Major Pulmonary Resection Research Articles

Subxiphoid Uniportal Robotic Assisted Right Upper Lobectomy in Swine: A Novel Technology.

Uniportal video assisted thoracoscopic surgery has become widely accepted with increasing subxiphoid approach for major pulmonary resections. The purpose of this study was to verify the safety and feasibility of a SHURUI single port (SP) Robotic Surgical System in subxiphoid right upper lobectomy. Five swine models were used to perform subxiphoid right upper lobectomy with SHURUI SP Robotic Surgical System. Operation details were recorded to assess the safety and feasibility of the SHURUI system. Results showed that the operation success was 100%. The time from anaesthesia to complete docking of the robotic system was 30.0 (20.0, 36.0) minutes and the total operation time was 125.0 (62.0, 142.5) minutes. Blood loss during operation was 30.0 (25.0, 125.0) mL. No death or complications occurred during the operation. Uniportal robotics assisted right upper lobectomy via subxiphoid approach with SHURUI system performed in this study preliminary showed its safety and feasibility.

Routine conventional leak test is not required for robotic major pulmonary resections.

We retrospectively evaluated whether or not conventional air leak testing is necessary in robotic major pulmonary resections. After excluding patients who received 2 or more days of postoperative drainage for chylothorax or excessive pleural effusion, 578 patients who underwent major pulmonary resection using minimally invasive approaches between February 2019 and November 2023 at our institution were included in this study. All patients were divided into two groups including thoracoscopic (n = 471) and robotic (n = 107) approaches. Conventional air leak testing was performed in all patients in the thoracoscopic approach but not in the robotic approach. After propensity score matching of patient backgrounds between the two groups, perioperative outcomes were compared (n = 100 each). The primary endpoint was the rate of drain removal on postoperative day (POD) 2 or later. In addition, factors associated with drain removal on POD 2 or later in the robotic group were identified. The rate of drain removal at POD 2 or later was not significantly different between the two groups (p = 0.011). Multivariable analysis to identify factors associated with drain removal at POD2 or later in the robotic approach showed that sealant application (p = 0.002) and lobectomy (vs. segmentectomy, p = 0.034) were significantly associated. In conclusion, even in the absence of air leak testing, a robotic approach for major lung resections can result in a drain removal rate on the day of surgery or POD1 that is comparable to a conventional thoracoscopic approach. However, it may be useful in selected patients requiring sealant placement or undergoing lobectomy.

Prior coronary stent does not exclude major pulmonary resection regardless of antiplatelet therapy.

We assessed the safety of general thoracic surgery in patients with prior coronary stents undergoing lung resection, based on differences in perioperative antiplatelet therapy management. We retrospectively examined 150 patients with coronary artery stents who underwent pulmonary resection between July 2009 and July 2018. The impact of the antiplatelet agent on thoracic surgery safety was assessed by comparing perioperative outcomes, including major adverse cardiac and cerebrovascular events, among the discontinued antiplatelet therapy (group D), heparin bridging (group H), and continuous antiplatelet therapy (group C) groups. Groups D, H, and C included twenty-four, eighty-four, and forty-two patients, respectively. Second-generation drug-eluting stents were used in > 50% of the patients. No significant differences were found in the estimated blood loss, transfusion rate, or operative duration. Major adverse cardiac and cerebrovascular events occurred in four (2.7%) patients, which was comparable among the groups. In group H, postoperative heart failure and transient ischemic attack with stroke occurred in one patient each. Major bleeding occurred in two (4.7%) patients in group C. Pulmonary resection surgical outcomes in patients with coronary artery stents were feasible regardless of antiplatelet therapy continuation. However, discontinuing dual-antiplatelet or single-antiplatelet therapy in such patients may be reasonable because this generation of drug-eluting stents has a higher safety profile than bare-metal and first-generation drug-eluting stents.

Early Clinical Outcomes of Thoracoscopic Major Pulmonary Resection and Thymectomy Using Novel Articulating Endoscopic Forceps.

