Thoracoscopic Group Research Articles

PS01.219: SINGLE-PORT THORACOSCOPIC MINIMALLY INVASIVE ESOPHAGECTOMY FOR ESOPHAGEAL CANCER

Abstract Background This study was conducted to optimize the surgical procedures for single-port thoracoscopic esophagectomy, and to explore its potential advantages over multi-port minimally invasive esophagectomy. Methods For single-port thoracoscopic esophagectomy, the patient was placed in left lateral-prone position and a 4-cm incision through the 4th-5th intercostal space was taken on the postaxillary line. The 10-mm camera and two or three surgical instruments were used for the VATS esophagectomy and radical mediastinal lymph node dissection. The camera position was different for the upper and lower mediastinal regions. Mobilization of stomach was conducted via multiple-port laparoscopic approach. Cervical end-to-side anastomosis was completed by hand-sewn procedures.A propensity-matched comparison was made between the single-port and four-port thoracoscopic esophagectomy groups. Results From 2014 to 2016, 56 matched patients were analyzed. There was no conversion to open surgery or operative mortality. The use of single-port thoracoscopic esophagectomy increased the length of operation time in comparison with using multiple-port minimally invasive technique (mean, 257 vs. 216 min, P = 0.026). The time taken for thoracic procedure in the single-port group was significant longer that in the multi-port group (mean, 126 vs. 84 min, P < 0.001). There were no significant differences between groups in the number of lymph nodes dissected, blood loss, complications or hospital stay (P > 0.05). In single-port thoracoscopic group, the pain in the abdomen was more severe than that in the chest (P = 0.042). The pain scores for postoperative day 1 and day 7 were significantly lower in the single-port group as compared with multiple-port group (P = 0.038 and P < 0.001), a similar trend could be seen for the pain score on postoperative day 3 (P = 0.058). Conclusion Single-port thoracoscopic esophagectomy contributes to reducing postoperative pain with an acceptable increase of operation time, which does not compromise surgical radicality and has similar short-term postoperative outcomes when compared with multiple-port minimally invasive approach. Disclosure All authors have declared no conflicts of interest.

Thoracoscopy Versus Open Surgery for Persistent Ductus Arteriosus and Vascular Ring Anomaly in Neonates and Infants.

The aim of our study was to report our experience in thoracoscopy in infants and neonates for vascular surgical conditions in neonates and infants and to compare our results to open surgery regarding the short-term outcome. We retrospectively reviewed all the patients operated in a single institution from 1997 to 2016 for persistent ductus arteriosus (PDA) and vascular ring (VR) anomalies. We compared our thoracoscopic series to a historical control group operated by open surgery. Data collection from charts and office notes included age and weight at surgery, cardiac ultrasound data for PDA, preoperative clinical symptoms for VR, type of surgery, operating time, analgesic treatment requirements, ventilation status during postoperative course, and early complications. The thoracoscopic group included 13 PDA (median age and weight at surgery: 34 days and 1800 g) and 11 VR (median age and weight at surgery: 8 months and 7000 g). The thoracoscopic group did not differ in preoperative symptoms and work-up, operating time, ventilation status, length of hospital-stay, and postoperative complications with the group operated on by thoracotomy, for either PDA or VR. Our short-term results in thoracoscopic PDA closure and VR anomalies surgery in neonates and infants are comparable to open surgery. Thoracoscopy seems to provide less pain especially for neonates and premature babies and allows to decrease the risk for postoperative chest wall deformities. Long-term outcome is mandatory to confirm these preliminary results.

Thoracoscopic Repair of Congenital Diaphragmatic Hernia After Extracorporeal Membrane Oxygenation: Feasibility and Outcomes.

