Video-assisted Thoracoscopic Lung Research Articles

Optimal effect-site concentration of remifentanil for preventing cough during removal of the double-lumen endotracheal tube from sevoflurane-remifentanil anesthesia: A prospective clinical trial.

Opioids are used as a treatment for coughing. Recent studies have reported an antitussive effect of remifentanil during recovery from general anesthesia by suppressed coughing. The coughing reflex may differ throughout the respiratory tract from the larynx to the bronchi. But the proper dose of remifentanil to prevent cough during double-lumen tube (DLT) extubation is unknown.Twenty-five ASA physical status 1 and 2 patients, 20 to 65 years of age who were undergoing video-assisted thoracoscopic lung surgery requiring 1-lung ventilation were enrolled. The effective effect-site concentration (Ce) of remifentanil for 50% and 95% of patients (EC50 and EC95) for preventing cough was determined using the isotonic regression method with a bootstrapping approach, following the Dixon up-and-down method. Recovery profiles and hemodynamic values after anesthesia were compared between patients with cough and patients without cough.EC50 and EC95 of remifentanil was 1.670 ng/mL [95% confidence interval (95% CI) 1.393–1.806] and 2.275 ng/mL (95% CI 1.950–2.263), respectively. There were no differences in recovery profiles and hemodynamic values after anesthesia between patients with/without cough. No patients suffered respiratory complications during the emergence period.Remifentanil can be a safe and reliable method of cough prevention during emergence from sevoflurane anesthesia after thoracic surgery requiring DLT. EC50 and EC95 of remifentanil that suppresses coughing is 1.670 and 2.275 ng/mL, respectively.

A multi-center evaluation of a powered surgical stapler in video-assisted thoracoscopic lung resection procedures in China.

Lung cancer is one of the most prevalent malignancies worldwide. The number of anatomic lung cancer resections performed via video-assisted thoracoscopic surgery (VATS) is growing rapidly. Staplers are widely used in VATS procedures, but there is limited clinical data regarding how they might affect performance and postoperative outcomes, including air leak. This clinical trial assessed the use of a powered stapler in VATS lung resection, with a primary study endpoint being occurrence and duration of air leak and prolonged air leak (PAL). Data was collected from a single arm, multi-center study in Chinese patients receiving VATS wedge resection or lobectomy. Intra-operative data included surgery duration; cartridge selection for ligation/transection of bronchus, major vessels, and lung parenchyma; staple line interventions; blood loss; and device usage. Post-operative data included air leak assessments, chest tube duration, length of hospital stay, and adverse events (AEs). A total of 94 procedures across four institutions in China were included in the final analysis: 15 wedge resections, 74 lobectomies, and five wedge resections followed by lobectomies. Post-operative air leak occurred in five (5.3%) patients who had lobectomy procedures, with PAL in one (1.1%) patient. Sites were generally consistent relative to cartridge use by tissue type. The incidence of stapler firings requiring surgical interventions was seven out of 550 (1.3%). Surgeons participating in the study were satisfied with the articulation and overall usability of the stapler. The powered staplers make the VATS procedure easier for the surgeons and have achieved intra- and post-operative patient outcomes comparable to those previously reported.

Video-assisted thoracoscopic anatomic lung resection: experience of 246 operations

