Video-assisted Thoracoscopic Approach Research Articles

The contemporary approach to chylothorax – Single-center experience with the proposal of a management algorithm

Objectives: Chylothorax is a relatively rare condition of lymphatic fluid accumulation in the thoracic cavity due to a leakage from the thoracic duct or its tributaries. Patients present with dyspnea, malnutrition, and immunosuppression. Treatment can be conservative or surgical, depending on etiology and clinical course. The optimal management algorithm for chylothorax is still controversial. Methods: This is a ten-year period retrospective study of all patients with chylothorax treated at our Department of Thoracic Surgery. Results: A total of 14 patients were identified for the study. Nine patients had chylothorax after lung or esophageal cancer surgery. Four patients had chylothorax in advanced lymphoma. One patient had chylothorax after blunt chest trauma. A conservative approach was initiated in most patients (92%), including pleural drainage, nil per mouth, total parenteral nutrition, and somatostatin 0.1 mg bid subcutaneously. Surgical treatment was indicated in patients with thoracic drain production >800 mL per day beyond the fifth day of treatment and those with blunt thoracic trauma. Two patients had thoracic duct ligation via right-sided thoracotomy, and five patients had video-assisted thoracoscopic thoracic duct ligation with the immediate arrest of chylous leakage. Conclusion: Chylothorax should be treated conservatively initially. Surgical treatment should not be delayed beyond the fifth day in case of failure. In our series of patients, a video-assisted thoracoscopic approach for thoracic duct ligation proved to be minimally invasive, highly efficient, and well tolerated. Therefore, it should be the preferable route of surgical treatment.

Trends and comparative outcomes between operative approaches for segmentectomy in lung cancer

BackgroundSegmentectomy is increasingly performed for non–small cell lung cancer. However, comparative outcomes data among open, robotic-assisted, and video-assisted thoracoscopic approaches are limited. MethodsA retrospective cohort study of non–small cell lung cancer segmentectomy cases (2013-2021) from the Society of Thoracic Surgeons General Thoracic Surgery Database was performed. Baseline characteristics were balanced using inverse probability of treatment weighting and compared by operative approach. Volume trends, outcomes, and nodal upstaging were assessed. ResultsOf 9927 patients who underwent segmentectomy, 84.8% underwent minimally invasive surgery, with robotic-assisted thoracoscopic surgery becoming the most common approach in 2019. Open segmentectomy is more likely to be performed at low-volume centers (P < .0001), whereas robotic-assisted thoracoscopic surgery is more likely to be performed at high-volume centers (P < .0001). Video-assisted thoracoscopic surgery had a higher open conversion rate than robotic-assisted thoracoscopic surgery (odds ratio, 11.8; CI, 7.01-21.6; P < .001). Minimally invasive surgery had less 30-day morbidity compared with open segmentectomy (video-assisted thoracoscopic surgery odds ratio, 0.71; 95% CI, 0.55-0.94; P = .013; robotic-assisted thoracoscopic surgery odds ratio, 0.59; CI, 0.43-0.81; P = .001). The number of nodes and stations harvested were highest for robotic-assisted thoracoscopic surgery; however, N1 upstaging was more likely in open compared with robotic-assisted thoracoscopic surgery (odds ratio, 0.63; CI, 0.45-0.89; P < .007) and video-assisted thoracoscopic surgery (odds ratio, 0.61; CI, 0.46-0.83; P = .001). ConclusionsSegmentectomy volume has increased considerably, with robotic-assisted thoracoscopic surgery becoming the most common approach. Minimally invasive surgery has less major morbidity compared with open segmentectomy, with no difference between video-assisted thoracoscopic surgery and robotic-assisted thoracoscopic surgery. However, risk of open conversion is higher with video-assisted thoracoscopic surgery. Robotic-assisted thoracoscopic surgery had increased nodal harvest, whereas hilar nodal upstaging was highest with thoracotomy. This study reveals significant differences in outcomes exist between segmentectomy operative approach; the impact of approach on survival merits further investigation.

Lymph node dissection in lung cancer surgery: a comparison between robot-assisted vs. video-assisted thoracoscopic approach.

