Video-assisted Thoracoscopy Research Articles

A case of a successful two-stage surgical treatment of an hourglass-shaped thoracic schwannoma

Hourglass schwannomas extending into the spinal canal, foramen intervertebrale and thoracic cavity are rare. Their surgical treatment presents a difficult task, and there is no consensus regarding the optimal approach to its solution. This article describes a surgical strategy consisting in performing a combined approach: removal of the intracanal component of the schwannoma through hemilaminectomy and, in the second stage, removal of the interpleural component by video-assisted thoracoscopy. This approach allows for safe resection at adequate angles of view with a low risk of spinal instability, pain or complications from the respiratory system in the postoperative period.

Lobectomy with high-position single-intercostal two-port video-assisted thoracoscope for non-small cell lung cancer is a safe and effective surgical procedure.

BackgroundHigh-position single-intercostal two-port video-assisted thoracic surgery (VATS) technique has been used for thoracic diseases. It can effectively avoid postoperative chronic pain compared with the traditional three-port VATS. This study aimed to evaluate the safety and efficacy of high-position single-intercostal two-port video-assisted thoracoscopic lobectomy.MethodsFrom June 2014 to December 2018, a total of 474 patients in our hospital with non-small cell lung cancer (NSCLC) underwent lobectomy with a high-position single-intercostal two-port video-assisted thoracoscope. A retrospective study of these patients was conducted, and follow-up was performed to analyze the patients’ 3- and 5-year survival rates.ResultsOf the total number of patients, 27.6%, 41.4%, and 31% underwent surgery between the third, fourth, and fifth intercostals, respectively. During the operation, 31 patients were converted to open surgery or three-port thoracoscopic surgery. The average surgical time was 160.9±44.9 min, the average postoperative hospital stay was 5.6±3.4 days, the incidence of postoperative complications was 7.2%, and the average number of lymph nodes resected was 13.6±5.3. The 3-year overall survival (OS) rate of IA1, IA2, IA3, IB, IIA, IIB and IIIA was 99.0%, 98.6%, 96.3%, 91.2%, 85.7%, 66.7%, and 60.8%, respectively. Meanwhile, the 5-year OS rate of IA1, IA2, IA3, IB, and IIIA was 99.0%, 94.5%, 87.5%, 85.5%, and 43.3%, respectively.ConclusionsLobectomy with a high-position single-intercostal two-port video-assisted thoracoscope for NSCLC is a safe and effective surgical procedure.

Efficacy of Iopamidol for Sealing an Injured Thoracic Duct: Pilot Experiments in a Large Animal

Chylothorax can be spontaneously healed by lymphangiography using lipiodol, but pulmonary or systemic embolization is a potential complication. We determined the efficacy of iopamidol for treating chylous leakage in an animal model. Twelve pigs were randomly divided into two groups. After inducing thoracic duct damage, pigs from groups A and B were injected with iopamidol and lipiodol, respectively. At 5, 10, and 30 min after damage induction, the drug effects were monitored by video-assisted thoracoscopy and lymphangiography. In vitro, chyle samples from the pigs were incubated with iopamidol and lipiodol. The damaged thoracic duct was harvested and examined using microscopy. In group A, four and two pigs did not show chylous leakage after 5 and 10 min, respectively. In group B, none showed chylous leakage after 5 min. Nevertheless, the p value was 0.46, and there was no statistically significant difference between groups A and B. In vitro, both iopamidol- and lipiodol-treated chyle samples adhered after 5 min and solidified at 30 min. Our findings confirmed that the damaged thoracic duct was clogged with an amorphous proteinaceous material (iopamidol). Therefore, iopamidol is potentially a new therapeutic agent for chylous leakage. Thoracic duct embolization failures or systemic embolization risks from lipiodol injection may be avoided by injecting iopamidol via the thoracic duct, and this warrants further investigation.

A case report of hybrid surgical resection of a giant dumbbell neurinoma in the thoracic spine

We report the clinical case of treating a female patient with a giant dumbbell neurinoma arising from the Th1 nerve root. For the treatment of neoplasm, a hybrid surgical tactic was chosen, including Th1 hemilaminectomy, mobilization of the dorsal part of the tumor and video-assisted thoracoscopy in order to remove its intrathoracic mass. The patient developed no neurological complications after surgery. A gross total tumor resection was documented by control computed tomography. Thus, well-coordinated work of the multidisciplinary surgical team provided good oncological and functional results in the treatment of a giant neurinoma with extension into the thoracic cavity.