To present one of the largest materials of video-assisted thoracoscopic (VATS) anatomic lung resections in Russia. It is a retrospective analysis of treatment of 246 patients who underwent VATS anatomic lung resection for the period from 2010 to 2014 at the Center for Thoracic Surgery of St. Petersburg Clinical Hospital №122. One surgical team has operated 125 men and 121 women aged from 20 to 85 years (58.8±13.4 years). There were 216 (87.8%) lobectomies, 4 (1.6%) bilobectomies, 9 (3.7%) pneumonectomies, 10 (4.1%) segmentectomies and 7 (2.8%) trisegmentectomies. Upper right-side lobectomy was the most frequent in this group (87 (40.3%)). Most of operations was performed via 2 approaches (119 patients). Average length of the longest incision was 4.3±0.93 cm (range 2-6 cm). All patients were examined according to a single plan. FEV1 less than 70% was observed in 26% of patients; comorbidity index was 5 scores or more in 24% of cases; 23.2% of patients were older than 70 years. Non-small cell lung cancer (NSCLC) was diagnosed in 168 patients (68.3%), pulmonary tuberculosis - in 27 (11%), chronic suppurative lung disease - in 27 (11%) cases. Furthermore there were 9 cases of pulmonary metastases, 11 cases of carcinoid, 1 - MALT-lymphoma, 1 - leiomyoma, 2 - small cell lung cancer, as well as one case of IgG-associated pseudotumor. Among 168 cases of NSCLC operations were performed in 87 (51.8%) cases for cancer stage I, in 46 (27.3%) patients for stage II, in 27 patients for stage III (including 16 cases of stage IIIA and 11 cases of stage IIIB). 8 patients (4.7%) with lung cancer stage IV have been operated in radical surgery for solitary metastasis. Mean duration of surgery was 202.1±58.2 minutes (range 100-380). On the average 12.8±5.6 (range 9-32) mediastinal lymph nodes were excised during lymph node dissection in cancer patients. Mean number of nodes groups was 4.1±1.1. In 11 (4.5%) patients conversion to open surgery was made due to intraoperative bleeding (3 cases) and technical difficulties (8 cases). Mean duration of postoperative pleural drainage and hospital-stay were 5.1±4.3 (median - 3 days) and 7.9±4.7 days (median - 6 days) respectively. Complications which were not associated with perioperative deaths were observed in 66 patients (26.8%). Prolonged air vent was the most common complication. VATS anatomical lung resections are safe and effective in most of pulmonary surgical diseases. Such interventions may be recommended for wider introduction at the Thoracic Departments of Russia because of small number of complications and rapid rehabilitation. Bleeding or its risk associated with fibrotic changes in pulmonary root are the most frequent causes of conversion to open access.

Survival and Local Recurrence After Video-Assisted Thoracoscopic Lung Metastasectomy.

Pulmonary metastasectomy is increasingly performed in selected patients by video-assisted thoracic surgery (VATS) on the base of thin-slice high-resolution CT-Scan (HRCT). This study determines the overall survival and ipsilateral recurrence rate and of patients undergoing after VATS lung metastasectomy. Retrospective single institution study of all patients who underwent VATS pulmonary metastasectomy on the base of HRCT with curative intent between 2005 and 2014. Seventy-seven patients (41 males, 36 females) underwent VATS pulmonary metastasectomy for solitary (n = 63) or multiple (n = 14) lung metastases in the context of colorectal carcinoma (n = 26), sarcoma (n = 17), melanoma (n = 16), or other primaries (n = 18). Nine patients had bilateral lung metastases and underwent synchronous (n = 4) or sequential (n = 5) VATS resections. Preoperative CT-guided hook wire localization of the lesions was performed in 65 patients (84 %). The postoperative mortality and morbidity rates were 0 and 5.2 %, respectively. During a mean follow-up time of 24 months (range 1–120 months), tumor progression occurred in 46 patients. Twenty-three patients (30 %) had pulmonary recurrence only, of them, eight patients (10 %) in the operated lungs. Seven of eight patients with recurrence in the operated lungs underwent a second metastasectomy by VATS (n = 5) or thoracotomy (n = 2). The overall 5-year survival rate was 54 % and without difference between patients without tumor recurrence and those with pulmonary recurrence treated by re-metastasectomy. Ipsilateral recurrence remains low after VATS pulmonary metastasectomy guided by preoperative HRCT and can be efficiently treated by re-metastasectomy.

Single-port video-assisted thoracoscopic surgery lung resection: experiences in Fujian Medical University Union Hospital.