TNM staging is the most important prognosticator for non-small cell lung cancer (NSCLC) patients. Staging has significant implications for the treatment modality for these patients. Lymph node dissection in robot-assisted thoracoscopic (RATS) surgery remains an area of ongoing evaluation. In this study, we aim to compare lymph node dissection in RATS and VATS approach for lung resection in NSCLC patients. We retrospectively compiled a database of 717 patients from July 31, 2015-July 7, 2022, who underwent either a wedge resection, segmentectomy or lobectomy. We analysed the database according to lymph node dissection. The database was divided into RATS (n = 375) and VATS (n = 342) procedures. The mean number of lymph nodes harvested overall with RATS was 6.1 ± 1.5 nodes; with VATS approach, it was 5.53 ± 1.8 nodes. The mean number of N1 stations harvested was 2.66 ± 0.8 with RATS, 2.36 ± 0.9 with VATS. RATS approach showed statistically higher lymph node dissection rates compared to VATS (p = 0.002). Out of the 375 RATS procedures, 26 (6.4%) patients undergoing a RATS procedure were upstaged from N0/N1 staging to N2. N0/N1-N2 upstaging was reported in 28 of 342 (8.2%) patients undergoing a VATS procedure. The majority of upstaging was seen in N0-N2 disease: 19 of 375 (5%) for RATS and 23 of 342 (6.7%) for VATS. We conclude that in RATS procedures, there is a higher rate of lymph node dissection compared to VATS procedures. Upstaging was mostly seen in N0-N2 disease, this was observed at a higher rate with VATS procedures.

Greater ipsilateral rectus muscle atrophy after robotic thoracic surgery compared with open and video-assisted thoracoscopic surgery approaches

ObjectiveRobotic thoracic surgery provides another minimally invasive approach in addition to video-assisted thoracoscopic surgery (VATS) that yields less pain and faster recovery compared with open surgery. However, robotic incisions are generally placed more inferiorly, which may increase the risk of intercostal nerve injury that affects the abdominal wall. We hypothesized that a robotic approach causes greater ipsilateral rectus muscle atrophy compared with open and VATS approaches. MethodsThe cross-sectional area and density of bilateral rectus abdominis muscles were measured on computed tomography scans in patients who underwent lobectomy in 2018. The differences between the contralateral and ipsilateral muscles were compared between preoperative and 6-month surveillance scans. Changes were compared among the open, VATS, and robotic approaches through a mixed effects model after adjustments of correlation and covariates. ResultsOf 99 lobectomies, 25 (25.3%) were open, 56 (56.6%) VATS, and 18 (18.1%) robotic. The difference between the contralateral and ipsilateral rectus muscle cross-sectional area was significantly larger at 6 months after robotic surgery compared with open (31.4% vs 9.5%, P = .049) and VATS (31.4% vs 14.1%, P = .021). There were no significant differences in the cross-sectional area between the open and VATS approach. ConclusionsIn this retrospective analysis, there was greater ipsilateral rectus muscle atrophy associated with robotic thoracic surgery compared with open or VATS approaches. These findings should be correlated with clinical symptoms and followed to assess for resolution or persistence.

Surgeon-modified fenestrated endovascular grafts and thoracoscope-assisted fixation for treatment of thoraco-abdominal aortic aneurysms.

Total endovascular technique with fenestrated endovascular graft might be hampered for the late dilatation of proximal landing zone, which may cause endografts migration. We describe a successful urgent hybrid procedure for extent III thoracoabdominal aortic aneurysm with aortic intramural hematoma. A 55-year-old female with thoracoabdominal aortic aneurysm was considered at high surgical risk and unfit for open repair due to multiple comorbidities. Therefore, a hybrid procedure of surgeon-modified fenestrated endovascular graft combined with thoracoscope-assisted Transaortic epicardial fixation of endograft was finally chosen and performed in the endovascular operating room. A 3-port technique was performed through a left video-assisted thoracoscopic approach. After the first tampering stent-graft was deployed, a double-needle suture was penetrated both the aortic wall and stent-graft to fixate it in the proximal descending aorta. Then the second endograft, which had been fenestrated on table, was introduced and oriented extracorporeally by rotating superior mesenteric artery and left renal artery fenestration radiopaque markers and deployed with perfect apposition between the fenestrations and target visceral artery. Each vessel was sequentially stented using Viabahn self-expandable stent to finish target vessel stenting. An Ankura cuff stent was deployed in the distal abdominal aortic artery. Surgeon-modified fenestrated endovascular graft combined with thoracoscope-assisted fixation may be an innovative and viable alternative for selected high-risk patients with extent III thoracoabdominal aortic aneurysm. A longer follow-up is needed to ascertain the success of this approach.