Video assisted thoracoscopic management of primary spontaneous pneumothorax

Abstract
 Objective: To analyze the outcome of Video assisted Thoracoscopy (Vats) in Primary Spontaneous Pneumothorax (PSP).
 Methods: This case series was carried out from Jan 2010 to Jan 2017 in Dept of Thoracic Surgery CMH Rawalpindi and Lahore. A total of 98 patients underwent Video-assisted thoracoscopic for PSP. Inclusion criteria were physiologically fit patients with PSP for recurrent attacks, occupational hazards and prolonged air leak. Exclusion criteria included secondary spontaneous pneumothorax, previous pleurodesis and physiologically unfit patient for general anesthesia. Vanderschueren's thoracoscopic classification was used for macroscopic staging. A 3-port technique was used for apical stapling with partial pleurectomy up to 6th rib. Parietal pleura and diaphragm was also abraded.
 Results: Occupational hazard was the commonest indication for surgery, n= 39 (39.7%). This was followed by recurrent pneumothorax n=37 (37.7%), persistent air leak n= 19 (19.38%), and contra lateral pneumothorax n=4 (4.08). Mean age was 22.8 years ± 6.5. Majority of the cases were in stage 3 of Vanderschueren’s classification, n=69 (70.4%). Stage 4 were n= 18 and stage 2 were n=7. Mean operative time was 51minutes ±14.4. Postoperative prolonged air leak occurred in 3 patients and post-operative neuralgia occurred in 8 patients. Mean follow-up was 22 months ± 5.5, range 5-24 months for all patients. One had generalized recurrence and 2 patients have subpulmonic trapping of air.
 Conclusions: Video-assisted thoracoscopic stapling and pleurectomy is an effective definitive treatment for primary spontaneous pneumothorax when indicated with minimal recurrence.
 Keywords: Video-assisted thoracoscopy, blebs, pneumothorax. Continuous...

Video assisted thoracoscopic management of primary spontaneous pneumothorax.

To analyze the outcome of Video assisted Thoracoscopy (Vats) in Primary Spontaneous Pneumothorax (PSP). This case series was carried out from Jan 2010 to Jan 2017 in Department of Thoracic Surgery CMH Rawalpindi and Lahore. A total of 98 patients underwent Video-assisted thoracoscopic for PSP. Inclusion criteria were physiologically fit patients with PSP for recurrent attacks, occupational hazards and prolonged air leak. Exclusion criteria included secondary spontaneous pneumothorax, previous pleurodesis and physiologically unfit patient for general anaesthesia. Vanderschueren's thoracoscopic classification was used for macroscopic staging. A 3-port technique was used for apical stapling with partial pleurectomy up to 6th rib. Parietal pleura and diaphragm was also abraded. Occupational hazard was the commonest indication for surgery, n= 39 (39.7%). This was followed by recurrent pneumothorax 37 (37.7%), persistent air leak 19 (19.38%) and contra lateral pneumothorax n=4 (4.08%). Mean age was 22.8 ± 6.5 years. Majority of the cases , 69(70.4%) were in stage 3 of Vanderschueren's classification. Stage 4 were (18.5%) and stage 2 were 7 (7.14%). Mean operative time was 51 ± 14. 4 minutes. Postoperative prolonged air leak occurred in 3 patients and post-operative neuralgia occurred in 8 patients. Mean follow-up was 22 ±5.5 months, range 5-24 months for all patients. One had generalized recurrence and 2 patients had subpulmonic trapping of air. Video-assisted thoracoscopic stapling and pleurectomy is an effective definitive treatment for primary spontaneous pneumothorax when indicated with minimal recurrence.

Uniportal Thoracoscopic Decortication for Stage III Tuberculous Empyema With Severe Rib Crowding

This study explored the safety and feasibility of uniportal video-assisted thoracoscopic (VATS) decortication in patients presenting with stage III tuberculous empyema with severe rib crowding. From August 2017 to January /2019, 33 patients with stage III tuberculous empyema and severe rib crowding underwent uniportal VATS decortication with partial rib resection and the use of a customized periosteal stripper. Preoperative and postoperative chest computed tomography (CT) imaging and pulmonary function testing were analyzed to evaluate the clinical significance of certain imaging findings and surgical efficacy. There was 1 conversion to open thoracotomy. Median operative time was 3.5 hours (range, 2.1-4.5 hours) and the median blood loss was 500 mL (range, 250-1000 mL). There were no perioperative mortalities. The incidence of prolonged air leaks (>5 days) was 81.8%. Median postoperative hospital stay was 4 days (range, 4-5 days). All patients were discharged with 2 chest tubes, and median duration drainage was 39 days (range, 30-60 days). The presence of a low-density line between the parietal fibrous pleural rind and chest wall was demonstrated on chest CT in 13 patients. Intraoperative blood loss was considerably lower in these patients compared with those without this imaging finding. Follow-up was complete in all patients over a median of 8 months (range, 6-11.5 months). All patients recovered well and achieved notable improvement in pulmonary function. Uniportal VATS decortication is safe and effective. Patients presenting with a low-density line around the thickened fibrous pleural rind on preoperative chest CT scan may be good candidates.