Video-assisted thoracoscopic surgery (VATS) is currently a better choice than thoracotomy for lung resection, and then single-port VATS has been increasingly applied in clinical settings with the improvements in both endoscopic instruments and surgical skills. Our center began to perform single-port VATS lobectomy in May 2014 and had performed all sort of lung resection in 168 patients till December 2014, including wedge resection, routine lobectomy, sleeve lobectomy, segmentectomy and pneumonectomy. All these procedures were successfully performed without any severe complication. We believe the single-port VATS lung resection is a safe and feasible procedure after surgery practice.

Robotic video-assisted thoracoscopic lung resection for lung tumors: a community tertiary care center experience over four years.

After its initial description in 1990, video-assisted thoracoscopic surgery (VATS) has emerged as the minimally invasive approach for lung resection in early lung cancer. A retrospective review of prospectively collected data on patients who underwent robotic pulmonary resection for cancer by a single surgeon, between years 2009 and 2013, was performed. Age, gender, type and duration of surgery, length of stay, estimated blood loss, early and late complications, follow-up time, and local recurrence were reviewed and analyzed descriptively. Three hundred and thirty-one patients underwent the procedure for pulmonary neoplasm. Two hundred and fifty-nine (79%) patients underwent anatomic lobectomies, 56 (17%) patients had wedge resection, while five (1.5%) patients underwent pneumonectomy. In 11 patients, no pulmonary resection was performed for different reasons. Most common neoplasm was adenocarcinoma (185, 56%). All procedures involved a systematic mediastinal and hilar lymph node exploration and removal of suspicious nodes. Twenty-six (6.9%) procedures were converted to open thoracotomy. Mean duration of surgery was 185.63 min. Mean length of hospital stay was 5.52 days. Mean estimated blood loss (EBL) was 47.85 ml. Mean follow-up was 249.41 days (20-1550 days), and five (1.5%) patients developed local recurrence. Early complications were seen in 29 patients (8.8%), most commonly cardiac arrhythmias (20, 6%). Robotic video-assisted thoracoscopic surgery is feasible in lung lesions, with all the advantages of VATS in terms of decreased length of stay and decreased blood loss with local recurrence rate and complication rate comparable to open procedures. There is a clear need for more studies comparing the apparent advantages of robotic-assisted surgery with increased cost of technology.

Non-intubated video-assisted thoracoscopic lung resections: the future of thoracic surgery?

Thanks to the experience gained through the improvement of video-assisted thoracoscopic surgery (VATS) technique, and the enhancement of surgical instruments and high-definition cameras, most pulmonary resections can now be performed by minimally invasive surgery. The future of the thoracic surgery should be associated with a combination of surgical and anaesthetic evolution and improvements to reduce the trauma to the patient. Traditionally, intubated general anaesthesia with one-lung ventilation was considered necessary for thoracoscopic major pulmonary resections. However, thanks to the advances in minimally invasive techniques, the non-intubated thoracoscopic approach has been adapted even for use with major lung resections. An adequate analgesia obtained from regional anaesthesia techniques allows VATS to be performed in sedated patients and the potential adverse effects related to general anaesthesia and selective ventilation can be avoided. The non-intubated procedures try to minimize the adverse effects of tracheal intubation and general anaesthesia, such as intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade, and postoperative nausea and vomiting. Anaesthesiologists should be acquainted with the procedure to be performed. Furthermore, patients may also benefit from the efficient contraction of the dependent hemidiaphragm and preserved hypoxic pulmonary vasoconstriction during surgically induced pneumothorax in spontaneous ventilation. However, the surgical team must be aware of the potential problems and have the judgement to convert regional anaesthesia to intubated general anaesthesia in enforced circumstances. The non-intubated anaesthesia combined with the uniportal approach represents another step forward in the minimally invasive strategies of treatment, and can be reliably offered in the near future to an increasing number of patients. Therefore, educating and training programmes in VATS with non-intubated patients may be needed. Surgical techniques and various regional anaesthesia techniques as well as indications, contraindications, criteria to conversion of sedation to general anaesthesia in non-intubated patients are reviewed and discussed.

Single-Port Video-Assisted Thoracoscopic Major Lung Resections: Experience with 150 Consecutive Cases.