Robot-Assisted Thoracoscopic Resection of Ectopic Parathyroid Tissue in Mediastinum: A Scoping Review.

Ectopic parathyroid tissue in the mediastinum represents a rare and potentially serious clinical entity with challenging diagnostic and surgical management. The main surgical approach for this issue is open thoracotomy, which is a safe technique but carries risks and complications associated with such as extensive surgery. The purpose of this study is to demonstrate robotic thoracic surgery as an alternative and potentially advantageous method to treat patients with ectopic parathyroid adenomas compared with open and video-assisted thoracoscopic surgery approaches. A total of 13 reports in the literature were identified that provided details in terms of complications, surgical approach, and results of minimally invasive surgical resection of mediastinal ectopic parathyroid tissue.

Robotic-Assisted Transthoracic Diaphragm Plication

Diaphragm dysfunction, either from congenital eventration or acquired paralysis, impairs the ability of the diaphragm to contract, thereby disrupting normal respiratory mechanics. While a proportion of patients will present with respiratory insufficiency or symptoms of dyspnea, the majority of patients are asymptomatic and most cases are identified incidentally on chest imaging by the presence of an elevated hemidiaphragm. In symptomatic patients, surgical plication of the diaphragm remains the gold standard treatment. Traditionally, diaphragm plication is performed through an open transthoracic approach via a posterolateral thoracotomy. However, more recently there has been increased utilization of minimally invasive techniques, including video-assisted thoracoscopic and laparoscopic approaches. Here, we present our technique for robotic-assisted transthoracic plication, with advantages including enhanced ergonomics, seamless motion, decreased surgeon fatigue, tremor filtering, and three-dimensional vision. This approach has been demonstrated to be a technically feasible and safe option for performing diaphragm plications with an associated decreased hospital length of stay and trend towards decreased 30-day post-operative complications compared to open plication.

Bilateral Cardiac Sympathetic Denervation for Refractory Multifocal Premature Ventricular Contractions in Patients With Nonischemic Cardiomyopathy

BackgroundBilateral cardiac sympathetic denervation (BCSD) for refractory life-threatening ventricular arrhythmias is a neuromodulatory intervention targeting sympathetically driven focal or re-entrant ventricular arrhythmias. ObjectivesThis study sought to provide a more complete and successful option for intervention in patients in whom premature ventricular contraction (PVC) ablation is not feasible or has been unsuccessful. MethodsA total of 43 patients with >5% PVC burden and concomitant nonischemic cardiomyopathy (NICM) who previously failed medical and ablation therapies were referred for BCSD. All patients underwent bilateral video-assisted thoracoscopic surgical approach with T1-T4 sympathectomy. Primary effectiveness endpoints were postprocedural PVC burden resolution, improvement in left ventricular ejection fraction (LVEF), and cessation of antiarrhythmic drugs (AADs). Safety endpoints included peri- and postprocedural complications. Outcomes were assessed over a 1-year follow-up period. ResultsAmong the 43 patients who underwent BCSD, the mean age was 52.3 ± 14.7 years, 69.8% of whom were male patients. Presenting mean LVEF was 38.7% ± 7.8%, and PVC burden was 23.7% ± 9.9%. There were significant reductions in PVC burden postprocedurally (1.3% ± 1.1% post-BCSD, compared with 23.7% ± 9.9% pre-BCSD, P < 0.001) and improvements in LVEF (46.3% ± 9.5% post-BCSD, compared with 38.7% ± 7.8% pre-BCSD, P < 0.001). The rate of ICD therapies decreased from 81.4% (n = 35) to 11.6% (n = 5) (P < 0.001), leading to a significant reduction in use of AADs (100.0% to 11.6%, P < 0.001) and improvement in mean NYHA functional class (2.5 ± 0.5 to 1.4 ± 0.2, P < 0.001). Major intraoperative complications were seen in 4.7% of patients (hemothorax and chylothorax). Of the patients, 81.4% (n = 35) experienced no mortality or major complications over a 1-year follow-up period, with the remaining still within their first year postprocedure. ConclusionsBCSD is effective for the management of refractory PVCs and ventricular tachycardia who have failed previous ablation therapy.