Primary lung carcinoma with tracheal bronchus treated with uniportal video-assisted thoracoscopic upper lobectomy: a case report

Tracheal bronchus is a rare, congenital abnormality of the tracheobronchial tree. Majority of patients with tracheal bronchus are asymptomatic. Lung malignancy associated with tracheal bronchus is rare. An asymptomatic 40-year-old female was diagnosed with right upper lobe lung carcinoma. CT thorax revealed a right upper lobe tracheal bronchus. The patient underwent right uniportal video-assisted thoracoscopic (VATS) lobectomy and recovered well. To our knowledge, this is the first reported case of primary lung carcinoma with tracheal bronchus treated with right uniportal VATS upper lobectomy in Malaysia, and the second reported case internationally.

Features of surgical treatment of esophageal injuries complicated by purulent mediastinitis

The goal of the work is to improve the results of treatment of patients with esophageal perforations complicated by purulent mediastinitis. Examination and treatment of 30 patients with esophageal perforation (EP) complicated by purulent mediastinitis were performed. The causes of EP were foreign body damages in 12 (40%) of 30 patients, spontaneous rupture of the esophagus – in 11 (36.6%), iatrogenic damage to the esophagus – in 7 (23.4%) patients. The main method of surgical treatment of esophageal perforations complicated by acute purulent mediastinitis is thoracotomy with suturing of the perforated wall of the esophagus and sanation of mediastinal tissue. In case of purulent melting of the esophageal wall and total mediastinitis with severe endogenous intoxication, surgical interventions should be aimed at minimizing surgical trauma and elimination of the purulent process in the mediastinum using video-assisted thoracoscopy. The use of developed surgical tactics for the treatment of esophageal perforations complicated by acute purulent mediastinitis with intramediastinal administration of antibacterial drugs and the method of irrigation of the esophageal sutures contributes to a significant rapid reduction in endogenous intoxication, namely leukocytosis units up to 2.103±0.182 d. units (p<0,001) with normalization of the indicator on the 5th day from the beginning of treatment, the severity of the condition on the APACHE II scale in the modification of Radzikhovsky AP from 14.91±1.80 points at the time of hospitalization to 9.4±0.3 points on the second day after surgery (p<0.001), the severity of patients’ condition on the SOFA scale on the 3rd day to 3.221±0.445 points, on the 5th day – 1.832±0.219 points (p<0.001), the level of C-reactive protein on the 2nd day after surgery decreased from 236.2±21.4 mg/l to 144.3±9.3 mg/l, and on the 3rd day was 112.1±7.2 mg/l (in both cases p<0.001), reducing the content of procaltcytonin from 8.7±0.9 ng/ml to 3.828±0.251 ng/ml on the 2nd day after surgery. The use of this surgical tactic allows you to quickly eliminate the purulent process in the mediastinum, reduce the healing time of the perforation of the esophagus and reduce mortality from 28.5 to 6.2%.

DOES SURGICAL LUNG BIOPSY CHANGE MANAGEMENT IN HOSPITALIZED PATIENTS WITH SUSPECTED INTERSTITIAL LUNG DISEASE?

DOES SURGICAL LUNG BIOPSY CHANGE MANAGEMENT IN HOSPITALIZED PATIENTS WITH SUSPECTED INTERSTITIAL LUNG DISEASE?

Retrospective Review of Preoperative Wire Localization for Peripheral Ground Glass Opacities.

Video-assisted thoracoscopy (VATS) is performed for diagnosis and treatment of peripheral lung nodules. Localization of peripherally located ground-glass opacities (GGOs) can be challenging. We report the results and usefulness of preoperative computed tomography (CT)-guided wire localization. Records for patients who underwent CT-guided wire localization prior to VATS resection for peripherally located GGOs were analyzed. Our technique for targeting the GGOs, complications, and histopathology of GGOs is reviewed. Forty patients (mean age 68years) underwent pulmonary resections following CT-guided wire localization. The mean diameter of the GGO was 11.0mm. The mean distance from the pleural surface to the peripheral margin of the GGO was 18.6mm. Complications from the wire localization included pneumothorax in 5 patients (12.5%), none of whom required insertion of a chest tube; parenchymal hemorrhage in 3 patients (7.5%); and pleural effusion requiring chest tube drainage (unrelated to the wire) in 1 patient (2.5%). The mean operative time was 74(range: 21-186) minutes. Pathological examination revealed lung malignancy in 36 patients (90%). The diagnostic yield was 100%. Preoperative CT-guided wire localization for solitary or multiple peripherally located GGOs allows for determination of histopathologic diagnosis and high diagnostic yield.