Video-assisted thoracoscopic surgery (VATS) is recognized as a safe and effective treatment modality for early-stage lung cancer and anterior mediastinal masses. Recently, novel articulating instruments have been developed and introduced to endoscopic surgery. Here, we share our early experiences with VATS major pulmonary resection and thymectomy performed using ArtiSential articulating instruments. At the Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 500 patients underwent VATS pulmonary resection between July 2020 and April 2023, while 43 patients underwent VATS thymectomy between January 2020 and April 2023. After exclusion, 224 patients were enrolled for VATS major pulmonary resection, and 38 were enrolled for VATS thymectomy. ArtiSential forceps were utilized in 35 of the 224 patients undergoing pulmonary resection and in 12 of the 38 individuals undergoing thymectomy. Early clinical outcomes were retrospectively analyzed. No significant differences were observed in sex, age, surgical approach, operation time, histological diagnosis, or additional procedures between the patients who underwent surgery using novel articulating instruments and the group treated with conventional endoscopic instruments for both VATS major pulmonary resection and thymectomy. However, the use of the novel articulating endoscopic forceps was associated with a significantly larger number of dissected lymph nodes (p=0.028) and lower estimated blood loss (p=0.009) in VATS major pulmonary resection. Major pulmonary resection and thymectomy via VATS using ArtiSential forceps were found to be safe and effective, with early clinical outcomes comparable to established methods. Further research into long-term clinical outcomes and cost-effectiveness is warranted.

Risk Factor Analysis of Morbidity and 90-Day Mortality of Curative Resection in Patients with Stage IIIA-N2 Non-Small Cell Lung Cancer after Induction Concurrent Chemoradiation Therapy.

Major pulmonary resection after neoadjuvant concurrent chemoradiation therapy (nCCRT) is associated with a substantial risk of postoperative complications. This study investigated postoperative complications and associated risk factors to facilitate the selection of suitable surgical candidates following nCCRT in stage IIIA-N2 non-small cell lung cancer (NSCLC). We conducted a retrospective analysis of patients diagnosed with clinical stage IIIA-N2 NSCLC who underwent surgical resection following nCCRT between 1997 and 2013. Perioperative characteristics and clinical factors associated with morbidity and mortality were analyzed using univariable and multivariable logistic regression. A total of 574 patients underwent major lung resection after induction CCRT. Thirty-day and 90-day postoperative mortality occurred in 8 patients (1.4%) and 41 patients (7.1%), respectively. Acute respiratory distress syndrome (n=6, 4.5%) was the primary cause of in-hospital mortality. Morbidity occurred in 199 patients (34.7%). Multivariable analysis identified significant predictors of morbidity, including patient age exceeding 70 years (odds ratio [OR], 1.8; p=0.04), low body mass index (OR, 2.6; p=0.02), and pneumonectomy (OR, 1.8; p=0.03). Patient age over 70 years (OR, 1.8; p=0.02) and pneumonectomy (OR, 3.26; p<0.01) were independent predictors of mortality in the multivariable analysis. In conclusion, the surgical outcomes following nCCRT are less favorable for individuals aged over 70 years or those undergoing pneumonectomy. Special attention is warranted for these patients due to their heightened risks of respiratory complications. In high-risk patients, such as elderly patients with decreased lung function, alternative treatment options like definitive CCRT should be considered instead of surgical resection.

Zero-leak prediction during major lung resection aiming for minimal chest drainage duration: a retrospective analysis

BackgroundEarly chest tube removal should be considered to enhance recovery after surgery. The current study aimed to provide a predictive algorithm for air leak episodes (ALE) and to create a knowledge base for early chest tube removal.MethodsThis retrospective study enrolled patients who underwent thoracoscopic anatomical pulmonary resections in our unit. We defined ALE as any airflow ≥ 10 mL/min recorded in the follow-up charts based on the digital thoracic drainage device. Multivariate regression analysis was used to control for preoperative and intraoperative confounding factors. The ALE prediction algorithm was constructed by combining an additive ALE risk-scoring system using the coefficients of the significant predictive factors with the intraoperative water-sealing test.ResultsIn 485 consecutive thoracoscopic major pulmonary resections, ALE developed in 209 (43%) patients. Statistically significant ALE-associated preoperative factors included male sex, lower body mass index, radiologically evident emphysema, lobectomy, and upper lobe surgery. Significant ALE-associated intraoperative factors were incomplete fissure and pleural adhesion. The ALE risk scoring demonstrated an average area under the receiver operating characteristic curve of 0.72 in the fivefold cross-validation test. The ALE prediction algorithm correctly predicted ALE-absent patients at a negative predictive value of 80%.ConclusionsThe algorithm may promote the optimization of the chest tube-dwelling duration by identifying potential ALE-absent patients for accelerated tube removal.

