Video-assisted Thoracoscopic Surgery Procedures Research Articles

Nexplanonectomy—the surgical removal of an embolized implanted contraceptive device: a case report and review of the literature

BackgroundNexplanon implants are a common hormonal contraceptive modality. Though rare, these devices can embolize into the injured wall of the basilic vein, through the right heart, and finally wedge itself into a pulmonary artery. With adherence to the arterial wall over time, it becomes less amenable to endovascular retrieval. Patients may present with symptoms mimicking a pulmonary embolism, or without any symptoms at all. In asymptomatic cases, endovascular retrieval and/or surgery is required when patients wish to begin having children prior to biological inactivity. The current literature showed as little as nine case reports detailing lung tissue removal in the aim of reversing a patient’s implanted contraceptive device.Case presentationA 22-year-old asymptomatic active-duty Caucasian female presented for elective outpatient Nexplanon removal. The suspicion of possible implant migration arose when it was discovered to be non-palpable in her left arm. After plain film x-rays failed to localize the implant, a chest x-ray and follow-up Computed Tomography (CT) scan revealed that the Nexplanon had migrated to a distal branch of the left pulmonary artery. Due to the patient’s strong desires to begin having children, the decision was made for removal. Initial endovascular retrieval failed due to Nexplanon encapsulation within the arterial wall. Ultimately, the patient underwent a left video-assisted thoracoscopic surgery (VATS) for exploration and left lower lobe basilar S7–9 segmentectomy, which successfully removed the Nexplanon.ConclusionsImplanted contraceptive devices can rarely result in migration to the pulmonary vasculature. These radiopaque devices are detectable on imaging studies if patients and clinicians are unable to palpate them. An endovascular approach should be considered first to spare lung tissue and avoid chest-wall incisions, but can be complicated by encapsulation and adherence to adjacent tissue. A VATS procedure with single-lung ventilation via a double-lumen endotracheal tube allows surgeons to safely operate on an immobilized lung while anesthesiologists facilitate single-lung ventilation. This patient’s case details the uncommon phenomenon of Nexplanon migration, and the exceedingly rare treatment resolution of lung resection to remove an embolized device.

Minimally-Invasive Diaphragmatic Plication in Patients with Unilateral Diaphragmatic Paralysis.

Background: Diaphragm eventration (DE) represents a frequent problem with consecutive major impacts on respiratory function and the quality of life of the patients. The role of diaphragmatic plication (DP) is still underestimated. The aim of the present study is to evaluate the efficacy of minimally-invasive surgical diaphragmatic plication for the management of unilateral diaphragmatic eventration, to the best of our knowledge, this is the largest series reported in the literature using a non-resectional technique. Methods: All patients with unilateral diaphragmatic paralysis admitted for diaphragmatic plication (DP) between January 2008 and December 2022 formed the cohort of this retrospective analysis. DP procedure was done to plicate the diaphragm without resection or replacement with synthetic materials. Patients were divided into two groups: Group I included patients who underwent DP through an open thoracotomy, and Group II included patients who underwent DP through video-assisted thoracoscopic surgery (VATS). Data from all patients were collected prospectively and subsequently analyzed retrospectively. Patients' characteristics, lung function tests, radiological findings, type of surgical procedures, complications, and postoperative follow-up were compared. The primary outcome measure was the postoperative result (deeper position of the paralyzed diaphragm) and improvement of dyspnea. The secondary outcome was lung function values over a long-term follow-up. Results: The study included a total of 134 patients who underwent diaphragmatic plication during the study period. 94 (71.7%) were males, mean age of 64 (SD ± 14.0). Group I (thoracotomy group) consisted of 46 patients (35 male). Group II (VATS-group) consisted of 88 patients (69 male). The majority of patients demonstrated impaired lung functions (n = 126). The mean length of diaphragmatic displacement was 8 cm (SD ± 113.8 cm). The mean duration of the entire procedure, including placement of the epidural catheter (EDC), was longer in group I than in group II (p = 0.016). This was also observed for the mean length of the surgical procedure itself (p = 0.031). Most patients in group I had EDC (n = 38) (p = 0.001). Patients in group I required more medication for pain control (p = 0.022). A lower position of the diaphragm was achieved in all patients (p < 0.001). The length of hospital stay was 7 (SD ± 4.5) days in group I vs. 4.5 (SD ± 3.2) days in group II (p = 0.036). Minor complications occurred in 3% (n = 4) in group I vs. 2% (n = 3) in group II. No mortality was observed in any of the groups. Postoperative follow-up of patients at 6, 12, and 24 months showed a significant increase in forced vital capacity (FVC) up to 25% (SD ± 10%-35%) (p = 0.019), in forced expiratory volume in 1 s (FEV1) up to 20% (SD ± 12%-38%) in both groups (p = 0.026), also in the diffusion capacity of carbon monoxide (DLCO) up to 15% (SD ± 10%-20%) was noticed in both groups. Chronic pain symptoms were noted in 13% (n = 6) in group I vs. 2% (n = 2) in group II (p = 0.014). Except for one patient in group II, no recurrence of DE was observed. Conclusions: Diaphragm plication is an effective procedure to reduce debilitating dyspnea and improve lung function in patients suffering from diaphragm eventration. Minimally invasive diaphragmatic plication using VATS procedures is a safe and feasible procedure for the management of unilateral diaphragmatic paralysis. VATS-DP is superior to open procedure in terms of pain management and length of hospital stay, hence, accelerated recovery is more likely. Careful patient selection is crucial to achieving optimal outcomes. Prospective studies are needed to validate these results.