BRONCHOGENIC CYST: A TALE OF THE THIRD RECURRENCE

SESSION TITLE: Medical Student/Resident Cardiothoracic Surgery Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Bronchogenic cysts (BCs) are singular congenital variances that surface early from anomalous budding of the maturing respiratory system between the 26th and 40th day of gestation (1). Most BCs are asymptomatic until they compress the surrounding structures. BCs are commonly seen in the mediastinum or intrapulmonary; with a previously reported prevalence of 1 per 42,000 and 1 per 68,000 admissions. They account for 50% to 60% of all mediastinal cysts. If incomplete resected, there is very high recurrence rate (2). We report a patient with second recurrence of mediastinal BC noted 18 years after initial drainage without resection. CASE PRESENTATION: A 57-year-old female with history of biopsy-proven BC with mediastinoscopy drainage followed by first recurrence treated with thoracoscopic drainage. Symptoms at presentation included three days of chest pain radiating between the scapula, associated with shortness of breath, low grade fever, and a dry cough. Vital signs were stable and lab-work was remarkable for WBC of 15.03 K/mm3 with 1% immature granulocytes. Chest x-ray showed a right paratracheal soft tissue density measuring 4.5 cm. Chest CT showed a large low-attenuation mass measuring 8 x 4.8 cm in the mediastinum region with 23 Hounsfield unit density (Image 1,2). Patient underwent video-assisted thoracoscopy converted to right thoracotomy for incision and drainage with sclerotherapy of the BC. Biopsy showed benign fibrous tissue with respiratory epithelium consistent with BC without atypia (Image 3). No growth was appreciated on stain and culture. Serial chest x-rays prior to discharge showed resolution of the soft tissue density. Improvement of respiratory symptoms upon surgery and treatment of community-acquired pneumonia with Rocephin 1gm IV QD and Azithromycin 500mg IV QD for five days. DISCUSSION: With the help of this case report we hope to shed light on the fact that symptomatic cysts should be resected either by thoracotomy or via video-assisted thoracoscopy (VAT) regardless of patient age, unless surgical risks are unacceptably high, as in our patient due to proximity of prominent vessels (3). Although many asymptomatic cases have been reported, a number of complications with BCs have been described, with infection being the most common followed by respiratory obstruction. While there has been a recent rise in the use of thoracoscopic techniques for resection of bronchogenic cysts in adults, one should not forget about patients with high surgical risks. The benefits of thoracoscopy drainage are decreased scarring, reduced pain, and shorter hospitalization (4). CONCLUSIONS: If incomplete resection or drainage is done, as seen in this patient, then residual mucosa should be treated by toxic agents or electrocautery (5). We propose serial imaging to monitor for recurrence when incomplete resection or drainage is done, as no current guidelines are present. Reference #1: 1) Reichelt O, Grieser T, Wunderlich H, Möller A, Schubert J. Bronchogenic cyst. A rare differential diagnosis of retroperitoneal tumors. Urol Int. 2000;64(4):216-219. Reference #2: 2) Limaïem F, Ayadi-Kaddour A, Djilani H, Kilani T, El Mezni F. Pulmonary and mediastinal bronchogenic cysts: a clinicopathologic study of 33 cases. Lung. 2008;186(1):55-61. Reference #3: 3) McAdams HP, Kirejczyk WM, Rosado-de-Christenson ML, Matsumoto S. Bronchogenic cyst: imaging features with clinical and histopathologic correlation. Radiology. 2000;217(2):441-446. 4) Lee DH, Park CK, Kum DY, Kim JB, Hwang I. Clinical characteristics and management of intrathoracic bronchogenic cysts: a single center experience. Korean J Thorac Cardiovasc Surg. 2011;44(4):279-284. [5] Rice DC, Putnam JB. Recurrent bronchogenic cyst causing recurrent laryngeal nerve palsy. Eur J Cardiothorac Surg 2002;21:561–3. DISCLOSURES: No relevant relationships by Loui Abdelghani, source=Web Response No relevant relationships by Hesham Afify, source=Web Response No relevant relationships by George Alvarez, source=Web Response No relevant relationships by Manuel Carrazana, source=Web Response No relevant relationships by Maria Wallis-Crespo, source=Web Response