Endobronchial ultrasound-transbronchial needle aspiration: effectiveness and accuracy in non-small cell lung cancer staging.

Endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) has a cardinal role in the diagnosis and staging of non-small cell lung cancer (NSCLC), providing an accurate nodal staging in a less invasive way than surgical biopsy. The aim of this study was to assess the diagnostic accuracy of EBUS-TBNA in the pre-operative NSCLC mediastinal staging, as well as to evaluate EBUS-TBNA specificity and sensibility in our cohort. We retrospectively analyzed data of NSCLC patients who underwent EBUS-TBNA followed by major pulmonary resection between January 2020 and December 2022. EBUS-TBNA was performed in patients with NSCLC (central T ≤ 3cm, peripheral/central T > 3cm), following the ESTS guidelines. The target nodes were selected on the basis of their radiologic/metabolic characteristics. Each procedure was conducted together with rapid on-site cytological evaluation (ROSE). Twenty-five patients were included (M/F = 17/8). At least three needle passages on each target lymph node were performed. No complications during or after the procedures occurred. We found a 100% correspondence between ROSE on the sampled nodes and postoperative pathologic findings. An upstaging occurred in three cases (12%) because of the involvement of stations 5 and 6 (not accessible via EBUS), while the only case of downstaging (N2 → N0, 4%) was probably due to intercurrent neoadjuvant chemotherapy. In all cases, EBUS-TBNA has proved to achieve a diagnostic procedure on the target nodes. EBUS-TBNA is a safe and effective procedure that offers high sensitivity and specificity when performed together with ROSE, which improves the accuracy of sampling. Doubt on nodal stations 5 and 6 involvement should be settled by other techniques.

Single-port robotic subcostal major pulmonary resection using the single-port robotic system.

The da Vinci single-port system (SPS) (Intuitive Surgical, Sunnyvale, CA, USA) was designed for single-port (SP) surgery. Although we have reported our clinical outcomes using the SPS for a simple procedure in general thoracic surgery, major pulmonary resection had been performed only in cadaveric experiments to date. This study evaluated the feasibility of SP subcostal robotic major pulmonary resection using the SPS. Here, we present our initial clinical experience of SP subcostal robotic major pulmonary resection at our institution. Twenty-five patients with lung cancer underwent SP major subcostal pulmonary resection using the SPS between March and November 2022. Patient characteristics, intraoperative and perioperative outcomes were assessed. Questionnaires were used to evaluate patient satisfaction with the cosmetic results and quality of life through face-to-face or telephone interviews on postoperative day 30. All patients underwent major pulmonary resection with complete radical resection (R0). Nineteen patients underwent lobectomy, whereas six patients underwent segmentectomy. The mean docking time and total operative time were 4.16±1.19min (range, 2.3-7.8min) and 197.6±55.33min (range, 130-313min), respectively. No patients underwent conversion to open thoracotomy. One patient required an additional assistant port due to severe pleural adhesions. SP subcostal robotic major pulmonary resection using the SPS is feasible and safe. With the continuous development of robotic technology and surgical techniques, we believe that more complex general thoracic surgeries will be performed in the future using SPS.

Perioperative outcomes in redo VATS for pulmonary ipsilateral malignancy: A single center experience

BackgroundThe role of video-assisted thoracoscopic surgery for oncological major pulmonary resections is now well established; however, the literature within pulmonary re-operations is still limited. The purpose of this study is to evaluate the safety and efficacy of redo thoracoscopic resections for ipsilateral pulmonary malignancy. MethodsData from patients undergoing video-assisted thoracoscopic surgery at the Unit of Thoracic Surgery of Padua were analyzed, comparing the results between the first and second ipsilateral surgery. The retrospective study included patients who underwent 2 thoracoscopic surgeries for oncological reasons between 2015 and 2022. The variables considered included patients' baseline characteristics, pre, intra, and postoperative data. ResultsThe study enrolled 51 patients undergoing ipsilateral thoracoscopic re-operation. The statistical analysis showed that surgical time (95min vs 115min; p = 0.009), the presence of intrapleural adhesions at second surgery (30 % vs 76 %; p < 0.001), overall pleural fluid output (200 vs 560 ml; p = 0.003), time with pleural drainage (2 vs 3 days; p = 0.027), air leaks duration time (p = 0.004) and post-operative day of discharge (3 vs 4 days; p = 0.043) were significantly higher in the re-operation group.No statistical differences were observed between the 2 groups respect to R0 resection rate (90.2 % vs 89.1 %; p=>0.9) and complications (5.8 % vs 15.6 %; p = 0.11).The conversion rate to open surgery was 11.8 %. ConclusionAlthough some differences emerged between the first and second intervention, they had minimal impact on the clinical course of the patients.Therefore, thoracoscopic surgery has been shown to be safe and effective in re-operations with satisfying perioperative outcomes. To achieve such results, these procedures should be reserved for experienced surgeons.