Background Video-assisted thoracic surgery (VATS) for major lung resection has undergone major changes from three or four-port approach to the recently possible single-port VATS approach. Outcomes following single-port VATS major lung resection are analyzed to determine safety and efficacy. Methods A prospective database of 150 consecutive patients who underwent single-port VATS major lung resection between March 2012 and January 2014 was reviewed. Patient demographics, perioperative parameters, histopathology, and outcomes up to follow-up of 2 years were analyzed by descriptive and Kaplan-Meier survival statistics. Results Single-port VATS major lung resection was successfully performed in 142 patients (conversion rate 5.3%) for both malignant and benign diseases of the lung. Overall, 130 patients (87%) had nonsmall-cell lung carcinoma (NSCLC), 9 (6%) had other types of primary lung cancer, and the remaining for secondary malignancies and benign diseases. Among the 130 patients with NSCLC, 93 (71.5%) were stage I, 28 were stage II (21.5%), and 9 (7%) were stage III or greater. There was no intraoperative or 30-day mortality. However, one perioperative death occurred on day 49, and another on day 60 postoperatively due to infective causes. The overall 2-year mortality rate for all patients was 3%. The disease-free survival rate for subgroups, stage I NSCLC, and stage II or greater NSCLC were 96 and 83%, respectively. Conclusions Single-port VATS major lung resection for malignant and benign lung diseases is associated with low perioperative morbidity and mortality. Disease-free survival rates for NSCLC are acceptable and comparable with conventional VATS.

Long-term outcomes of open and video-assisted thoracoscopic lung lobectomy for the treatment of early stage non-small cell lung cancer are similar: a propensity-matched study.

Generally, in retrospective studies, favourable short- and long-term outcomes for patients after lung lobectomy for early stage non-small cell lung cancer (NSCLC) using video-assisted thoracoscopic surgery (VATS) have been reported. However, the interpretation of lung lobectomy outcomes may be biased in retrospective settings. We retrospectively reviewed patients who underwent lung lobectomy for cT1-2N0M0 NSCLC from 2001 to 2010. The outcomes of patients who underwent VATS lobectomy were compared to those who underwent open lobectomy before and after performing propensity score matching. Preoperative covariates were entered when developing the propensity score-matching model. This study reviewed the outcomes of 101 VATS patients and 184 open lobectomy patients. Before propensity score matching, the VATS group had a higher mean age (p < 0.0001), smaller solid tumour size (p = 0.0042), similar whole tumour size (p = 0.2082), and larger tumour-disappearance ratio (p = 0.0007). The VATS group had a shorter mean operation time (p = 0.0002), less blood loss (p < 0.0001), shorter chest tube duration (p = 0.0002), and shorter hospital stay (p < 0.0001). As for long-term outcomes, the VATS group had higher disease-free, disease-specific, and overall survival rates (p values by log-rank test: 0.0049, 0.0154, and 0.032, respectively). After propensity score matching, all differences, except operation time, blood loss, chest tube duration, and hospital stay, were no longer significant. VATS lobectomy is less invasive than open lobectomy, but in terms of survival outcomes, VATS lobectomy was oncologically equivalent to open lobectomy. The oncological benefit of VATS reported by retrospective studies might be overestimated.

Index of prolonged air leak score validation in case of video-assisted thoracoscopic surgery anatomical lung resection: results of a nationwide study based on the French national thoracic database, EPITHOR.