PNEUMOMEDIASTINUM IN PATIENTS WITH SUBSTANCE ABUSE: A CASE SERIES

SESSION TITLE: Medical Student/Resident Disorders of the Mediastinum Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pneumomediastinum (PM) is the presence of air in the mediastinum. PM is associated with asthma exacerbation, severe cough or vomiting, and other activities associated with breathing maneuvers. Although the majority of cases could be managed conservatively, PM could be potentially fatal if it progresses to malignant PM, which requires thoracotomy or video-assisted thoracoscopy for management. Therefore closely monitoring the patient is necessary. CASE PRESENTATION: Case 1: A 20-year-old male who uses marijuana, was admitted due to 3 days of intractable nausea, vomiting, and right-side anterior pleuritic chest pain. Vital signs were normal. Abdominal exam showed epigastric tenderness, without guarding or rebound. Laboratory showed leukocytosis. CXR revealed subcutaneous emphysema in the left supraclavicular region without PM. Chest CT showed free air in posterior mediastinum (Figure 1). Evaluation did not demonstrate esophageal rupture. He was treated conservatively. The symptoms improved and he was discharged. Case 2: A 20-year-old male with marijuana use for 4 years presented with shortness of breath, intractable vomiting, bloody emesis, chest pain, and shortness of breath. Vital signs were normal. Examination showed subcutaneous emphysema along anterior chest up to neck, with clear and equal breath sound. Laboratory showed leukocytosis. CXR and chest CT showed subcutaneous emphysema and PM (Figure 2). With investigation, there was no evidence of esophageal rupture. The symptoms resolved and he was discharged. Case 3: An 18-year-old male with type 1 diabetes mellitus and polysubstance abuse history presented with sudden severe right-side chest pain, mild shortness of breath, and nausea over 2 days. He admitted smoking methamphetamine prior to his symptoms. Vital signs were normal. Examination was notable for moderate dehydration. Laboratory revealed leukocytosis, elevated blood glucose, and wide-anion gap metabolic acidosis with elevated acetone. Urine drug screen was positive for methamphetamine. CXR showed PM and left supraclavicular subcutaneous emphysema. Chest CT showed isolated PM (Figure 3). The patient was given pain medication and was treated for DKA. He improved and was discharged. DISCUSSION: PM among substance users is believed to be a result from barotrauma during breathing maneuvers. An increase in alveolar pressure with development of a pressure gradient between alveoli and surrounding blood vessels leads to increased alveolar pressure, rupture of the alveolar septa, collapse of the adjacent vascular structures, and air dissection around the peribronchial and perivascular sheaths. Conservative management is sufficient for the majority of PM. CONCLUSIONS: Pneumomediastinum is a rare condition that could be potentially life threatening. PM should be considered in patients with history of inhaled drug use who develop sudden chest pain. Reference #1: Kouritas VK, Papagiannopoulos K, Lazaridis G, et al. Pneumomediastinum. J Thorac Dis 2015;7(Suppl 1):S44–S49. Reference #2: Weiss ZF, Gore S, Foderaro A. Pneumomediastinum in marijuana users: a retrospective review of 14 cases. BMJ Open Respir Res. 2019 Feb 12;6(1):e000391. doi: 10.1136/bmjresp-2018-000391. Reference #3: Miller WE, Spiekerman RE, Hepper NG. . Pneumomediastinum resulting from performing Valsalva maneuvers during marijuana smoking. Chest. 1972 Aug;62(2):233-4. DISCLOSURES: No relevant relationships by Amr Ismail, source=Web Response No relevant relationships by Passisd Laoveeravat, source=Web Response No relevant relationships by Arunee Motes, source=Web Response No relevant relationships by Victor Test, source=Web Response