Outside the Cage Subcostal RATS Lobectomy: Technical Aspects and Results of the First Series of a Novel Approach to Pulmonary Lobectomy.

The goal of minimally invasive surgery is to reduce trauma to patients and improve their postoperative outcomes. In this context, the utilization of robot-assisted thoracic surgery (RATS) in the treatment of lung cancer has increased worldwide. The feasibility of single-incision major pulmonary resections by RATS was recently reported, with the objective of minimizing the surgical trauma of the traditional multiportal RATS approach. However, both techniques require intercostal incisions, potentially causing immediate and chronic pain resulting from intercostal nerve injury. To reduce postoperative pain resulting from intercostal approaches, we developed a nonintercostal, outside the thoracic cage (OTC) approach for RATS lobectomy, avoiding intercostal instrumentation. This report aims to describe the results of the first reported series of OTC subcostal RATS lobectomies. Retrospective analysis of a series of the first consecutive patients operated on using the novel OTC subcostal RATS lobectomy technique. Between August and December 2022, a total of 10 consecutive cases were analyzed. The median age was 63 (55 to 84) years, the mean body mass index was 29 (24 to 45) kg/m2, and the median American Society of Anesthesiologists score was III (II to IV). No serious adverse events were observed, and there was no conversion of the surgical technique. The mean operative time was 132.6 (98 to 223) min. The median length of stay was 2 days. No pain-related complications, readmissions, or 30-day mortality were observed. This series demonstrates that OTC RATS lobectomy is feasible and safe. A phase I clinical trial is currently underway to prospectively assess the safety of the technique as well as its clinical relevance.

Short-term outcomes of uniportal robotic-assisted thoracic surgery anatomic pulmonary resections: experience of Shanghai Pulmonary Hospital.

To share our experience of uniportal robotic-assisted thoracic surgery (U-RATS) anatomic pulmonary resection. A retrospective study was conducted to compare the efficacy of U-RATS and biportal-RATS (B-RATS; 2 ports). From March 2021 to June 2022, 109 patients were enrolled in this study. The perioperative results of U-RATS and B-RATS were compared. Perioperative outcomes were comparable between the two groups, including the length of hospital stay and the rate of post-operative (post-op) complications. The mean duration of surgery of the two groups were 124.1 vs. 103.6 min (P=0.049), mean intraoperative blood loss was 131.7 vs. 143.1 mL, mean post-op hospital stay was 3.83 vs. 3.05 days (P=0.037), and the thoracic drainage of the first day after surgery were 230.9 vs. 207.1 mL. The visual analogue scale (VAS) scores after the first post-op day were 3.83 vs. 4.57 (P=0.018). No perioperative mortality occurred in either group. Both U-RATS and B-RATS are safe and feasible methods for major pulmonary resections. U-RATS achieved similar perioperative outcomes and lower VAS-scores for the patients, which may improve the post-op experience and the quality of patients' lives. Further follow-up investigations are required to evaluate the long-term efficacy of U-RATS.

Standardization of intra- and peri-operative management to reduce postoperative drainage time after major thoracoscopic pulmonary resections.