Interpretable machine learning accurately reclassifies lobectomy surgical approaches by cost

BackgroundThe volume of robotic lung resection continues to increase despite its higher costs and unproven superiority to video-assisted thoracoscopic surgery. We evaluated whether machine learning can accurately identify factors influencing cost and reclassify high-cost operative approaches into lower-cost alternatives. MethodsThe Florida Agency for Healthcare Administration and Centers for Medicare and Medicaid Services Hospital and Physician Compare datasets were queried for patients undergoing open, video-assisted thoracoscopic surgery and robotic lobectomy. K-means cluster analysis was used to identify robotic clusters based on total cost. Predictive models were built using artificial neural networks, Support Vector Machines, Classification and Regression Trees, and Gradient Boosted Machines algorithms. Models were applied to the high-volume robotic group to determine patients whose cost cluster changed if undergoing a video-assisted thoracoscopic surgery approach. A local interpretable model-agnostic explanation approach personalized cost per patient. ResultsOf the 6,618 cases included in the analysis, we identified 4 cost clusters. Application of artificial neural networks to the robotic subgroup identified 1,642 (65%) cases with no re-assignment of cost cluster, 583 (23%) with reduced costs, and 300 (12%) with increased costs if they had undergone video-assisted thoracoscopic surgery approach. The 5 overall highest cost predictors were patient admission from the clinic, diagnosis of metastatic cancer, presence of cancer, urgent hospital admission, and dementia. ConclusionK-means cluster analysis and machine learning identify a patient population that may undergo video-assisted thoracoscopic surgery or robotic lobectomy without a significant difference in total cost. Local interpretable model-agnostic explanation identifies individual patient factors contributing to cost. Application of this modeling may reliably stratify high-cost patients into lower-cost approaches and provide a rationale for reducing expenditure.

Off-Label Use of COR-KNOT Automated Fastener for Manual Bronchial Closure Through a Video-Assisted Thoracoscopic Surgery Approach.

Manual closure of the bronchial stump can be challenging during minimally invasive thoracic surgery. An automated fastener has been used for more than a decade in minimally invasive heart valve surgery to eliminate the need for manual knot tying during the suturing of prosthetic valves. Herein, we describe the use of the COR-KNOT automated fastener (LSI SOLUTIONS®, Victor, NY, USA) in a case of video-assisted left upper lobectomy with open section of the bronchus and manual closure with interrupted resorbable sutures for a malignant bronchial tumor located on the proximal part of the left upper lobe bronchus. This case represents, to our knowledge, the first case using the COR-KNOT device for minimally invasive pulmonary surgery.

Laser-assisted lung metastasectomy: a systematic review.

Laser-assisted resection (LAR) of pulmonary metastases offers several potential advantages compared to conventional surgical techniques. However, the technical details, indications and outcomes of LAR have not been extensively reviewed. We conducted a systematic literature search to identify all original articles reporting on LAR of pulmonary metastases. All relevant outcomes, including morbidity rate, R0 rate, pulmonary function tests, overall- (OS) and relapse-free survival (RFS) rates were collected. Additionally, a comparison between outcomes obtained by laser-assisted and conventional resection techniques was provided. Of 2629 articles found by the initial search, 12 were selected for the systematic review. Following LAR, the R0 rate ranged between 72 and 100% and the morbidity rate ranged from 0 to 27.5%. The postoperative decline in forced expiratory volume in 1s varied between 3.4 and 11%. Median OS and RFS were 42-77.6months and 9-34.1months, respectively. Compared with patients treated by other resection techniques, patients treated by LAR frequently had a higher number of metastases and a higher rate of bilateral disease. Despite this, no significant differences were observed in R0 rate, morbidity rate, and median OS rate, while only 1 study found a lower RFS rate in the LAR cohort. Although selection bias limits the comparability of outcomes, the findings of this review suggest that LAR is a valid alternative to conventional procedures of lung metastasectomy. The main difficulties of this technique consist in the adoption of a video-assisted thoracoscopic approach, and in the pathologic assessment of resection margins.