Use of Video-Assisted Thoracoscopic Surgery (VATS) in the Treatment of Primary Spontaneous Pneumothorax (PSP) in Children.

This study aims to review the primary spontaneous pneumothorax (PSP) patients we have treated and to discuss the results in terms of PSP treatment management and video-assisted thoracoscopic surgery (VATS) use in the light of the literature. The study was designed retrospectively and conducted at a tertiary referral university hospital between January 1, 2015 and May 1, 2021. Patients under the age of 18 years with a diagnosis of pneumothorax (PTX) were included in the study. Medical records were analyzed in terms of clinical characteristics, demographic data, findings from imaging data, procedures performed, and course of the disease at hospital. Patients with no evidence of PTX on radiologic imaging (direct postero-anterior chest X-ray (PACXR) or thoracic computed tomography (TCT)), incomplete medical records for follow-up, history of trauma, and neonatal PTX were excluded from the study. The study was conducted on a total of 98 PTX cases in 69 patients, 61 (88.4%) males and eight (11.6%) females. The ages of the patients ranged between 13 and 17 years with a mean of 16.59 ± 0.95 years. While 48 (49%) PTX cases were treated with tube thoracostomy, 19 (19.4%) were treated with medical follow-up (nonsurgical treatment) and 31 (31.6%) were treated with VATS. A total of 31 VATS procedures were performed on 28 patients. The follow-up period after VATS ranged from tthree to 78 months, with a mean of 31.5 ± 20.3 months and a median of 28 months. Our retrospective study showed that TCT scanning did not provide additional benefit when PSP was detected on PACXR in patients presenting with chest pain and respiratory distress. According to the findings of our study, it was thought that the probability of undergoing an invasive procedure and surgical intervention increased as the percentage of PTX detected in PACXR increased. Tube thoracostomy may be required in a patient with PSP if PTX does not start to decrease and lung expansion does not increase after an average of 60 hours after the decision for medical follow-up, and if PTX is progressive in the follow-up. VATS can be performed on a patient with PSP when lung expansion does not increase after an average of 18 hours after tube thoracostomy, when PTX progresses, when air leakage continues for more than 10 days despite increased lung expansion, and when recurrent PTX occurs.

Uniportal versus triportal video-assisted thoracic surgery in the treatment of tuberculous empyema

To examine the effectiveness of decortication to treat chronic tuberculous empyema (TE) using uniport video-assisted thoracoscopic surgery (VATS) versus conventional triport VATS. Data from consecutive patients with stage II or III TE who underwent decortication with either uniport VATS (uniportal group) between July and December 2017, or triport VATS between January and July 2018 (triportal group), were retrospectively analysed. VATS procedures were performed under general anaesthesia with double lumen endotracheal intubation and clinical outcomes were compared between the two groups. Clinical data were comparable between the groups (20 patients in each) regarding demographic and baseline characteristics, operative and postoperative characteristics, surgical procedure-related complications, and postoperative adverse events. No surgical procedure-related complications occurred during the perioperative period in either group. Threshold values for mechanical pain at 8 h postoperatively were significantly higher in the triportal group versus the uniportal group. Furthermore, the incidence of nausea and vomiting was significantly lower in the uniportal versus triportal group. In the triportal group, one patient required readmission and further intervention due to recurrence. Uniport VATS decortication for stages II and III TE may be a feasible and safe procedure in selected patients. Moreover, uniport VATS may be less painful than triport VATS.