It is important to reduce the postoperative drainage time after thoracic surgery to relieve postoperative pain and facilitate patient mobilization. We standardized intra- and peri-operative management of major, thoracoscopic pulmonary resections in February 2019. In this study, we investigated whether this standardization reduced the postoperative drainage time. Moreover, we examined how such management affected re-admission within 30 days after operation (because of pleural complications). Between May 2012 and February 2022, 815 patients with malignant or benign disease underwent major thoracoscopic pulmonary resections in our department. The patients were classified into two groups: those who received standardized management (n=352) and those who did not (n=463). After propensity score-matching, we compared characteristics and perioperative results between the two groups (n=234 in each group) by univariate analysis. The factors affecting postoperative drainage time and re-admission within 30 days after operation (because of pleural complications) were evaluated via multivariate analysis. Standardized management was as follows: (I) intraoperatively, any dense fissures were left untreated to avoid postoperative air leakage. A fissureless or unidirectional dissection technique served as an alternative; pulmonary vessels and bronchi were divided at the hilum in patients with dense fissures. (II) The chest drain was removed when air leakage ceased, regardless of the fluid volume or surgeon's preference. The standardized management group evidenced superior results in terms of operative time (P<0.0001) and postoperative drainage time (P<0.0001). There were no significant differences in the remaining perioperative parameters. Moreover, standardized management significantly reduced postoperative drainage time, as revealed by multivariate analysis [estimated regression coefficient: -0.47; 95% confidence interval (CI): -0.78 to -0.16; P=0.003]. Moreover, standardized management did not significantly increase re-admission (because of pleural complications) [odds ratio (OR) =1.76; 95% CI: 0.557 to 5.58; P=0.34]. Standardized intra- and peri-operative management significantly reduced the postoperative drainage time after major thoracoscopic pulmonary resections, without increasing re-admissions within 30 days among patients with pleural complications caused by insufficient drainage. Surgeons must master a fissureless or a unidirectional dissection technique, avoid dissection of fused fissures, and apply standardized perioperative drainage management.

Second surgery for complications of major pulmonary resection—the technique of thoracoplasty with muscle flap

: Second surgery for postoperative complications after lung resection is one of the important issues that thoracic surgeons must overcome. Chronic empyema after lung resection, which is caused by bronchopleural or pleural fistula remains a challenge in modern medicine. Especially in cases in which decortication is not indicated, treatment is difficult, hospitalization is prolonged, and the condition is sometimes life-threatening. Surgical treatment of chronic empyema requires not only decortication and debridement, but also closure of the bronchopleural fistula and obliteration of dead space. From this viewpoint, thoracoplasty and muscle flap transposition are important techniques that lead to complete and reliable closure of the empyema cavity. Although they are performed less frequently today, they are procedures with which every thoracic surgeon should be familiar. This clinical practice review focuses on the use of muscle flaps in thoracoplasty and describes the historical background, types of muscle flaps, tips on surgical techniques, and treatment results. There is a wide variety of types and utilization of muscle flaps. Since the selection of an appropriate muscle flap is directly related to the success of the treatment, careful preoperative planning is necessary. It is important to understand the characteristics of each type of muscle flap and to select the appropriate technique for the patient’s pathological and general condition.

FROM ALL LUNG TO ALL AIR: A CASE OF IATROGENIC FUNCTIONAL PNEUMONECTOMY

FROM ALL LUNG TO ALL AIR: A CASE OF IATROGENIC FUNCTIONAL PNEUMONECTOMY

Second surgery for complications of major pulmonary resection: the knack of air plombage in thoracoplasty

: Air plombage is a surgical procedure that reduces the pleural space. In 1953, Dr. Chamberlain designed the original “extraperiosteal plombage” to prevent complications after pulmonary segmentectomy for tuberculosis. This surgical technique was developed to prevent the formation of an intrapleural pocket of dead space, and allow collapse of the cavity and obliteration of the extrapleural space. Thus, this technique has been called as “(extraperiosteal) air plombage.” In Japan, a modified air plombage called “Kinchu method” has been performed. The indication for air plombage is as follows: (I) the remaining pulmonary parenchyma after resection does not expand and fill the residual pleural space, (II) large raw surfaces of pulmonary parenchyma remain in a plane, which cannot easily contact the chest wall, (III) there is an excessive air leak from the parenchyma. Surgical procedure is as follows: portion of the ribs above the pleural space are stripped subperiosteally, leaving attached periosteum on their outer surfaces. The size, shape, and location of the “resultant air pocket” is made to fill the defect left by lung resection. The pleura, periosteum, and intercostal muscles and facia drop into the pleural space and contact the resected surface of pulmonary parenchyma. However, care should be taken with regards to pre-, intra-, and post- operation. Particularly, to minimize atrophic and deformative changes in late phase after air plombage, it is important to avoid dissecting the costal periosteum and intercostal muscles of lower (the 8th–12th) ribs.

Early postoperative pain after subxiphoid uniportal thoracoscopic major lung resection: a prospective, single- blinded, randomized controlled trial.