Thymoma and Thymic Carcinoma: Surgical Resection and Multidisciplinary Treatment

Thymoma and thymic carcinoma are the most common tumors of the anterior mediastinum and a relatively rare type of thoracic cancer. The prerequisite for surgery is clinical staging and operative evaluation, both of which are based on medical imaging. The best strategy for treating a thymic epithelial tumor is surgical resection of the organ and surrounding tissue. Thymectomy modalities vary, including open surgery and minimally invasive surgery, and surgeons have used various innovations to better meet the needs of the procedure; therefore, it is critical to select the appropriate procedure based on the patient's characteristics. Evaluation of resectability is the first step of surgical resection for thymic tumors without distant metastasis. The decision regarding unresectability should be made carefully. During subsequent chemotherapy or chemoradiotherapy, reevaluation of whether an area is resectable or not remains essential. Despite numerous technological advances in the surgical treatment of thymic tumors, several contentious issues remain, including the selection of surgical approaches for difficult cases, the selection of video-assisted thoracoscopic approaches, the evaluation of resectability, minimally invasive surgery for locally advanced thymic tumors, lymphadenectomy in thymic tumors, neoadjuvant therapy for thymic tumors, debulking surgery, and salvage surgery. In solving these problems, the surgeon's judgment, surgical experience, and surgical skills are especially important.

The perioperative outcomes of uniportal robotic-assisted thoracic surgeries-a systematic review and meta-analysis of surgical cohort studies and case reports.

Early results have illustrated the multiportal robotic approach to be safe and oncologically efficacious in the treatment of thoracic malignancies. Industry leaders have improved upon the lessons learned during the early multiportal studies and have now come to establish the feasibility of the biportal, and subsequently the uniportal robotic-assisted approach, all in an effort to offer patients equivalent or better outcomes with less surgical trauma. No current, coherent body of evidence currently exists outlining the early-term outcomes of patients undergoing uniportal robotic-assisted thoracic surgery. This systematic review and meta-analysis sought to clarify the early-phase outcomes of these patients. An electronic search of four databases was performed to identify relevant studies outlining the immediate post-operative outcomes of patients undergoing uniportal robotic-assisted thoracic surgeries. The primary endpoint was defined as technical success (i.e., no conversion to secondary robotic, video-assisted thoracoscopic, or open approaches). Secondary endpoints of interest included post-operative outcomes and complication rates. A meta-analysis using a random effects model of proportions or means was applied, as appropriate. The search strategy ultimately yielded 12 relevant studies for inclusion. A total of 240 patients (52% male) split across cohort studies and case reports were identified. The mean age of the two groups was 59.7±3.0 and 58.1±6.8 years, respectively. The mean operative time was 133.8±38.2 and 150.0±52.2 minutes, respectively. Length of hospital stay was 4.4±1.6 and 4.3±1.1 days, respectively. The mean blood loss was 80.0±25.1 mL The majority of identified procedures were lobectomies, segmentectomies, and wedge resections, though complex sleeve resections and anterior mediastinal mass resections were also completed. Cumulative technical success was 99.9%. The uniportal robotic-assisted approach, when completed in expert hands, has been illustrated to have exceedingly low rates of conversion to secondary procedures, along with short length of stay (LOS), minimal blood loss, and short procedural times (variable depending on operation type). Current evidence on the feasibility of this approach will be bolstered by upcoming multi-institutional series.

Combined spinal and video-assisted thoracoscopic (VATS) approach to thoracic neurogenic dumbbell tumour in the prone position: a case report

Combined spinal and video-assisted thoracoscopic (VATS) approach to thoracic neurogenic dumbbell tumour in the prone position: a case report

A uniportal video-assisted thoracoscopic surgery hybrid approach for posterior mediastinal dumb-bell tumours

Posterior mediastinal dumb-bell tumours are neurogenic tumours that extend from the mediastinum to the intraspinal canal. They represent a surgical challenge because they may be resected using a staged or a single-stage approach. Until recently, a classic posterolateral thoracotomy was the gold standard for surgical resection for the intrathoracic segment. In the meantime, video-assisted thoracoscopic surgery has gained great acceptance among most thoracic surgeons because of the decreased surgical trauma, less operative blood loss and fewer postoperative complications and the shorter hospital stays. Proper selection of cases for thoracoscopic excision is crucial for ensuring good surgical outcomes. Factors such as tumour size, location and presence or absence of features suggesting malignancy should be considered. This procedure can offer great help in different case scenarios involving posterior mediastinal dumb-bell tumours. For giant tumours that will eventually need a thoracotomy, video-assisted thoracoscopic surgery helps the surgical team to choose an optimal site for a tailored thoracotomy incision and rule out any metastatic pleura seedings. In cases of small intrathoracic segments of dumb-bell tumours (≤ 6-8 cm) that require combined spinal and thoracic procedures in a single-stage approach, a combined posterior and video-assisted thoracoscopic surgical approach can be implemented for total resection of the tumour.