Primary Spontaneous Pneumothorax: Open Thoracotomy vs. Video-assisted Thoracoscopic Surgery: A Single-center Retrospective Cohort Study.

Primary spontaneous pneumothorax (PSP) is a spontaneous pneumothorax without underlying lung disease. The main goals of this study were to compare the outcomes of video-assisted thoracoscopic surgery (VATS) and open thoracotomy in patients with PSP. The current study is a retrospective cohort study of patients who were admitted to the emergency department or general surgery ward at Dr. Masih Daneshvari Hospital (Tehran, Iran) with the diagnosis of PSP and underwent surgery by open or VATS approach from 2006 to 2012. The groups were compared in terms of the length of operation, the length of hospitalization, recurrence, and postoperative complications. Data were analyzed using SPSS version 18.0, and Student's t test, analysis of variance (ANOVA), Chi square, and Fisher's exact test were employed. P values less than 0.05 were considered statistically significant. PSP was diagnosed in 90 patients who underwent surgery. Open thoracotomy and VATS procedures were performed in 65 (72.2%) and 25 (27.8%) patients, respectively. VATS was converted to open in seven cases (7.7%). Recurrent pneumothorax was the most common surgical indication for PSP. There was no significant difference between the two groups in terms of mean age, sex, smoking, side of the involved lung, previous pneumothorax history, mean length of hospitalization for recurrence, post-operation bleeding, and failure of lung expansion. However, the length of surgery (P=0.011) and air leakage (P=0.048) significantly differed between the two groups. When compared to open thoracotomy, VATS could be the primary treatment option in the surgical treatment of PSP due to the shorter length of surgery and decreased complications such as air leakage.

A CASE OF CHRONIC EMPYEMA REQUIRING ELOESSER FLAP SURGERY

A CASE OF CHRONIC EMPYEMA REQUIRING ELOESSER FLAP SURGERY

Contemporary Role of Computed Tomography in Managing Pediatric Primary Spontaneous Pneumothorax.

The value of chest computed tomography (CT) in pediatric primary spontaneous pneumothorax (PSP) remains controversial. This study sought to evaluate the utility of CT scans in a contemporary cohort of children with PSP. An institutional review board approval was obtained for a retrospective review of all children (aged ≤18y) who underwent video-assisted thoracoscopic surgery (VATS) for PSP between 2009 and 2019 at a university-affiliated pediatric hospital. Preoperative CT scans were evaluated for diagnostic accuracy of the CT of bleb disease. Thirty nine patients underwent VATS procedures for PSP, 34 (87%) of the patients were noted to have blebs. Twenty eight (72%) patients received preoperative CT scans with a 5.5:1 male to female ratio. On CT, 17 (61%) were diagnosed with blebs and all had blebs intraoperatively. CT did not identify disease in 11 patients, but seven had blebs intraoperatively. The positive and negative predictive values of preoperative CT for detecting ipsilateral bleb disease were 100% and 36%, respectively, with a sensitivity of 71%. Eleven patients had a contralateral disease on CT (39%). Five received elective contralateral VATS and three developed spontaneous PSP, with intraoperative blebs in all eight patients. Three never developed contralateral PSP. Six (21%) patients with no contralateral disease on CT developed spontaneous PSP with intraoperative blebs. The decision to operate for PSP should be made based on clinical findings rather than on the presence or absence of blebs identified by CT.

Video-Assisted Thoracoscopic Surgery (VATS) for Spontaneous Pneumothorax and Emphysematous Bullous Lung Disease: A Study From Northern India.