Thoracoscopic repair of congenital diaphragmatic hernia (CDH) has been associated with faster recovery, earlier extubation, and decreased morbidity. Nevertheless, thoracoscopic repair is rarely attempted in the post-extracorporeal membrane oxygenation (ECMO) patient. Commonly cited reasons for not attempting thoracoscopy include concerns that the patients' respiratory status is too tenuous to tolerate insufflation pressures or that presumed defect size is so large that it precludes thoracoscopic repair. Our purpose is to review our experience with post-ECMO thoracoscopic CDH repair and evaluate the success of this approach. We performed retrospective analysis of attempted thoracoscopic CDH repairs after ECMO decannulation at our institution from 2001 to 2015. Primary outcome was rate of conversion. Secondary outcomes were intraoperative end-tidal CO2, time to extubation, and rate of recurrence. We identified 21 post-ECMO patients in whom thoracoscopic CDH repair was attempted. Thoracoscopic repair was successfully completed in 28%. No patients had reported intolerance to insufflation at 3-7 mmHg. Average end-tidal CO2 at 15 operative minutes was 36.9 mmHg in the thoracoscopic group versus 50.7 mmHg in the open group and at 60 minutes was 34.25 mmHg versus 45.6 mmHg, respectively. One patient in the thoracoscopic group died and 1 experienced a large pneumothorax. In the converted group there was one clinically significant pneumothorax and three pleural effusions. Survivors after thoracoscopy were extubated an average of 5.6 ± 2.6 days after surgery versus 19.4 ± 10 days in the converted group (P < .05). Recurrence rates at last follow-up were equal between the two groups at 20%. Thoracoscopic CDH repair is both safe and feasible after ECMO with no increase in operative morbidity or mortality. Insufflation pressures of 3-7 mmHg are well tolerated without undue increase in end-tidal CO2. When compared to conversion cases, thoracoscopic repair is associated with significantly decreased time to extubation with no difference in recurrence.

Efficacy of thoracoscopic surgery in the treatment of lung cancer in the perioperative period and its effects on serum D-dimer.

The aim of this study was to investigate the feasibility and safety of thoracoscopic surgery in the treatment of lung cancer and its effect on serum D-dimer. A total of 218 patients with lung cancer treated in the Department of Thoracic Surgery of Ningbo No. 2 Hospital from January 1, 2013 to December 31, 2016, were retrospectively analyzed. Of the 218 patients, 120 patients underwent thoracotomy (thoracotomy group) and 98 patients underwent thoracoscopic surgery (thoracoscopy group). The clinical efficacy in the perioperative period and serum D-dimer level were compared between the two groups. In the present study, the intraoperative blood loss, blood transfusion rate, postoperative hospital stay, thoracic drainage time and volume in the thoracoscopy group were significantly shorter or smaller than those in the thoracotomy group (P<0.05), but there was no statistically significant difference in the average operation time between the thoracoscopy and the thoracotomy group. The incidence rate from moderate to severe pains in incisions after operation, the use rate of analgesics and the average disappearance time of the pain in incisions in the thoracoscopy were lower than those in the thoracotomy group (P<0.05). The amount of serum D-dimer immediately after operation in the thoracotomy group was significantly increased compared with that before operation (P<0.05), but there was no significant increase in the thoracoscopy group. At 24 h after operation, the serum D-dimer level in the two groups was further increased (P<0.05), and the comparison between the two groups showed that the levels of serum D-dimer in the thoracoscopy group immediately and at 24 h after operation were significantly lower than those in the thoracotomy group (P<0.05). The incidence rate of postoperative complications in the thoracoscopy was lower than that in the thoracotomy group, but the difference was not statistically significant. Our results show that thoracoscopic surgery is feasible and safe in the treatment of lung cancer. Compared with the thoracotomy group, the intraoperative condition and postoperative recovery have obvious advantages. The postoperative blood of patients is hypercoagulable and D-dimer increased gradually after 24 h. The effect of thoracoscopic surgery on serum D-dimer is relatively less effective.