The incidence rate of prolonged air leak (PAL) after lobectomy, defined as any air leak prolonged beyond 7 days, can be estimated to be in between 6 and 15%. In 2011, the Epithor group elaborated an accurate predictive score for PAL after open lung resections, so-called IPAL (index of prolonged air leak), from a nation-based surgical cohort constituted between 2004 and 2008. Since 2008, video-assisted thoracic surgery (VATS) has become popular in France among the thoracic surgical community, reaching almost 14% of lobectomies performed with this method in 2012. This minimally invasive approach was reported as a means to reduce the duration of chest tube drainage. The aim of our study was thus to validate the IPAL scoring system in patients having received VATS anatomical lung resections. We collected all anatomical VATS lung resections (lobectomy and segmentectomy) registered in the French national general thoracic surgery database (EPITHOR) between 2009 and 2012. The area under the receiver operating characteristic (ROC) curve estimated the discriminating value of the IPAL score. The slope value described the relation between the predicted and observed incidences of PALs. The Hosmer-Lemeshow test was also used to estimate the quality of adequacy between predicted and observed values. A total of 1233 patients were included: 1037 (84%) lobectomies and 196 (16%) segmentectomies. In 1099 cases (89.1%), the resection was performed for a malignant disease. Ninety-six patients (7.7%) presented with a PAL. The IPAL score provided a satisfactory predictive value with an area under the ROC curve of 0.72 (0.67-0.77). The value of the slope, 1.25 (0.9-1.58), and the Hosmer-Lemeshow test (χ(2) = 11, P = 0.35) showed that predicted and observed values were adequate. The IPAL score is valid for the estimation of the predictive risk of PAL after VATS lung resections. It may thus a priori be used to characterize any surgical population submitted to potential preventive measures.

Idiopathic pulmonary hemosiderosis presenting in an adult: A case report and review of the literature.

Diffuse alveolar hemorrhage (DAH) is characterized by the presence of hemoptysis, anemia, and the presence of diffuse parenchymal infiltrates on imaging studies. Idiopathic pulmonary hemosiderosis (IPH) is an uncommon cause of diffuse alveolar hemorrhage (DAH) and is classically known to present in childhood. Adult-onset IPH is extremely rare. We report the case of a 48-year-old female patient who presented with hemoptysis and acute hypoxic respiratory failure, requiring intubation and mechanical ventilation. Imaging studies showed diffuse bilateral patchy infiltrates. Bronchoalveolar lavage (BAL) confirmed the diagnosis of DAH. Extensive workup including video-assisted thoracoscopic surgical lung biopsy (VATS) failed to reveal any vasculitis, infectious, immunological or connective tissue disorder, as the underlying cause for DAH. The patient was successfully treated with high-dose steroid therapy.

The clinical-radiologic-pathologic features of imported pulmonary histoplasmosis

To describe the clinical features and treatment of imported pulmonary histoplasmosis and therefore to improve the recognition and differential diagnosis of this disease. The clinical data of 3 patients with imported pulmonary histoplasmosis in our hospital were collected and analyzed. Literatures published since 1989 were retrieved with 'pulmonary histoplasmosis' from PubMed, China National Knowledge Infrastructure (CNKI), Wanfang Data and VIP data, of which all the literatures about imported pulmonary histoplasmosis were reviewed. The clinical manifestations, diagnostic methods and treatment were summarized. All the 3 cases of imported pulmonary histoplasmosis were immunocompetent hosts, all were males, age were from 44-67 years, and had a history of exploring the cave or tunnel inhabited by bats in the epidemic areas. All of them developed influenza-like symptoms varying in severity after the onset of the disease. Pulmonary multiple nodules and mediastinal lymphadenopathy were found on chest images. One patient underwent percutaneous lung biopsy and the other two received video-assisted thoracoscopic lung biopsy. All the 3 patients showed consistent histopathological findings, such as granulomatous inflammation with necrosis. Pathogen culture with lung biopsy in the first case was identified as histoplasma. All the 3 cases were treated with itraconazole, and recovered with good prognosis. Thirteen literatures in English were obtained, which reported 60 cases with imported pulmonary histoplasmosis. Forty-two of them were males, 16 were females and 2 undefined. The range of their age was from 17-64 years. No imported pulmonary histoplasmosis was reported so far in Chinese literature. Common features of imported pulmonary histoplasmosis were consistent with our patients, including epidemiology, influenza-like symptoms and bilateral pulmonary nodules, recovery with or without antifungal therapy. The epidemiologic history, influenza-like symptoms and bilateral pulmonary nodules provide valuable diagnostic clues for imported histoplasmosis. Clinical features with pathologic findings and good response to antifungal therapy could make the diagnosis even without pathogen detection if other etiology is unlikely.