STRAIGHT TO THE LUNGS: UNUSUAL ETIOLOGY OF BILATERAL PULMONARY OPACITIES

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Extraskeletal myxoid chondrosarcoma (EMC) is a rare soft tissue sarcoma of chondroblastic origin by EWSR1-NR4A3 rearrangement. Its insidious nature frequently delays diagnosis. CASE PRESENTATION: 70-year-old male with a past medical history of hypertension presented with dyspnea at rest, fever, malaise, and productive cough without hemoptysis for one week. He is a retired electrical engineer with no recognized employment hazardous material exposure. He had mild recent mold exposure from home woodcutting, tree burning. Physical exam was significant for bilateral posterior lower lobe rhonchi on pulmonary auscultation. Labs revealed highly elevated CRP, mild leukocytosis, lactic acidosis, and elevated procalcitonin. Chest radiographs demonstrated left lower lobe infiltrates and multiple, bilateral soft tissue densities. He was started on broad-spectrum antibiotics for presumptive pneumonia. Chest CT demonstrated numerous bilateral noncalcified pulmonary nodules, the largest in the right lung measuring 3.7 cm, and the largest in the left lung measuring 3.6 cm; no hilar or mediastinal lymphadenopathy. Bronchoscopy and bronchoalveolar lavages showed no endobronchial lesions and were negative for cytological abnormalities or infection with negative bacterial, fungal, and mycobacterial cultures. CT-guided left lower lobe nodule biopsy was suggestive of low-grade myxoid neoplasm. PET-CT demonstrated diffuse pulmonary nodule uptake in addition to a hypermetabolic mass lesion in the left lateral thigh, 3.2 x 2.8 cm, with a maximum uptake value 3.9. Video-assisted thoracoscopy guided wedge resection of left lower lobe was then performed. Immunohistochemical staining from lung tissue was positive for vimentin, CD117, bcl2, p63, CD138. Fluorescence in situ hybridization revealed the presence of a fusion transcript and chromosomal rearrangement involving EWSR1 from t(9;22)(q22;q12), pathognomonic for extraskeletal myxoid chondrosarcoma. Biopsy of the left thigh mass confirmed primary disease origin. Patient followed up with an orthopedic oncologist and is currently on sunitinib, considering future wide local excision. DISCUSSION: Soft tissue sarcomas are rare, comprising 1% of adult malignancies with EMC accountable for <2% of all soft tissue sarcomas. Chromosomal reciprocal translocation of t(9;22)(q22;q12.2) resulting in fusion of EWSR1 to NR4A3 is responsible for carcinogenesis in 70-80% of cases, whereas another fusion gene, RBP56/TEC, is associated with translocation of t(9:17)(q22;q11.2) and comprises 15% of EMC. It has a high propensity to develop pulmonary metastases. Previous published reports have confirmed the therapeutic activity of sunitinib in EMC. Genotype/phenotype analyses support a correlation between chemotherapy response and EWSR1-NR4A3 fusion. CONCLUSIONS: We reported this rare etiology, its pathology and the diagnosis of bilateral pulmonary opacities, found to be metastatic EMC. Reference #1: Stacchiotti S, Pantaleo MA, Astolfi A, et al. Activity of sunitinib in extraskeletal myxoid chondrosarcoma. Eur J Cancer. 2014;50(9):1657–64. Reference #2: Hisaoka M, Hashimoto H. Extraskeletal myxoid chondrosarcoma: Updated clinicopathological and molecular genetic characteristics. Pathol Int. 2005;55:453–63. Reference #3: Oliveira AM, Sebo TJ, McGrory JE, Gaffey TA, Rock MG, Nascimento AG. Extraskeletal myxoid chondrosarcoma: A clinicopathologic, immunohistochemical, and ploidy analysis of 23 cases. Mod Pathol. 2000; 13:900–8. DISCLOSURES: No relevant relationships by Phyo Kyaw, source=Web Response No relevant relationships by Thomas Massutti, source=Web Response No relevant relationships by Peter White, source=Web Response

Oncological advantage of nonintubated thoracic surgery: Better compliance of adjuvant treatment after lung lobectomy.

BackgroundVideo‐assisted thoracoscopic (VATS) surgery contributes to improved survival, adjuvant chemotherapy delivery and less postoperative complications. Nonintubated thoracic surgery (NITS) VATS procedures improves immunological responses in lung cancer patients; however, there is no data regarding adjuvant chemotherapy delivery effectiveness following NITS lobectomies. In this study, we aimed to compare protocol compliance and toxic complications during adjuvant chemotherapy after intubated and nonintubated VATS lobectomies in non‐small cell lung cancer (NSCLC).MethodsWe retrospectively reviewed the medical records of 66, stage IB–IIIB NSCLC patients who underwent intubated or nonintubated VATS lobectomy and received adjuvant chemotherapy.ResultsA total of 38 patients (17 males, mean age 64 years) underwent conventional VATS and 28 (7 males; mean age 63 years) uniportal VATS NITS. Both groups had comparable demographic data, preoperative pulmonary function, and Eastern Cooperative Oncology Group (ECOG) status. Among the intubated and nonintubated patients, 82% and 75% were diagnosed with adenocarcinoma, respectively. The incidence of adenocarcinoma and squamous cell carcinoma cases were similar in both groups; however, the pathological staging showed significant differences, as 5 (18%) nonintubated patients had stage IB lung cancer, compared with the intubated group (P = 0.01). Further distribution of stages was similar between the groups. We observed significant differences in chest tube duration and operation time in the nonintubated group (P < 0.01). Among nonintubated patients, 92% completed the planned chemotherapy protocol, compared to 71% of the intubated group (P = 0.035). Grade 1/2 toxicity occurred significantly more often in the intubated group (16% vs. 0%, P = 0.03) and there was a lower incidence of grade 4 neutropenia in the nonintubated group (0% vs. 16%, P = 0.03).ConclusionsOur results showed that the nonintubated procedure resulted in improved adjuvant chemotherapy compliance and lower toxicity rates after lobectomy.Key pointsSignificant findings of the study Oncological advantage of the non‐intubated thoracic surgery: better compliance with therapy protocol. What this study adds NITS lobectomies contribute to better administration of adjuvant chemotherapy with the planned cycle number and dosage.