Outcomes of Extended Thymectomy in Myasthenic and Non-Myasthenic Thymus Tumors

Aim: We retrospectively reviewed the results of patients who underwent extended thymectomy for thymic malignancy and planned to demonstrate the therapeutic effect of surgical treatment in patients with thymus tumors. Material and Method: The results of 29 patients with thymic malignancy who underwent consecutively expanded thymectomy between October 2012 and January 2018 in our clinic were examined in detail. Preoperative, postoperative and postoperative follow-up parameters of the cases were recorded. Results: 13 of the patients were male and 16 were female. The mean age was calculated as 41.4±17.7 (range 9–75 years). Nine of the cases (31%) were accompanied by myasthenia graves (MG) disease. Mean FEV1 was 2678.17±954.5 ml and mean FEV1 was calculated as 94±19.8 ml. Thymectomy was performed with sternotomy in 20 patients and thoracoscopic thymectomy was performed in 9 patients. The mean duration of operation was 137.9±31.8 minutes (133.1±45.5 minutes in thoracoscopy group, 134.1±26.5 minutes in sternotomy group), mean perioperative bleeding was 116.6±107 ml, postoperative drainage amount was 417.3±339.9 ml and duration of drainage was 2.6±0.89 days. Complication rate was found to be 13.7% while mortality was not observed. When the postoperative pain scores of the patients were evaluated, the first 24 hour visual analogue pain score (VAS) averaged 3.4, 24–48 hours 2.71 and 48–72 hours 1.9. Mean hospital stay was 4.3±2.5 days and mean follow-up was 34.7 months (1.5–124 months). Recurrence was developed only in one patient with type B2 thymoma and a myasthenic crisis was observed in one patient, on the 10th postoperative day. While no tumor metastasis was observed in any patient during the follow-up, the mean disease-free survival was 34.9 months. Conclusion: Extended thymectomy can be safely performed with low morbidity and mortality using transsternal or thoracoscopic approach in myasthenic and non-myasthenic thymus tumors.

Medical thoracoscopy versus image-guided pleural biopsy for diagnosing pleural diseases

Background The diagnostic role of medical thoracoscopy and image-guided pleural biopsy in patients with undiagnosed exudative pleural effusion has increased over the last few years. Objective The aim was to compare the efficacy and safety of medical thoracoscopy versus image-guided [ultrasound (US) and computed tomography] pleural biopsy in the diagnosis of pleural lesions. Patients and methods A total of 40 patients with undiagnosed pleural lesions were divided into two groups. After full investigations, pleural biopsies were taken by medical thoracoscopy and the image-guided technique in groups I and II, respectively. Results In group I, the results of 19 (95%) patients yielded a positive diagnosis, whereas in group II, the results of 17 (85%) patients yielded a positive diagnosis (where results were positive in 80% of US-guided biopsies and 90% in computed tomography-guided biopsies), with no significant difference in the diagnostic yield of the two groups. The US-guided biopsy showed significantly the least duration (P=0.001). Complications were significantly fewer in the image-guided biopsy group (P=0.008). The mean duration of hospital stay was significantly less in the image-guided group than in the medical thoracoscopy group (P=0.001). In conclusion, the overall diagnostic yield is comparably high for medical thoracoscopy and image-guided pleural biopsies, and both are complementary techniques used in different clinical situations. Each diagnostic procedure has its own advantages and disadvantages. Image-guided biopsy is less invasive and can be carried out as an outpatient procedure, whereas medical thoracoscopy provides diagnostic and therapeutic capabilities in one setting.

Thoracoscopic Versus Transaxillary Approach to First Rib Resection in Thoracic Outlet Syndrome

This study assessed the feasibility of fully endoscopic thoracoscopic first rib resection (FRR) in the treatment of neurogenic thoracic outlet syndrome by comparing early outcomes of the thoracoscopic technique against the traditional transaxillary FRR. Between 2009 and 2016, 60 consecutive FRRs were performed on 47 patients with neurogenic thoracic outlet syndrome (13 bilateral procedures). The first 30 procedures were performed using the traditional transaxillary technique, and the novel thoracoscopic technique was used in the next 30 operations with the same indications for operative repair. All data were collected retrospectively by independent investigators. The main issues were operation time, learning curve, hospital length of stay, complications, and clinical follow-up status at 3 months. The groups were similar at baseline. The mean operation time was 83 ± 27 minutes in the thoracoscopic group and 48 ± 12 minutes in the transaxillary group (p < 0.001). The first thoracoscopic procedures were 2 hours long, after which, a steady 1-hour procedure time was achieved. Differences regarding the hospital stay or the need for postoperative pain medication were not significant. Two-thirds reported good or excellent recovery at follow-up in both groups. There were no immediate complications. Plexus neuralgia developed in 1 patient 3 weeks after the thoracoscopic operation, and 3 patients were diagnosed with superficial wound infection after the transaxillary procedure. This study showed that FRR for neurogenic thoracic outlet syndrome can be done safely with a fully endoscopic approach. However, the technique requires experience with thoracoscopic surgery, and there is a learning curve to the procedure.