Introduction: Bullous lung disease is the most common cause of spontaneous pneumothorax. The management of the same is primarily surgical, aiming at the bullectomy, which was earlier performed by standard postero-lateral thoracotomy. The last two decades have seen more frequent use of video-assisted thoracoscopic surgery (VATS) for the same and has been shown to be a low morbidity, efficacious, and cost-effective method. In this study we assess the role of VATS in the spectrum of bullous lung disease.Method: The study was conducted in the Department of Surgery, Dayanand Medical College and Hospital, Ludhiana, for a period of three years from January 1, 2016 to December 31, 2019 in which patients with bullous lung diseases were enrolled and the role of video-assisted thoracoscopic surgery was assessed in them.Results: The study included a total of 75 patients who were managed operatively either by VATS or open thoracotomy. In the study group, the average age of patients was 35.6 years (range 16-68 years). The most common presentation was only bullous lung disease (BLD) in 40% of patients followed by 32% of patients having both BLD and broncho-pleural fistula (BPF). Apical segmentectomy/non-anatomical wedge resection was done in 36% of patients whereas VATS bullectomy was done in 36% of patients. Elective conversion to thoracotomy was planned in six patients because of dense adhesions and thick pleural peel. We performed pleurodesis in almost all cases (96%). Mean blood loss in the VATS procedure was 48.7 ml and mean operative time was 67.2 minutes. Mean duration of hospital stay was 4.8 days. Forced expiratory volume (FEV1) increased significantly from a mean of 65.80% to 77.60%. There was significant increase in forced vital capacity (FVC) mean from 70.30% to 79.50%.Conclusion: VATS can be used as a safe, feasible and effective procedure in patients presenting with spontaneous pneumothorax and bullous lung disease with or without a broncho-pleural fistula or parenchymal leak. It should be preferred over the traditional open thoracotomy procedure, whenever feasible to do so, in view of decreased perioperative morbidity and better functional outcome.

Addition of Local Anesthetic Epidural Infusion Catheter to Intravenous Opioid Analgesia for Postoperative Pain Control in Children Undergoing Video Assisted Thoracoscopic Surgery (VATS)

PurposePostoperative analgesia following minimally invasive video assisted thoracoscopic surgery (VATS) in pediatric patients may involve intravenous opioid analgesics and continuous local anesthetic infusions via an epidural infusion catheter. The use of epidural catheters may avoid systemic side effects of intravenous opioids in this vulnerable population. DesignOur primary aim was to compare total morphine equivalents (MEQ) required, and pain scores between local anesthetic epidural infusion catheters combined with intravenous opioids, versus intravenous opioids alone in pediatric patients following VATS procedure. MethodsFollowing Institutional Review Board approval, we performed a retrospective chart review of children (ages 1 month to 18 years) who underwent VATS procedure for noncardiac thoracic surgery. Based on the postoperative analgesic technique used, the study population was divided into two groups that is, epidural group and nonepidural group. Both groups received intravenous systemic opioids. The primary outcome variables were total MEQ required and pain scores in the perioperative period. FindingsNinety-two patients were included in the study. Of these, 22 patients belonged to the epidural group versus 70 patients to the nonepidural group. There was no statistical difference in MEQ requirements or pain scores between the groups intraoperatively (P = .304), in the postanesthesia care unit (P = .166), or at postoperative time intervals of 24 hours (P = .805) and 48 hours (P = .844). The presence of infection or empyema was a significant factor for the avoidance of epidural placement by providers (P = .003). ConclusionsThere was no significant difference in the perioperative MEQ or postoperative pain scores between the epidural catheter group and the nonepidural group. More research is necessary to determine if this could be due to epidural catheter malposition and/or inadequate dermatomal coverage of surgical chest tubes.

Comparative study of open thoracotomy and thoracoscopy on the efficacy of treatment and complications of patients with stage ΙΙ thoracic empyema