Stage surgical tactics in the treatment of pulmonary aspergilloma

Purpose: To describe the clinical case of pulmonary aspergilloma with step-by-step surgical treatment. Surgical treatment of aspergilloma is justified in the case of ineffective drug therapy and life-threatening complications. The high risk of developing surgical complications on the background of immunodeficiency of different origins may be an obstacle to radical intervention. The course of aspergillosis can significantly limit the ability to compensate for background diseases such as diabetes. The case of a stage approach in preoperative preparation of a patient with severe diabetes mellitus and aspergilloma is presented. In the first stage, a video-assisted thoracoscopy of aspergilloma was performed with histological examination; evacuation of detritus and mycelium by transthoracic drainage and topical diabetes treatment. In the second stage: standard lower lobectomy and postoperative drug therapy with antifungal drugs. Observations up to 2 years after treatment with favorable course are analyzed. Conclusions. Aspergilloma is one form of aspergillosis that requires surgical treatment. Lack of effective correction of comorbidities may be an obstacle to one-step intervention because of the high risk of surgical complications. The use of video thoracoscopy in the diagnosis and stage treatment of this pathology is appropriate due to the minimal trauma of the intervention, which can be used for preoperative preparation and to obtain good results of radical treatment in this category of patients.

Perioperative risk factors for atrial fibrillation (AF) in patients underwent uniportal video-assisted thoracoscopic (VATS) pneumonectomy versus open thoracotomy: single center experience.

To evaluate perioperative risk factors for AF in patients undergoing uniportal VATS pneumonectomy versus open thoracotomy, and to investigate mediastinal lymph nodes dissection (MLND) on the occurrence of AF. Patients were divided into 2 groups based on the surgical approach: uniportal VATS and open pneumonectomy. Analysis was done using chi-square test. Multiple variables were tested using univariate analysis. A p value ≤ 0.05 was considered statistically significant. Three-hundred and forty-one patients underwent pneumonectomy between 2014 and 2018 in Shanghai Pulmonary Hospital. Fifty-eight patients underwent uniportal VATS, and 283 underwent thoracotomies. AF was the most common event observed. The overall occurrence of peri-operative AF was 33/341 (9.67%). In the uniportal, converted, and open group the incidence of AF was: 3/52 (5.76%), 1/6 (16.6%), and 29/283 (10.42%), respectively. Overall, there was no specific surgical technique correlated with increased incidence of AF (p = 0.432). By univariate analysis; large tumor size > 4.5cm (p < 0.010), operative time (OT) > 125min (p < 0.002), and greater volume of blood loss (p < 0.001) increased the risk of AF. Additionally, patients who experienced higher post-operative pain (p < 0.002) were more vulnerable to developing AF. Mortality occurred in one AF patient (1/33, 3%). Number of lymph nodes harvested was not related to AF incidence (p = 0.520). Although AF incidence was lower in uniportal group, it was not statistically significant. Large tumor size, long operative time, and increased blood loss were associated with increased risk of perioperative AF. These results need to be confirmed by larger studies.

Are Thoracic Wall Blocks Efficient After Video-Assisted Thoracoscopy Surgery-Lobectomy Pain? A Comparison Between Serratus Anterior Plane Block and Intercostal Nerve Block