Three-dimensional versus two-dimensional imaging systems in thoracoscopic lobectomy for lung cancer in different year

Objective To compare the clinical application of three-dimensional (3D) and two-dimensional (2D) imaging systems in thoracoscopic lobectomy for non-small cell lung cancer (NSCLC). Methods In 2014 and 2016, the patients with NSCLC undergoing thoracoscopic lobectomy with 2D or 3D imaging systems were performed by a single experienced surgeon. The baseline characteristics and perioperative data of the patients were collected and analyzed. Results In 2014, 19 patients underwent 3D thoracoscopic lobectomy and the other 23 patients underwent 2D thoracoscopic lobectomy. Compared to 2D thoracoscopic lobectomy group, 3D thoracoscopic lobectomy group had a significantly shorter operative time [(147.0±23.9)min vs (179.1±54.4)min, P=0.016], a smaller volume of intraoperative blood loss [(142.1±69.3)ml vs (203.0±90.4)ml, P=0.018]. In 2016, 36 patients underwent 3D thoracoscopic lobectomy and the other 32 patients underwent 2D thoracoscopic lobectomy. No significant differences were found between two groups in terms of preoperative indicators. Conclusions To some extent, 3D thoracoscopy reduces the operation difficulty, shortens the operative time and reduces intraoperative blood loss. However, with the accumulation of surgical experience, 2D can effectively compensate for the disadvantages of thoracoscope. Key words: Thoracoscopy; Lung neoplasms/SU

Thoracoscopy versus thoracotomy in hemodynamically stable patients with closed thoracic trauma

BackgroundIn this prospective study, we aimed to compare thoracoscopy and thoracotomy in hemodynamically stable patients with closed thoracic trauma. MethodsThe study included 30 patients with closed chest trauma. All patients were diagnosed as cases of hemothorax and a chest tube was inserted following investigations, including chest x-ray and computed tomography. All patients were indicated for surgery (thoracoscopy: 15 patients and thoracotomy: 15 patients). A comparison between the two groups was performed in terms of preoperative, operative and postoperative data. ResultsBoth groups had comparable baseline and preoperative data (p > 0.05). Traffic accidents were the most common cause of thoracic trauma in both groups, followed by fall from a height and violence. Injuries were most common to the intercostal arteries, followed by the lungs. The thoracotomy group was associated with a longer operative time and length of hospital stay (p < 0.001) than the thoracoscopy group. Moreover, thoracoscopy provided the advantages of minimally invasive surgery with a significant reduction (p < 0.001) in the amount of postoperative drainage. Only two cases (13.3%) in the thoracoscopy group were converted into thoracotomy for either uncontrolled bleeding or voluminous hematoma. ConclusionsThoracoscopy is feasible and safe for the diagnosis and treatment of hemodynamically-stable patients with blunt thoracic trauma.

Thoracoscopic Treatment of Pulmonary Hydatid Cysts May Have a High Morbidity Risk in Children: Retrospective Analysis.

Thoracoscopic treatment of pulmonary hydatid cyst (PHC) has been considered to be a good treatment option in both children and adults for nearly 25 years. However, there have been very few pediatric studies published during this period. Our goal is to review our results and evaluate the efficiency of thorascopy in pediatric patients. The medical records of patients with PHC who were surgically treated between 2005 and 2015 were reviewed. As all cysts larger than 5 cm in diameter were surgically removed, cysts less than 5 cm in diameter were medically treated and were not included in the study. Demographics, cyst characteristics, and operative/postoperative data were compared between patients who underwent thorascopy (thoracoscopy group) and patients who underwent thoracotomy (thoracotomy group). Chi-square and t-test were used for statistical analysis where appropriate. There were 26 consecutive children (14 girls, 12 boys; mean age 9.4±2.7) included in the study. Except for 2 incidentally diagnosed patients, all were symptomatic, 4 had multifocal lesions, and multiorgan involvement was detected in 11 patients. Thoracoscopy was performed in 10 patients, and conversion was necessary in 2 patients due to unsuccessful fistula ligation attempts. The thoracoscopy group included 8 thoracoscopically treated patients, and remaining patients constituted the thoracotomy group (n=18). Comparison of preoperative characteristics of the groups was insignificant, whereas the overall complication rate (residual bronchial fistula, prolonged air leak, pneumothorax, and localized air cyst) and median hospital stay were significantly higher in the thoracoscopy group. There was no mortality and no recurrence at the postoperative follow-up after 37.4 months. The thoracoscopic approach to PHC may have a high risk of conversion and postoperative complication rate. Thoracotomy in children still seems to be the approach of choice for PHC larger than 5 cm. Routine thoracoscopic hydatid cyst treatment is yet far from being the gold standard, whereas thoracoscopy may be preferred in selected patients.