Early experience with uniportal robotic thoracic surgery lobectomy.

Invasiveness is considered one of the cornerstones of every field of surgery, and video-assisted thoracoscopic (VATS) approaches are now routinely used worldwide to perform pulmonary resections. Recently, robotic-assisted thoracic surgery (RATS) has become the preferred technique in many centers; it is routinely performed using three or four ports with at least one service incision, contrasting with the real concept of invasiveness, especially when compared to uniportal VATS (U-VATS). Hereby, we present our early experience with uniportal RATS (U-RATS) pulmonary resections for early-stage lung cancer. Technical details of surgical steps are accurately described and commented on. Twenty-four consecutive patients with lung cancer underwent U-RATS anatomical pulmonary resections at our institute. All procedures were completed with the uniportal approach. The mean operative time was 210 min (range 120-350); in the last 10 cases, the operative time was significantly reduced (180 min) compared to the first 10 cases (232 min) (p < 0.02), showing a very fast learning curve. The postoperative pain score was comparable to that for U-VATS and was constantly low. U-RATS is a safe and feasible technique, combining the advantages of U-VATS with the well-known advantages of robotic surgery.

Combined left thoracoscopic and median sternotomy approach to resect aortopulmonary mediastinal paraganglioma following feeding artery embolization: a case report

BackgroundAortopulmonary mediastinal paragangliomas are rare. Complete resection of the tumor is desirable regardless of tumor size in view of the risk of sudden death induced by adjacent organ compression and poor prognosis after partial resection or untreated observation. Due to the hypervascularity of the tumor, the risk of intraoperative bleeding is significant, and cardiopulmonary bypass is often required for complete resection.Case presentationThe patient was diagnosed as having bilateral carotid body tumors and supposedly an aortic body tumor at the age of 43 and eventually underwent resections of bilateral carotid body tumors at the age of 52. The pathology of the carotid body tumors was compatible with paraganglioma on both sides. A familial succinate dehydrogenase subunit D mutation was subsequently identified. Five years later, a contrast-enhanced computed tomography scan showed an enlarged tumor of 45 mm in size in the aortopulmonary mediastinum. Based on the previously known genetic mutation, the tumor was thought to be a paraganglioma. After confirming with an endocrinologist that the aortic body tumor was non-functional, radiologists performed preoperative embolization of the feeding vessels. Subsequently, a surgical team consisting of thoracic and cardiovascular surgeons resected the aortic body tumor using a video-assisted small left thoracotomy approach combined with a median sternotomy approach. The procedure was completed without cardiopulmonary bypass or blood transfusion. The patient was discharged home on postoperative day 9 uneventfully.ConclusionsAfter conduction of preceding interventional embolization of multiple feeding vessels, we employed a video-assisted thoracoscopic surgical approach to dissect the aspects of the tumor adjacent to the esophagus, descending thoracic aorta, and left pulmonary artery, followed by a median sternotomy approach to dissect the other aspects of the tumor adjacent to the ascending aorta, aortic arch, right pulmonary artery, and trachea. There have been no reports on scheduled preoperative embolization of feeding vessels to an aortopulmonary mediastinal paraganglioma. Multidisciplinary approach was effective for complete resection of this challenging rare mediastinal tumor.