Video-assisted thoracoscopy surgery-lobectomy is less invasive than conventional thoracotomy and is associated with fewer complications. However, the pain related is classified as moderate and requires adequate treatment. Ultrasound-guided serratus anterior plane block (SAPB) provides analgesia by blocking the lateral branches of the intercostal nerves, avoiding the complications of epidural analgesia and paravertebral block. The aim of the present study was to evaluate the efficacy and safety of the SAPB compared with the intercostal nerve block (ICNB). This was a non-randomized prospective study, in which surgery-lobectomy pain after video-assisted thoracoscopy was treated with the following multimodal approach: SAPB or ICNB, morphine-patient controlled analgesia, and paracetamol. The study was undertaken in a single community hospital. The study comprised 40 patients. Execution of ultrasound-guided SAPB. Nineteen (47.5%) men and 21 (52.5%) women were enrolled, and the mean age was 67.22 ± 11 years. Both groups showed any visual analog scale values >4, which was significantly lower in the SAPB group at the 6th hour and at the 12th and 24th hours only during coughing (p < 0.05). The sedation score was significantly lower in the ICNB group at 0 and at the 2nd and 4th hours; it was lower in the SAPB group at the 6th hour. All patients had a sedation score <1, and they all were awake and oriented. After 24 hours, the total morphine requirement was 19.3 ± 14.4 mg and 11.3 ± 8.5 mg (p = 0.038); after 48 hours, it was 12.2 ± 7.9 mg and 8.2 ± 5.8 mg in the ICNB and SAPB groups, respectively. The multimodal approach of SAPB, morphine-patient controlled analgesia, and paracetamol is effective, safe, and time efficient.

453 LAPAROSCOPIC RESECTION OF A GIANT EPIPHRENIC DIVERTICULUM

Abstract Epiphrenic diverticula are acquired mucosal out-pouchings of the distal third of the oesophagus; vastly undiagnosed due to their usual asymptomatic status, with limited number in all published series, and a still ongoing debate both in their surgical indication and technique. This video shows all steps we think that are necessary when operating an epiphrenic diverticulum, in order to illustrate them all and to show the feasibility of performing such operation with minimally invasive procedures. Methods A 52-year-old male was diagnosed of a symptomatic giant epiphrenic diverticulum after previous complaints of dysphagia and regurgitation of undigested food. Preoperative barium-swallow and upper endoscopy confirmed the diagnosis, excluding any other secondary aetiology, and conventional oesophageal manometry did not show any relevant findings. Results Surgery was indicated for symptomatic disease, and a laparoscopic procedure was performed, with pneumoperitoneum created through a Veress needle and trocars placed similar to those used for a hiatal hernia repair. After opening the hiatus, access was granted to the mediastinum and the diverticulum was identified and dissected, and when its neck was completely exposed, diverticulectomy was performed using endostapler loads reinforced with Peri-strips Dry®. Aferwards, both an oesphageal myotomy (from the oesophago-gastric junction to the distal point of the diveticulum’s neck) and a partial Dor fundoplication (despite the absence of relevant findings in the conventional manometry) were performed. Conclusion Surgical management of epiphrenic diverticula should entail both resection of the pouch (diverticulectomy, to avoid postoperative persistent symptoms) and treatment of the underlying motility disorder that has been demonstrated in other studies in nearly 100% of the patients using high-resolution manometry (myotomy and fundoplication, both to avoid recurrences and leakages of the staple line). The laparoscopic approach is feasible without video-assisted thoracoscopy in diverticula with their neck up to 10 cm from the oesophagogastric junction. Video https://www.dropbox.com/s/hugbemgi6wl55kp/EpiphrenicDiverticulumx2.mp4?dl=0

Comparison Between Supraclavicular Versus Video-Assisted Intrathoracic Phrenic Nerve Section for Transfer in Patients With Traumatic Brachial Plexus Injuries: Case Series.

The phrenic nerve has been extensively reported to be a very powerful source of transferable axons in brachial plexus injuries. The most used technique used is supraclavicular sectioning of this nerve. More recently, video-assisted thoracoscopic techniques have been reported as a good alternative, since harvesting a longer phrenic nerve avoids the need of an interposed graft. To compare grafting vs phrenic nerve transfer via thoracoscopy with respect to mean elbow strength at final follow-up. A retrospective analysis was conducted among patients who underwent phrenic nerve transfer for elbow flexion at 2 centers from 2008 to 2017. All data analysis was performed in order to determine statistical significance among the analyzed variables. A total of 32 patients underwent supraclavicular phrenic nerve transfer, while 28 underwent phrenic nerve transfer via video-assisted thoracoscopy. Demographic characteristics were similar in both groups. A statistically significant difference in elbow flexion strength recovery was observed, favoring the supraclavicular phrenic nerve section group against the intrathoracic group (P=.036). A moderate though nonsignificant difference was observed favoring the same group in mean elbow flexion strength. Also, statistical differences included patient age (P=.01) and earlier time from trauma to surgery (P=.069). Comparing supraclavicular sectioning of the nerve vs video-assisted, intrathoracic nerve sectioning to restore elbow flexion showed that the former yielded statistically better results than the latter, in terms of the percentage of patients who achieve at least level 3 MRC strength at final follow-up. Furthermore, larger scale prospective studies assessing the long-term effects of phrenic nerve transfers remain necessary.