A large single-institution review of tracheoesophageal fistulae with evaluation of the use of transanastomotic feeding tubes

IntroductionTransanastomatic feeding tube (TAT) use in the repair of tracheoesophageal fistulas (TEF) with or without esophageal atresia (EA) and EA with or without TEF allows for earlier enteral feedings, however, may predispose to esophageal stricture. MethodsWe review our institutional experience with esophageal atresia repair over a 15-year period from 2000 to 2015 and report on our observed complication rate with emphasis on the surgical approach and use of TATs. ResultsWe identified 110 TEF repairs. Ninety-six were Type C, 7 were Type A, 4 were Type D, and 3 were Type E (H-Type). TATs were used in 74% of patients. The stricture rate with the TAT approached 56% versus 17% without a TAT (p<0.0005). There was no difference in leak rate (p=0.27). Ninety-four TEF repairs were performed via open thoracotomy, and 16 were initially approached thoracoscopically. Six out of 16 that were started thoracoscopically were completed with the minimally invasive approach. Whether the case was started thoracoscopically, completed thoracoscopically, or performed open made no difference in the rate of stricture or anastomotic leak, but we did observe an increase in musculoskeletal complications in the open thoracotomy group (28% vs. 0). ConclusionOur data suggests that the use of TATs does not protect against anastomotic leak, but may increase stricture rate. Further, the thoracoscopic group showed no difference in the leak or stricture rate and demonstrated less musculoskeletal complications. Confirmation of these findings will require a prospective study. Level of evidenceIII.

Outcomes for thoracoscopic versus open repair of small to moderate congenital diaphragmatic hernias.

Indications for thoracoscopic versus open approaches to repair congenital diaphragmatic hernia (CDH) are unclear as the variability in defect size, disease severity and patient characteristics pose a challenge. Few studies use a patient and disease-matched comparison of techniques. We aimed to compare the clinical outcomes of open versus thoracoscopic repairs of small to moderate sized hernia defects in a low risk population. All neonates receiving CDH repair of small (type A) and moderate (type B) size defects at an academic children's hospital between 2006 and 2016 were retrospectively reviewed and analyzed. Patients <36weeks gestation, birth weight <1500g, or requiring extracorporeal life support were excluded. Demographics, including CDH severity index, and hernia characteristics were recorded. The primary outcome parameter was recurrence. Secondary outcomes included length of hospital stay, length of mechanical ventilation, time to goal feeds, and mortality. The 51 patients receiving thoracoscopic (35) and open (16) repairs were similar in patient and hernia characteristics, with median 2-year follow-up for both groups. Patients with thoracoscopic repair had shorter hospital stay (16 vs. 23days, p=0.03), days on ventilator (5 vs. 12, p=0.02), days to start of enteral feeds (5 vs. 10, p<0.001), and days to goal feeds (11 vs. 20, p=0.006). Higher recurrence rates in the thoracoscopic groups (17.1% vs. 6.3%) were not statistically significant (p=0.28). Median time to recurrence was 88days for the open repair and 183days (IQR 165-218) for the thoracoscopic group. There were no mortalities in either group. In low risk patients born with small to moderate size defects, a thoracoscopic approach was associated with decreased hospital length of stay, mechanical ventilation days, and time to feeding; however, there was a trend towards higher recurrence rates. Level III.

Thoracoscopic surgery versus open surgery for lung metastases of colorectal cancer: a multi-institutional retrospective analysis using propensity score adjustment†.