Surgical treatment of lung metastasis in patients with refractory gestational trophoblastic neoplasia: A retrospective study

PurposeThe lungs are the most common site of metastasis in patients with gestational trophoblastic neoplasia. We investigated surgical management and prognostic factors of patients with refractory gestational trophoblastic neoplasia to assess the value of lung metastasis resection. Patients and methodsThe clinical data of patients with refractory gestational trophoblastic neoplasia and lung metastasis treated at Peking Union Medical College Hospital from January 2005 to December 2020 were retrospectively analyzed. Surgical characteristics and survival outcomes were analyzed. ResultsIn total, 213 patients with refractory gestational trophoblastic neoplasia and lung metastasis were screened, and 148 patients who underwent unilateral lung resection were analyzed. Patients' median age was 32 years. Lobectomy was performed in 65.5% of patients, while wedge resection was performed in 34.5%. The rate of postoperative complications was 12.2%. The pathological rate was 66.2%. Video-assisted thoracoscopic surgery showed better surgical characteristics than thoracotomy did. Compared with lobectomy, wedge resection had a shorter operative time, shorter duration of chest tube placement, shorter postoperative hospital stay, and fewer postoperative complications. The median follow-up period was 36 months. During follow-up, 90.5% of patients achieved complete remission. The 5-year disease-free and overall survival rates were 80.4% and 92.6%, respectively. More previous chemotherapy courses and failure to achieve normal β-human chorionic gonadotropin levels postoperatively were predictors of poor prognosis. ConclusionsSurgical treatment of lung metastasis is valuable and safe for patients with refractory gestational trophoblastic neoplasia. The minimally invasive video-assisted thoracoscopic approach and wedge resection are recommended.

Thoracic surgery in Taiwan.

Taiwanese surgeons have pioneered major advances in the field of minimally invasive thoracic surgery. Since the establishment of the Taiwan Association of Thoracic and Cardiovascular Surgery [1986], the landscape of thoracic surgery has rapidly evolved from traditional thoracotomy to multi-port video-assisted thoracoscopic approaches. By early 21st century, further developments have included the single-port and subxiphoid techniques. This paper provides an overview of the Taiwanese thoracic surgery environment and its major accomplishments. With the increasing use of low-dose computed tomography for lung cancer screening, the detection of small pulmonary nodules has been growing steadily. High-end hybrid operating rooms comprising both imaging and surgical equipment are increasingly being applied in Taiwan as platforms for image-guided video-assisted thoracoscopic surgery (iVATS). Recently, we described an iVATS workflow for simultaneous detection and removal of small pulmonary nodules which was entirely performed by thoracic surgeons. With respect to esophageal malignancies, the implementation of robot-assisted esophagectomy has been a significant milestone in Taiwan. This technique allowed conducting an extensive lymph node dissection along the bilateral recurrent laryngeal nerve in a safe and effective manner. With 14 medical schools and 26 medical centers located on the island, Taiwan has been able to maintain a constant doctor-to-population ratio of 1-to-500. By partnering with the National Health Insurance and by taking advantage of state-of-the-art technologies, Taiwanese thoracic surgeons are continuously striving to deliver high-quality and cost-effective surgical care.

VATS surgical anatomical resection of bronchopulmonary sequestration presenting as chest sepsis

BackgroundBronchopulmonary sequestration (BPS) is a malformation of the lungs resulting in lung tissue lacking direct communication to the tracheobronchial tree. Most cases demonstrate systemic arterial blood supply from the descending thoracic aorta, the abdominal aorta, celiac axis or splenic artery and venous drainage via the pulmonary veins with occasional drainage into azygos vein. BPS is considered a childhood disease and accounts for 0.15–6.40% of congenital pulmonary malformations. BPS is divided into intralobar sequestrations (ILS) and extralobar sequestrations (ELS) with ILS accounting for 75% of all cases.MethodsHere we present our 11-year experience of dealing with BPS; all cases presented with recurrent chest sepsis in young-late adulthood regardless of the type of pathological sequestration. The surgical technique employed was a minimally invasive video-assisted thoracoscopic anterior approach (VATS).ResultsBetween May 2010 and September 2021, we have operated on nine adult patients with bronchopulmonary sequestration who presented late with symptoms of recurrent chest sepsis. Most patients in the cohort had lower lobe pathology, with a roughly even split between right and left sided pathology. Moreover, the majority were life-long never smokers and an equal preponderance in males and females. The majority were extralobar sequestrations (56%) with pathological features in keeping with extensive bronchopneumonia and bronchiectasis. There were no major intra-operative or indeed post-operative complications. Median length of stay was 3 days.ConclusionsDissection and division of the systemic feeding vessel was readily achievable through a successful anterior VATS approach, regardless of the type of sequestration and without the use of pre-operative coiling of embolization techniques. This approach gave excellent access to the hilar structures yet in this pathology, judicious and perhaps a lower threshold for open approach should be considered.