) or traditional median sternotomy (MS) surgery and determine the short- and mid-term clinical outcomes of the MI approach. All patients who received either MIs (n=405) or MS (n=691) mitral valve replacement surgery at the Guangdong Cardiovascular Institute between January 2012 and July 2015 were analyzed for outcome differences due to surgical approach using propensity score matching. The best 202 matches from the MI group and the MS group were analyzed. The clinical data of the two groups were collected, including preoperative cardiac function, operative data, postoperative complications, and follow-up. A final total of 404 patients were included in this study after propensity score matching; the MIs group and the MS group each contained 202 patients. The two groups were similar in age, weight, pathological changes, and surgical approach. Compared with the MS group, the MIs group had a longer cardiopulmonary bypass time (P<0.001), aortic cross-clamping time (P<0.001), and total procedure time (P<0.001). There were no significant differences between the groups regarding in-hospital mortality, stroke, pneumonia, acute renal failure, arrhythmia, and chylothorax. The MS group had significantly more patients with poor wound healing than the MIs group (P=0.004). The MI group had a lower rate of transfusion (P=0.037), shorter ventilation time (P=0.041), shorter ICU stay (P=0.033), reduced chest tube drainage and length of chest tube stay (P<0.001), and shorter hospital stay (P<0.001). There was no significant difference between the groups in hospital re-admission for bleeding, but the total hospitalization cost was higher in the MIs group (P=0.002). The mean follow-up was 26.59±12.33 months, the 1-year postoperative survival rate was 98.86%, and the overall survival rate was 97.44%. Compared with the MS group, the MIs group recovered earlier (P<0.05), and returned to work or study earlier (P<0.05). More patients in the MIs group were satisfied with the wound (P<0.001). The MS group had a higher incidence of postoperative osteomyelitis than the MIs group (P=0.028). There were no significant differences between groups in rates of mortality, stroke, pacemaker, reoperation, or 36-item Short Form Health Survey score. Compared with the MS approach, the MIs method of mitral valve replacement has longer cardiopulmonary bypass time and aortic cross-clamp time; however, it does not increase the risk of mortality and complications. Furthermore, MIs causes less trauma, fewer transfusions, less wound infection, faster recovery, faster return to work or study, and greater satisfaction with the incision in the mid-term. MI cardiac surgery is safe, effective, and feasible.

Minimally invasive thoracoscopic surgery is an effective approach for treating inappropriate sinus tachycardia.

Inappropriate sinus tachycardia (IST) is characterized by increased heart rate out of proportion to normal physiologic demand. IST ablation is challenging for the electrophysiology community due to the epicardial location of the sinus node and the risk of phrenic nerve (PN) injury during catheter ablation. In this study, we investigated the safety and efficacy of a minimally invasive thoracoscopic surgery for elimination of IST. Patients with IST who failed medical therapy or endocardial ablation underwent minimally invasive thoracoscopic epicardial ablation. Epicardial activation mapping was performed to identify the earliest activation site and any possible migration of earliest activation along the lateral right atrium. The PN in each patient was protected by a pericardial retraction suture. From 1 January 2000 to 15 June 2018, 10 patients (eight females and two males) underwent minimally invasive thoracoscopic IST ablation. Mean age of the patients was 36.7 ± 12.5 years. Mean baseline sinus rate was 113.8 ± 21.8 beats per minute. After surgery, the mean heart rate significantly decreased to 79.8 ± 8.2 at postoperative day 1 and to 75.8 ± 8.1 at day 30 (both P < .001). No in-hospital death, stroke, or PN injury occurred. One patient required reintubation, one patient developed postoperative pericarditis, and another patient had a pulmonary embolus. Median follow-up was 6 months (range, 1-50). Freedom from reintervention was 88% at 6 months. Minimally invasive thoracoscopic ablation for IST is a safe and effective approach that preserves the phrenic nerve. Due to the possibility of IST activation site migration, continued follow-up after surgery is required.

Image-guided pulmonary metastasectomy in the hybrid operating room

Surgical radicality is the main prognostic factor in patients who have undergone pulmonary metastasectomy, despite potential differences in underlying primary cancer biology. Current localization techniques place fiducial markers into the lung parenchyma to facilitate detection and guide resection of pulmonary nodules during minimally invasive thoracoscopic surgery. Markers include metal, dye, radiopaque agents, fluorescent contrast, and radiolabeled agents. Traditional marker-guided pulmonary resection comprises a two-stage workflow: (I) preoperative computed tomography (CT)-guided transthoracic implantation of a fiducial marker in the interventional CT suite followed by (II) patient transfer to the operation room for surgical removal. However, the patient is at risk for procedural adverse effects or dislodgement of the marker during the interval period between localization completion and surgery start. The development of a hybrid operating room allows for a one-stage approach to localization, as well as the integration of new imaging modalities and localization methods to pulmonary metastasectomy. In this review, we will explore several current and novel technologies in development relevant for image-guided pulmonary metastasectomy, informed by studies in the setting of hybrid operating room as well as our own experience with the Guided Therapeutics operating room at Toronto General Hospital.