OBJECTIVESPreoperative selection bias led to the inability to generalize the proposed benefit of subxiphoid uniportal video-assisted thoracoscopic surgery (SVATS) as having less postoperative pain than uniportal intercostal VATS. So, we conducted this prospective, single-blinded, randomized controlled trial to investigate the hypothesis that SVATS may have less early postoperative pain than UVATS in patients who undergo major lung resection for early-stage lung cancer.METHODSA total of262 patients were randomly allocated between 2 groups (each with 131 patients), the first being the UVATS group and the second being the SVATS group. The values indicated on the numerical rating scale (NRS) of pain were collected at 24 h and 48 h during rest and during coughing. In addition, different perioperative variables were analysed and compared between the 2 groups.RESULTSMultiple linear regression analysis showed that the type of surgical approach was a significant predictor of the postoperative NRS values. The postoperative NRS pain values were significantly lower in the SVATS group after 24 h during rest and coughing and after 48 h during coughing. Postoperatively, patients in the SVATS group got out of bed significantly earlier [16.37 (2.54) vs 18.05 (3.29) h, p < 0.001]. The SVATS group showed a significantly higher rate of intraoperative arrhythmia [20 (15.3%) vs 3 (2.3%) patients, p = 0.03].CONCLUSIONSSVATS major pulmonary resection in early-stage lung cancer is associated with less early postoperative pain than the UVATS approach. Operating on patients with cardiac problems using the SVATS approach is still a limiting factor for randomization due to the potential compression on the heart with resulting arrhythmia.Clinical trial registrationThe trial was registered under clinical trials.gov Identifier: NCT03331588. https://clinicaltrials.gov/ct2/show/NCT03331588.

“Obesity paradox” has not an impact on minimally invasive anatomical lung resection

IntroductionThe paradoxical benefit of obesity, the ‘obesity paradox’, has been analyzed in lung surgical populations with contradictory results. Our goal was assessing the relationship of body mass index (BMI) to acute outcomes after minimally invasive major pulmonary resections. MethodsRetrospective review of consecutive patients who underwent pulmonary anatomical resection through a minimally invasive approach for the period 2014–2019. Patients were grouped as underweight, normal, overweight and obese type I, II and III. Adjusted odds ratios regarding postoperative complications (overall, respiratory, cardiovascular and surgical morbidity) were produced with their exact 95% confidence intervals. All tests were considered statistically significant at p<0.05. ResultsAmong 722 patients included in the study, 37.7% had a normal BMI and 61.8% were overweight or obese patients. When compared with that of normal BMI patients, adjusted pulmonary complications were significantly higher in obese type I patients (2.6% vs 10.6%, OR: 4.53 [95%CI: 1.86–12.11]) and obese type II–III (2.6% vs 10%, OR: 6.09 [95%CI: 1.38–26.89]). No significant differences were found regarding overall, cardiovascular or surgical complications among groups. ConclusionsObesity has not favourable effects on early outcomes in patients undergoing minimally invasive anatomical lung resections, since the risk of respiratory complications in patients with BMI≥30kg/m2 and BMI≥35kg/m2 is 4.5 and 6 times higher than that of patients with normal BMI.

Major Pulmonary Resection for Non-Small Cell Lung Carcinoma during the COVID-19 Pandemic-Single Israeli Center Cross-Sectional Study.

Background: The highly contagious COVID-19 has created unprecedented challenges in providing care to patients with resectable non-small cell lung carcinoma (NSCLC). Surgical management now needs to consider the risks of malignant disease progression by delaying surgery, and those of COVID-19 transmission to patients and operating room staff. The goal of our study was to describe our experience in providing both emergent and elective surgical procedures for patients with NSCLC during the COVID-19 pandemic in Israel, and to present our point of view regarding the safety of performing lung cancer surgery. Methods: This observational cross-sectional study included all consecutive patients with NSCLC who operated at Tel Aviv Medical Center, a large university-affiliated hospital, from February 2020 through December 2020, during the COVID-19 pandemic in Israel. The patients’ demographics, COVID-19 preoperative screening results, type and side of surgery, pathology results, morbidity and mortality rates, postoperative complications, including pulmonary complications management, and hospital stay were evaluated. Results: Included in the study were 113 patients, 68 males (60.2%) and 45 females (39.8%), with a median age of 68.2 years (range, 41–89). Of these 113 patients, 83 (73.5%) underwent video-assisted thoracic surgeries (VATS), and 30 (26.5%) underwent thoracotomies. Fifty-five patients (48.7%) were preoperatively screened for COVID-19 and received negative results. Fifty-six postoperative complications were reported in 35 patients (30.9%). A prolonged air leak was detected in 11 patients (9.7%), atrial fibrillation in 11 patients (9.7%), empyema in 5 patients (4.4%), pneumonia in 9 patients (7.9%) and lobar atelectasis in 7 patients (6.2%). Three patients (2.7%) with postoperative pulmonary complications required mechanical ventilation, and two of them (1.6%) underwent tracheostomy. Two patients (1.6%) were postoperatively diagnosed as positive for COVID-19. Conclusions: Our data demonstrate the feasibility and efficacy of implementing precautionary strategies to ensure the safety of lung cancer patients undergoing pulmonary resection during the COVID-19 pandemic. The strategy was equally effective in protecting the surgical staff and healthcare providers, and we recommend performing lung cancer surgery during the pandemic era.