Thoracoscopic surgery for lung metastasectomy remains controversial. The study aimed at determining the efficacy of thoracoscopic surgery for lung metastasectomy. This was a multi-institutional, retrospective study that included 1047 patients who underwent lung metastasectomy for colorectal cancer between 1999 and 2014. Prognostic factors of overall survival were compared between the thoracoscopic and open thoracotomy groups using the multivariate Cox proportional hazard model. The propensity score, calculated using the preoperative covariates, included the era of lung surgery as a covariate. A stepwise backward elimination method, with a probability level of 0.15, was used to select the most powerful sets of outcome predictors. The difference between the radiological tumour number and the resected tumour number (delta_num) was also evaluated. The c -statistics and the P -value of the Hosmer-Lemeshow Chi-square of the propensity score model were 0.7149 and 0.1579, respectively. After adjusting for the propensity score, the thoracoscopy group had a better survival rate than the open group (stratified log-rank test: P = 0.0353). After adjusting for the propensity score, the most powerful predictive model for overall survival was that which combined thoracoscopy [hazard ratio (HR): 0.468, 95% CI: 0.262-0.838, P = 0.011] and anatomical resection (HR: 1.49, 95% CI: 1.134-1.953, P = 0.004). Before adjusting for the propensity score, the delta_num was significantly greater in the open group than in the thoracoscopy group (thoracoscopy: 0.06, open: 0.33, P = 0.001); however, after adjustment, there was no difference in the delta_num (thoracoscopy: 0.04, open: 0.19, P = 0.114). Thoracoscopic metastasectomy showed better overall survival than the open approach in this analysis. The thoracoscopic approach may be an acceptable option for resection of pulmonary metastases in terms of tumour identification and survival outcome in the current era.

The efficacy of dexmedetomidine combined with sufentanil for postoperative analgesia and the effect on immune function and pulmonary complications in patients undergoing operation of lung cancer

Objective To evaluate the efficacy of patient-controlled intravenous analgesia(PCIA) using dexmedetomidine (Dex) combined with sufentanil and the effect on postoperative immune function and pulmonary complications in patients undergoing operation of lung cancer. Methods One hundred and twenty patients with lung cancer were recruited in this study, and randomly divided into two groups for PCIA after thoracoscopic lobectomy, group A(Dex and sufentanil group, n=60) and group B (sufentanil group, n=60). VAS scores, observer's assessment of alertness/sedation(OAA/S) scores, and pulmonary complications were recorded after operation. And the number of natural killer (NK) cells, the level of interferon-γ (IFN-γ) or IL-4, and the ratio of T helper cells 1/T helper cells 2(Th1/Th2) were measured perioperation. Results There was no significant difference between the two groups in VAS, OAA/S scores and additional analgesics(P>0.05). The cases of pruritus, postoperative nausea and vomiting(PONV), and pulmonary complications in group B were 8, 16, 8 and 11, while they were 0, 2, 2 and 3 in group A, respectively(P 0.05), however, in group B, they all restored in 2 weeks after surgery(P>0.05). Conclusions Dex combined with sufentanil is efficient for PCIA in patients undergoing thoracoscopic lobectomy, it could decrease the incidence of pruritus, PONV and pulmonary complications, and promote the recovery of immune function. Key words: Dexmedetomidine; Lobectomy; Patient-controlled analgesia; Immunocompetence; Complication

Thoracoscopic division of vascular rings

Background/PurposeVascular rings are traditionally treated via an open thoracotomy. In recent years the use of thoracoscopy has increased. Herein we report our experience with thoracoscopic division of vascular rings in pediatric patients. MethodsWe reviewed all patients who underwent thoracoscopic or open division of a vascular ring at our institution between 2007 and 2015. We analyzed patient demographics, presenting symptoms, diagnostic imaging modality, ring anatomy, operative details, complications, and symptom resolution. ResultsThirty-one patients underwent thoracoscopic division of a vascular ring while sixteen had open operations. Median age was 24months in the thoracoscopic group and 13months in the open group. Operative time averaged 74min (thoracoscopic) and 95min (open). There were no mortalities at 30days. There was complete symptom resolution in 71% of thoracoscopic patients and 63% of open. Patients in the thoracoscopic group had decreased ICU admissions (10% vs. 94%), chest tube use (62% vs. 100%), chylothorax (6% vs. 38%) and overall length of stay (1.7days vs. 5days). ConclusionsThoracoscopic division of vascular rings in pediatric patients is a feasible alternative to open division and is associated with comparable rates of symptom resolution and decreased length of hospital stay and chylothorax. Level of evidenceIII.