Background. Thoracic empyema is an inflammatory condition of the pleura that can cause many complications and can even threaten people's lives. So, choosing the right treatment method from all available methods can improve the prognosis, reduce costs and post-treatment complications, thus improving the health of patients after the disease. Video-assisted thoracoscopic surgery (VATS) and open thoracotomy are the most commonly used surgical methods. In this study, these two surgical methods have been investigated, in terms of duration of hospitalization, postoperative pain level and the possibility of air leakage (as postoperative complications). Methodology. Patients with thoracic empyema stage II referred (between 2011 and 2020) to the Poursina and Razi Hospital Medical Center, Rasht, Iran were included in a retrospective cohort study. SPSS software and other statistical tests such as the Shapiro-Wilk test, Mann-Whitney non-parametric test, and Chi-square test were used for statistical analysis, and a P-value of less than 0.05 was considered an acceptable value. Results. The investigation on different qualitative and quantitative factors and complications after surgery showed that patients who underwent a VATS procedure had a shorter hospital stay (5.09±1.67 vs. 7.61±2.03), had a lower pain level (4.81±2.22 vs. 8.24±2.39), and the possibility of air leakage as a postoperative complication (41% vs. 56%) was lower than in the case patients who have undergone open thoracotomy. Conclusions. It can be concluded that choosing the VATS method instead of the open thoracotomy can reduce postoperative complications (such as length of hospital stay, pain level and possibility of air leakage) and can reduce the costs of treatment and the degree of health system use, especially during Covid-19 pandemic.

Sleeve resection after neoadjuvant chemoimmunotherapy in the treatment of locally advanced non-small cell lung cancer.

BackgroundWe aimed to characterize the outcomes of sleeve resection after neoadjuvant chemoimmunotherapy for the treatment of non-small cell lung cancer (NSCLC), including perioperative and oncologic outcomes, and to identify any impact of operative approach on resultant findings.MethodsWe identified patients with NSCLC who underwent sleeve resection after ≥2 cycles of neoadjuvant chemoimmunotherapy between May 2019 and April 2021 and retrospectively reviewed clinical records. Perioperative data were collected and compared between video-assisted thoracoscopic surgery (VATS) (n=8) and thoracotomy (n=15) groups. Immunohistochemistry (IHC) scores were compared between tumors with and without major pathological response (MPR).ResultsTwenty-three patients met inclusion criteria, with clinical stages as follows: IB, 2 (8.7%); IIIA, 14 (60.9%); and IIIB, 7 (30.4%). Treatment-related adverse events (TRAE) were recorded in 17 patients (73.9%), including anemia and neutropenia, with no patients exhibiting serious TRAE. Radiological evaluation revealed 5 (21.7%) patients with complete response (CR), 14 (60.9%) with partial response (PR), and 4 (17.4%) with stable disease (SD). Complete resection was accomplished for all patients. One VATS procedure was converted to thoracotomy due to extensive pleural adhesions. There were no significant differences in intraoperative blood loss (87.5±51.8 vs. 193.9±145.3 mL), operative time (198.8±79.7 vs. 225.5±55.0 min), number of lymph node examined (16.9±6.6 vs. 18.2±6.5), and hospital stay (5.5±2.8 vs. 9.2±11.2 days) between the VATS and thoracotomy groups (all P>0.05). Postoperative complications occurred in 3 patients, and 1 patient died of bronchopleural fistula (BPF) in the thoracotomy group. Complete pathological response (CPR) and MPR were achieved in seven (30.4%) and 13 (56.5%) patients, respectively. Both preoperative histopathology (P=0.024) and radiological response (P=0.002) were significantly associated with MPR. In postoperative specimens with MPR, the IHC scores of cluster of differentiation (CD)4, CD8, and CD20 were modestly higher, while programmed cell death receptor 1 (PD-1), lymphocyte-activation gene 3 (LAG3) and T cell immunoglobulin and ITIM domain (TIGIT) were lower compared with non-MPR specimens, albeit insignificantly.ConclusionsSleeve resection after neoadjuvant chemoimmunotherapy was feasible in patients with locally advanced NSCLC. Perioperative outcomes were comparable between the VATS and thoracotomy groups.

Developing Virtual Reality Head Mounted Display (HMD) Set-Up for Thoracoscopic Surgery of Complex Congenital Lung MalFormations in Children.

Video assisted thoracoscopic surgery (VATS) has been adopted in pediatric age for the treatment of congenital lung malformations (CLM). The success of VATS in pediatrics largely depends on the surgeon’s skill ability to understand the airways, vascular system and lung parenchyma anatomy in CLM. In the last years, virtual reality (VR) and 3-dimensional (3D) printing of organ models and VR head mounted display (HMD) technologies have been introduced for completion of preoperative planning in adult patients. To date no reports about the use of VR HMD technologies in a pediatric setting are available. The aim of this report is to introduce a VR HMD model in VATS procedure to improve the quality of care in children with CLM. VR HMD set-up for planning thoracoscopic surgery was performed in a series of pediatric patients with diagnosis of CLM. The preoperative VR HMD evaluation allowed a navigation into the malformation with the aim to explore, interact, and make the surgeon more confident and skilled to answer to the traps. A development of surgical simulations models and teaching program dedicated to education and training in pediatric VATS is suitable among the pediatric surgery community. Further studies should demonstrate all the benefits of such technology in pediatric patients submitted to VATS procedure.