Non-intubated Thoracoscopic Surgery-Tips and Tricks From Anesthesiological Aspects: A Mini Review.

BackgroundIn the last few decades, surgical techniques have been developed in thoracic surgery, and minimally invasive strategies such as multi-and uniportal video-assisted thoracic surgery (VATS) have become more favorable even for major pulmonary resections. With this surgical evolution, the aesthetic approach has also changed, and a paradigm shift has occurred. The traditional conception of general anesthesia, muscle relaxation, and intubation has been re-evaluated, and spontaneous breathing plays a central role in our practice by performing non-intubated thoracoscopic surgeries (NITS-VATS).MethodsWe performed a computerized search of the medical literature (PubMed, Google Scholar, Scopus) to identify relevant articles in non-intubated thoracoscopic surgery using the following terms [(non-intubated) OR (non-intubated) OR (awake) OR (tubeless) OR (regional anesthesia)] AND [(VATS) OR (NIVATS)], as well as their Medical Subject Headings (MeSH) terms.ResultsBased on the outcomes of the reviewed literature and our practice, it seems that pathophysiological concerns can be overcome by proper surgical and anesthetic management. All risks are compensated by the advantageous physiological changes that result in better patient outcomes. With the maintenance of spontaneous breathing, the incidence of potential adverse effects of mechanical ventilation, such as ventilator-induced lung injury and consequent postoperative pulmonary complications, can be reduced. The avoidance of muscle relaxants also results in the maintenance of contraction of the dependent hemidiaphragm and lower airway pressure levels, which may lead to better ventilation-perfusion matching. These techniques can be challenging for surgeons as well as for anesthetists; hence, a good knowledge of physiological and pathophysiological changes, clear inclusion and exclusion and intraoperative conversion criteria, and good communication between team members are essential.ConclusionNITS-VATS seems to be a feasible and safe method in selected patients with evolving importance as a part of the minimally invasive surgical and anesthetic conception and has a role in reducing perioperative complications, which is crucial in the thoracic surgical patient population.

Controlling bleeding during uniportal thoracoscopic major pulmonary resection

Aim: In uniportal thoracoscopic major pulmonary resection, it is important to appropriately manage significant vessel injury, to ensure patient safety and minimize conversion to thoracotomy. We analyzed cases of significant vessel injury and investigated efficacy of an algorithm to manage bleeding during thoracoscopic uniportal major pulmonary resection. Methods: A total of 169 patients underwent “uniportal thoracoscopic major pulmonary resection” (lobectomy or segmentectomy) at our department between February 2019 and April 2021. These patients were classified into groups with (group A, n = 8) and without (group B, n = 161) intraoperative massive bleeding. Patient characteristics and perioperative results were compared between the two groups. Patients with significant vessel injury and conversion to thoracotomy were analyzed in detail. Results: Group B had significantly less blood loss (A: 197 ± 173 g; B: 42 ± 74 g, P &lt; 0.0001) and shorter-duration postoperative drainage (A: 2.6 ± 1.8 days; B: 1.6 ± 1.3 days, P = 0.036). There were no group differences in any other factors. The most frequently injured vessel in group A was the pulmonary artery (75%). Emergent conversion was required in four cases (cases 7, 76, 128, and 133; 2.4%) due to intraoperative bleeding. No patient developed catastrophic bleeding or required an intraoperative transfusion. Conclusion: We managed significant vessel injury appropriately during uniportal thoracoscopic major pulmonary resection using the troubleshooting algorithm. The algorithm for the uniportal approach was considered effective and easy to apply even by less-experienced surgeons.