Open versus Thoracoscopic RFA-Assisted Lung Resection

ABSTRACTThe purpose of this study was to evaluate Radio Frequency Ablation (RFA)-assisted lung parenchymal transection through thoracotomy and thoracoscopy. Twelve domestic pigs underwent RFA-assisted lingulectomy: six through thoracotomy (group A), and six with thoracoscopy (group B). There was no mortality, no bleeding, or air leak intra- or postoperatively in either of the groups, and no conversion to open thoracotomy in group B. Group A had longer operating period and more pleural adhesions. A barotrauma, a skin burn, and a localized infection were observed in this group. Histopathology confirmed a sharply demarcated area of coagulation necrosis without damage to adjacent structures. RFA-assisted lung resection through thoracotomy bears the inherent problems of an open approach, and the use of RFA device does not add to morbidity. The thoracoscopic use of RFA probe by experienced surgeons is considered safe, maintaining the advantages of key-hole surgery.

Comparative clinical outcomes after thymectomy for myasthenia gravis: Thoracoscopic versus trans-sternal approach

Thymectomy is an effective treatment option for long-term remission of myasthenia gravis. The superiority of the trans-sternal and thoracoscopic surgical approaches is still being debated. The aims of this study are to compare postoperative outcomes and neurologic outcomes between the two approaches and to identify prognostic factors for complete stable remission (CSR). Myasthenia gravis patients who underwent thymectomy with trans-sternal or thoracoscopic approach in MahaRaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand between January1, 2006 and December 31, 2013 were retrospectively reviewed. The endpoints were postoperative outcomes and cumulative incidence function for CSR. The analysis was performed using multilevel model, Cox's proportional hazard model, and propensity score. Ninety-eight patients were enrolled in this study: 53 in the thoracoscopic group and 45 in the trans-sternal group. There were no significant differences between groups in composite postoperative complications, surgical time, ventilator support days, and length of intensive care unit stay. Intraoperative blood loss and length of hospital stay were significant less in the thoracoscopic group. The CSR and median time to remission were not significantly different between the two approaches. Prognostic factors for CSR were nonthymoma (hazard ratio: 3.5, 95% confidence interval: 1.01-12.22) and presence of pharmacological remission (hazard ratio: 24.3, 95% confidence interval: 3.27-180.41). Thoracoscopic thymectomy is safe and provides good neurologic outcomes in comparison to the trans-sternal approach. Two predictive factors should be considered for CSR. Further prospective studies with a larger sample size and longer follow-up period are warranted to confirm these results.

Efficacy of video-assisted thoracoscopic surgery in the treatment of lung cancer

Objective To compare the efficacy of video-assisted thoracoscopic surgery and open-thoracotomy in the treatment of lung cancer. Methods 77 patients with lung cancer were chose as study objects, all the patients were divided into two groups, 43 cases of video-assisted thoracoscopic surgery group (VATS) and 34 cases of open-thoracotomy group (OT) The operative time, blood loss, postoperative chest tube indwelling time and hospital stay and postoperative complication rate were compared.The VAS postoperative 1d, 3d, 5d after operation were calculated, and the serum CRP preoperative and postoperative 1d, postoperative 5d were detected. Results The operative time, postoperative chest tube indwelling time, hospital stay, the blood loss, the complication rate in VATS group and OT group were (134±52)min and (167±45)min, (2.50±0.30)d and (4.68±0.66)d, (4.77±0.54)d and (7.20±0.68)d, 103±26)mL and (248±43)mL, 11.63% and 38.24%, the differences were statistically significant (t=3.563, 3.725, 9.621, 3.402 and χ2=7.504, all P<0.05). The VAS postoperative 1d, 3d in VATS group and OT group were (6.22±0.82)score and (8.13±0.72)score, (4.46±0.48)score and (6.31±0.54)score, the differences were statistically significant, t=3.927, 3.742, all P<0.05; the serum CRP after 1d, 5d postoperative in VATS group and OT group were (38.32±9.59)μg/L and (58.43±10.62)μg/L, (17.71±5.42)μg/L and (36.65±8.25)μg/L, which were all higher than those of before surgery, but the serum CRP after 1d, 5d postoperative in VATS group were lower than those of OT group, the differences were statistically significant(t=5.541, 6.662, all P<0.05). Conclusion VATS lobectomy is a trauma, quicker recovery, less postoperative pain surgical methods, and can reduce postoperative acute phase reaction, which should be recommended as a treatment for lung cancer. Key words: Lung cancer; Lobectomy; Video-assisted thoracoscopic surgery; Open-thoracotomy