A Novel Shape-Memory Monofilament Suture for Minimally Invasive Thoracoscopic Cardiac Surgery.

Endoscopic knot tying can complicate or prolong minimally invasive surgical procedures. A novel shape-memory monofilament suture with a spiral tail has been developed to speed up suture fixation during minimally invasive cardiac surgery. The purpose of this study was to evaluate its usefulness and safety in minimally invasive cardiac surgery. We installed a needle with a 4-0 monofilament suture, composed of polyvinylidene difluoride and hexafluoropropylene copolymers, in an originally invented jig and heated it in an oven. By only passing through the needle and then into the spiral made at the tail of the suture, a hangman's knot was easily made. For the fundamental experiment, to evaluate the effectiveness of the novel shape-memory monofilament suture, 4 surgeons with varying thoracoscopic experience tied knots within a simulated minimally invasive setting, using both the novel shape-memory and conventional monofilament sutures. The time elapsed for knot tying and tensile strength of each knot was measured. The mean knot-tying time was significantly shorter with the novel suture than with the conventional suture (108 ± 29 vs. 172 ± 42 seconds, P = 0.01). The ultimate tensile strength of each knot was 17.4 N in the novel suture and 16.5 N in the conventional suture. The novel shape-memory monofilament suture has great potential for reducing operative time of minimally invasive thoracoscopic surgery while retaining the strength of the knot.

Advances in Surgical Approach and Resection of Non-small Cell Lung Cancer

随着疾病谱的改变，肺癌的发病率和死亡率在全球范围内一直居高不下，自从外科干预被应用于肺癌的治疗，其地位日益提高，目前以外科手术为主的综合治疗已成为肺癌治疗的首选方案，外科手术入路和术式种类繁多，并且新的技术不断出现，本文拟总结不同手术方式和手术入路的研究进展。随着手术软硬件技术的发展和微创理念深入人心，胸腔镜微创手术较传统开胸手术为肺癌患者带来了更多的福音，手术方式的改变也可更大限度保留肺组织，提高患者的生存质量，相信随着各类手术适应证和手术方式的进一步规范，微创胸腔镜手术会给肺癌患者带来更多的益处。

Supine awake subxiphoid lung resection in a severe obese patient with idiopathic pulmonary fibrosis

Surgical biopsy of idiopathic pulmonary fibrosis (IPF) is still associated with not negligible mortality, especially for acute exacerbation. Nowadays, minimally invasive thoracoscopic surgery under general anesthesia is the gold standard procedure. We report a case of a very high-risk patient because of severe obesity and acute respiratory failure who underwent surgical biopsy. A multidisciplinary approach is mandatory to achieve good results in such fragile patients. Awake thoracoscopic subxiphoid approach could be very effective to reduce morbidity and mortality in IPF patients who needs surgical biopsy. The supine position could be useful in obese patients or in patients with difficult airway management.

Subxiphoid robotic thymectomy for myasthenia gravis

The robotic system provides a three-dimensional (3D) visual field and has articulated forceps that function in a manner similar to the human wrist, which enables natural dissection, resection, and suturing manipulations. In the present paper, the history and current state of robot-assisted thymectomy for myasthenia gravis (MG) are presented, and the surgical procedure for subxiphoid robotic thymectomy for MG is described. In robot-assisted thymectomy by a subxiphoid approach, the insertion of a camera through the subxiphoid incisional wound enables observation of the entire innominate vein, and the presence of robotic articulations in the mediastinum enables the surgeon to easily and safely tape the blood vessels. Therefore, robot-assisted subxiphoid thymectomy enables minimally invasive thoracoscopic surgery to be performed on patients who have been unsuitable candidates for thoracoscopic surgery, and indications for thoracoscopic thymectomy have increased. Future improvements in robot-assisted systems may enable surgery that cannot be currently performed by human hands to be completed by robot-assisted surgery.

A case report of cardia cancer complicated with idiopathic muscular hypertrophy of the oesophagus treated with thoracoscopic surgery

The incidence of idiopathic muscular hypertrophy of oesophagus (IMHE) is low, and <100 cases of IMHE have been reported. IMHE is a benign oesophageal disease, characterised by hyperplasia of all layers of the wall and in particular, muscle layer. Only a few cases have been reported regarding its clinical symptoms and images. In this present case, we report a cardia cancer with IMHE, showing significant hypertrophy of muscular layer of middle part of the oesophagus and successfully treated with minimally invasive thoracoscopic surgery.