Nonspecific interstitial pneumonia and usual interstitial pneumonia: comparison of the clinicopathologic features and prognosis.

Nonspecific interstitial pneumonia (NSIP) has recently been proposed as a histologic type of idiopathic interstitial pneumonia (IIP), but its broad spectrum of clinicopathologic findings and variable prognosis are poorly understood. It is particularly unclear how NSIP and usual interstitial pneumonia (UIP) are related. The present study investigated the clinicopathologic features and prognosis of NSIP, and its differential diagnosis from UIP. The clinicopathologic findings and prognosis in 21 NSIP and 18 UIP patients who underwent surgical or video-assisted thoracoscopic lung biopsy were reviewed. NSIP was more frequent in women and showed nonspecific clinical manifestations. High-resolution computed tomography (HRCT) demonstrated ground-glass, net-like, and patchy attenuation in both lungs. Semiquantitative HRCT showed a median fibrosis score of 3 (range, 0 to 7) in NSIP patients and 5 (range, 2 to 7) in UIP patients (P<0.01). On histopathologic examination, NSIP cases were heterogeneous and the findings could be categorized into cellular and fibrosing patterns. The mean age of the NSIP and UIP patients was 48 and 60 years, respectively. The frequencies of fibroblast foci, myogelosis, honeycomb lesions, and pulmonary structural destruction in NSIP and UIP patients were 16.7% and 100% (P<0.001), 22.2% and 85.7% (P<0.05), 16.7% and 92.9% (P<0.001), and 27.8% and 100% (P<0.05), respectively. The responses to glucocorticoid treatment and the prognosis were significantly greater in NSIP than those in UIP. NSIP was difficult to be differentiated from UIP by general clinical manifestations, but HRCT can be helpful for this purpose. Definitive diagnosis depends on the results of surgical lung biopsy.

Thoracoscopic lung biopsy in 285 patients with diffuse pulmonary disease.

Surgical lung biopsy is generally considered the most appropriate method for diagnosing diffuse lung disease. However, there are few reports focusing on only one thoracoscopic technique. This study was designed to determine the morbidity and mortality related to video-assisted thoracoscopic lung biopsy in a single center, thereby providing data on the severity of morbidity and clarifying the risk factors. We analyzed 285 patients with undiagnosed diffuse lung disease who underwent video-assisted thoracoscopic lung biopsy at Kanagawa Cardiovascular and Respiratory Center from February 2007 to April 2012. We recorded the severity of postoperative complications using the Clavien-Dindo classification. The surgical morbidity was 7.0% (20/285), including delayed pulmonary fistulas in 11 patients, acute exacerbation in 3, prolonged air leakage (>7 days) in 2, hypoxemia in 2, atrial fibrillation in 1, and premature ventricular contraction in 1. Based on the Clavien-Dindo classification, grade I, II, IIIa, IIIb, and IVa complications accounted for 20%, 10%, 50%, 5%, and 15%, respectively. The 30-day mortality was 0%. The diagnostic yield was 100%. Although acute exacerbation occurred in 2 patients with idiopathic pulmonary fibrosis and 1 with fibrotic nonspecific interstitial pneumonia, there were no distinctive features that allowed preoperative prediction of acute exacerbation. Our findings indicate that video-assisted thoracoscopic lung biopsy is a feasible procedure. We hope to clarify risk factors in future research.

Case Report: Double lumen tube insertion in a morbidly obese patient through the non-channelled blade of the King Vision (™) videolaryngoscope.

We describe the insertion of the double lumen endobronchial tube (DLT) using a non-channeled standard blade of the King Vision (TM) videolaryngoscope for one lung ventilation (OLV) in a morbidly obese patient with a predicted difficult airway, severe restrictive pulmonary function, asthma, and hypertension. The patient was scheduled for a video-assisted thoracoscopic lung biopsy. The stylet of the DLT was bent to fit the natural curve of the #3 non-channeled blade of the King Vision (™) videolaryngoscope. We conclude that the use of King Vision (™) videolaryngoscope could offer an effective method of DLT placement for OLV.