Management of Bronchial Stumps in Anatomic Lung Segmentectomy

Stapling or suturing techniques are commonly used to close bronchial stumps in lung lobectomy, although with the segmentectomy procedure, various types of closure are likely to be performed. Weinvestigated the safety of various types of bronchial closure methods used in anatomic lung segmentectomy. Between 2005 and 2013, we performed anatomic lung segmentectomies including segmentectomies through open thoracotomy for 41 patients and thoracoscopy for 167 patients. Bronchial closures were performed through open and thoracoscopy methods for 66 and 231 stumps, respectively. Data were collected regarding segmental bronchus type, stump closure methods, and closure-related complications. Since 2006, bronchial caliber was measured from preoperative 1 mm(3) computed tomography. In the open group, 17 stumps (26%) were closed by stapling, 48 (73%) by thread ligation, and 1(1%)by suturing. In the thoracoscopy group, 116 stumps (50%) were closed by stapling, 76 (33%) by thread ligation, and39 (17%) by polymer clip ligation (p < 0.001). Staplers were used for all bronchial trunks that supplied more than a single segment; the mean diameter was 8.1mm. For single segmental bronchi, ligation was usedfor 80% in the open group and stapling for 75% inthe thoracoscopy group; the mean diameter was 6.6mm. For subsegmental bronchi, ligation or clipping were applied for 95% in both groups; the mean diameter was 4.6 mm. One bronchopleural fistula was observed at 6 months postoperatively in upper division segmentectomy of the left upper lobe using a stapler in the open group. Ligation can be used safely for small-diameter segmental bronchial stump closures in anatomic lung segmentectomies or subsegmentectomies. The use of a polymer clip can be an alternative method toclose the bronchial stump of subsegmentectomies.

Physiologic and immunologic effects of subxiphoid pulmonary lobectomy compared with transthoracic pulmonary lobectomy in a canine survival model.

Subxiphoid thoracoscopic surgery has been used in various thoracic surgical procedures. The aim of this study is to compare the physiological and inflammatory responses between subxiphoid thoracoscopic surgery and standard transthoracic thoracoscopic surgery for anatomic pulmonary lobectomy in a canine model. Nineteen dogs were assigned to subxiphoid (n=10) or standard thoracoscopy (n=9). Animals in the subxiphoid and standard thoracoscopy group received anatomic lobectomy via a 3-cm xiphoid and thoracic incision, respectively. Physiological and inflammatory parameters were compared between the two groups before surgery, during the operation, and on postoperative days 1, 3, 7, and 14. The animals were sacrificed and necropsied at 2 weeks after surgery. All procedures were performed successfully with no conversion nor complication. The physiologic changes were similar in both groups. There was no observable different between the two groups in terms of C-reactive protein (CRP) level, interleukin-6 (IL-6) level, neutrophil count, neutrophil 20,70-dichlorodihydrofluorescein (DCFH) expression, monocyte count, monocyte inducible nitric oxide synthase (iNOS), and CD4/CD8 ratios. However, the reduction of total lymphocyte count, CD4, and CD8 lymphocyte counts were observed in the subxiphoid anatomic lobectomy group on postoperative day 7, which was significantly lower than that of the standard transthoracic thoracoscopic approach. Subxiphoid thoracoscopic surgery resulted in similar physiologic impact and surgical outcome to those of standard transthoracic thoracoscopic surgery. Nevertheless, subxiphoid thoracoscopic surgery is associated with more pronounced immunosuppression than the standard transthoracic thoracoscopic approach.