VATS biopsy for undetermined interstitial lung disease under non-general anesthesia: comparison between uniportal approach under intercostal block vs. three-ports in epidural anesthesia.

Video-assisted thoracoscopic (VATS) biopsy is the gold standard to achieve diagnosis in undetermined interstitial lung disease (ILD). VATS lung biopsy can be performed under thoracic epidural anesthesia (TEA), or more recently under simple intercostal block. Comparative merits of the two procedures were analyzed. From January 2002 onwards, a total of 40 consecutive patients with undetermined ILD underwent VATS biopsy under non-general anesthesia. In the first 20 patients, the procedures were performed under TEA and in the last 20 with intercostal block through a unique access. Intraoperative and postoperative variables were retrospectively matched. Two patients, one from each group, required shift to general anesthesia. There was no 30-day postoperative mortality and two cases of major morbidity, one for each group. Global operative time was shorter for operations performed under intercostal block (P=0.041). End-operation parameters significantly diverged between groups with better values in intercostal block group: one-second forced expiratory flow (P=0.026), forced vital capacity (P=0.017), oxygenation (P=0.038), PaCO2 (P=0.041) and central venous pressure (P=0.045). Intraoperative pain coverage was similar. Significant differences with better values in intercostal block group were also experienced in 24-hour postoperative quality of recovery-40 questionnaire (P=0.038), hospital stay (P=0.033) and economic expenses (P=0.038). Histology was concordant with radiologic diagnosis in 82.5% (33/40) of patients. Therapy was adjusted or modified in 21 patients (52.5%). Uniportal VATS biopsies under intercostal block can provide better intraoperative and postoperative outcomes compared to TEA. They allow the indications for VATS biopsy in patients with undetermined ILD to be extended.

Hilar closure using staplers or Hem-o-lok clips in a rabbit model

BackgroundLung lobectomy is necessary in neonatal patients for the treatment of a variety of congenital bronchopulmonary malformations. The working space required for traditional stapling devices limits their use in pediatric video-assisted thoracoscopic (VATS) lung lobectomy. The use of Hem-o-lok clips (Teleflex Medical Inc. Research Triangle Park, NC) has been described for a number of applications in minimally invasive surgery and may provide an alternative to traditional stapling devices for bronchial closure. Materials and methodsTwenty-four New Zealand White rabbits were used in the study. The hilus of each cranial lung lobe was sealed with the Endo GIA (Covidien Inc, Mansfield, MA) stapler or 2 Hem-o-lok clips and the lung lobe was removed. Lung inflation to leakage point was induced by incrementally increasing tidal volume. Side of leakage, volume at leakage, and airway pressure before leakage were recorded. ResultsFourteen rabbits were included in the data analysis. Leakage of air was first observed at the Hem-o-lok closure site in five rabbits and from the Endo GIA site in three rabbits. In the remaining six, both resection sites leaked simultaneously. The mean pressure before failure was 16.39 ± 7.35 mm Hg for the Hem-o-lok clips, 17.98 ± 11.12 mm Hg for the Endo GIA stapler, and 16.95 ± 3.48 mm Hg for the simultaneous failures. No statistical differences were detected in airways pressures before leakage between hilar closure devices. ConclusionsDespite advances in VATS, options for bronchial closure in pediatric patients undergoing VATS lung lobectomy remain limited. Hem-o-lok clips require less working space than traditional stapling devices and may represent an equally efficacious alternative to traditional stapling devices.

Case Report: Double lumen tube insertion in a morbidly obese patient through the non-channelled blade of the King Vision™ videolaryngoscope

We describe the insertion of the double lumen endobronchial tube (DLT) using a non-channeled standard blade of the King Vision (TM) videolaryngoscope for one lung ventilation (OLV) in a morbidly obese patient with a predicted difficult airway, severe restrictive pulmonary function, asthma, and hypertension. The patient was scheduled for a video-assisted thoracoscopic lung biopsy. The stylet of the DLT was bent to fit the natural curve of the #3 non-channeled blade of the King Vision (™) videolaryngoscope. We conclude that the use of King Vision (™) videolaryngoscope could offer an effective method of DLT placement for OLV.

The efficacy of video-assisted thoracoscopic surgery lung biopsies in patients with interstitial lung disease: a retrospective study of 66 patients

BackgroundDiagnosing a specific type of Interstitial Lung Disease (ILD) is a challenging process and often necessitates that a Video-assisted Thoracoscopic Surgery (VATS) Lung Biopsy be performed. By analysing the proportion of patients who have their treatment changed after undergoing a VATS lung biopsy, this study aimed to determine the utility of performing this procedure in patients with ILD.MethodsThe clinical data from sixty-six patients with suspected ILD, who underwent VATS lung biopsies at the New Royal Infirmary of Edinburgh (NRIE) in the period of 16th May 2011 – 11th February 2013, were analysed retrospectively. The main outcome measures considered in this study were: CT scan differential diagnoses, VATS lung biopsy histological differential diagnoses, post-VATS lung biopsy consensus diagnoses, 30-day mortality, surgical complications (minor and major), resultant changes in treatment and responses to these changes in treatment.ResultsFollowing VATS biopsy a definite pathological diagnosis was made in 74.2% of cases. A change in treatment was initiated in 47.2% of patients, including in 80% of patients diagnosed with Hypersensitivity Pneumonitis and 60% of patients diagnosed with sarcoidosis. A positive response to treatment was experienced in 58% of patients whom underwent a change in treatment. Only 54% of patients who received a consensus diagnosis of UIP after VATS lung biopsy, had been given a differential diagnosis of “probable UIP” at CT scan. 15% of patients who received a differential diagnosis of “probable UIP” at CT scan, had their diagnosis changed to Hypersensitivity Pneumonitis after lung biopsy. There was one mortality (1.5%) in this series of patients and no other major complications. Minor complications to surgery were experienced in 28.8% of patients.ConclusionsThis study highlights the effectiveness of performing VATS lung biopsies in patients with suspected ILD. The procedure leads to a change in treatment in almost half of all patients, including in the vast majority of cases of Hypersensitivity Pneumonitis. It also prevents what would be the inappropriate over-treatment of UIP. It has been shown to be a relatively safe procedure and thus, should be performed in all patients with suspected ILD, indeterminate in type from prior CT imaging.

Defining the Cost of Care for Lobectomy and Segmentectomy: A Comparison of Open, Video-Assisted Thoracoscopic, and Robotic Approaches

Knowledge about the cost of open, video-assisted thoracoscopic (VATS), or robotic lung resection and drivers of cost is crucial as the cost of care comes under scrutiny. This study aims to define the cost of anatomic lung resection and evaluate potential cost-saving measures. A retrospective review of patients who had anatomic resection for early stage lung cancer, carcinoid, or metastatic foci between 2008 and 2012 was performed. Direct hospital cost data were collected from 10 categories. Capital depreciation was separated for the robotic and VATS cases. Key costs were varied in a sensitivity analysis. In all, 184 consecutive patients were included: 69 open, 57 robotic, and 58 VATS. Comorbidities and complication rates were similar. Operative time was statistically different among the three modalities, but length of stay was not. There was no statistically significant difference in overall cost between VATS and open cases (Δ = $1,207) or open and robotic cases (Δ = $1,975). Robotic cases cost $3,182 more than VATS (p < 0.001) owing to the cost of robotic-specific supplies and depreciation. The main opportunities to reduce cost in open cases were the intensive care unit, respiratory therapy, and laboratories. Lowering operating time and supply costs were targets for VATS and robotic cases. VATS is the least expensive surgical approach. Robotic cases must be shorter in operative time or reduce supply costs, or both, to be competitive. Lessening operating time, eradicating unnecessary laboratory work, and minimizing intensive care unit stays will help decrease direct hospital costs.