Uniportal thoracoscopic decortication: start away from empyema approach

Aim: Video-assisted thoracoscopic surgery (VATS) is now a gold standard in treating early-stage empyema, while much debate still exists considering the effectiveness of this approach for late-stage empyema. Most concerns arise from the crowded rib cage, narrow working space, and ability to free trapped lungs quickly, mainly if uniportal VATS is used. However, unlike uniportal VATS lobectomy, there is no consensus about standard steps for uniportal VATS decortication to ensure smooth and effective surgery. We try to offer standard, easy-to-replicate steps for this approach to evaluate the efficacy and safety of the “start away from empyema” approach for uniportal VATS decortication in the management of stage II and III empyema. Methods: A prospective case series study has been conducted on 25 patients. All patients with stage II and III empyema were admitted to the Cardiothoracic Surgery Department between October 2017 and March 2020. VATS procedure was done under general anesthesia by a double-lumen tube for selective ventilation. Demographic data, preoperative diagnosis, intraoperative findings, hospital stay, and complications were recorded. Results: Twenty-five patients were enrolled in this study with a median age of 35 years. The duration of illness ranged between 14 and 60 days, with a median (IQR) of 25 (17) days. In (88%) of the patients, there was a successful outcome defined as a near-complete resolution on Chest X-ray (scoring of 3 or 4) and chest US (scoring of 2 or 3). Only three (12%) patients had a partially successful outcome. All patients with partial success suffered from infection associated with malignant effusion. Conclusion: “Start away from empyema” approach for uniportal VATS decortication in stage II and III empyema could be safe and effective in treating loculated nonmalignant pleural effusion.

Pleural empyema management: The impact of Video-assisted thoracoscopic surgery

In recent years, Video-assisted Thoracoscopic Surgery (VATS) has caused many changes in thoracic surgery practice. This study aimed to analyze the results of early VATS surgery in patients with empyema. Thirty-two cases of empyema who underwent VATS drainage, debridement, pleural pouch jointing, and partial decortication between November 2018 and June 2022 were included in the study retrospectively. The cases were examined for demographic information, the duration of symptoms, the stages of empyema, treatment outcomes, and complications. Twenty-three (79.9%) cases were male, 9 (28.1%) were female, and the mean age was 46.4±19.9. Preoperative symptom duration was 2.68±1.46 weeks. 28 (87.5%) cases were in stage 2 and 4 (12.5%) cases were in stage 3 empyema. A single incision VATS was performed in 23 (71.9%) cases, and double incision VATS was performed in 9 (28.1%) cases. Postoperative hospital stay was 12.1±3.3 days. Acceptable symptomatic and radiological improvement was observed in 28 (87.5%) cases after VATS. Pleural decortication with thoracotomy was used in four (12.5%) cases of stage 3 empyema. In cases of stage 2 empyema, which occurs within the first four weeks of the onset of symptoms, the VATS procedure with drainage, debridement, pouch jointing, and partial decortication provides curative results. We recommend evaluating VATS as the first-line therapy in treating early-stage empyema.

Computed tomography-guided Sens-cure needle localization for scapular-blocked lung nodules.

The use of preoperative computed tomography (CT) to guide the wedge resection (WR) of lung nodules (LNs) in video-assisted thoracoscopic surgery (VATS) is widely accepted. However, some LNs may be blocked by the scapula and a trans-scapular approach should be used when performing the localization procedures. To investigate the feasibility, safety, and clinical effectiveness of preoperative CT-guided Sens-cure needle (SCN) localization for scapula-blocked LNs (SBLNs). One hundred and eighty patients with LNs who had undergone CT-guided SCN localization before VATS were enrolled in this single-center retrospective study from January 2018 to December 2021. Ten of these patients (5.6%) had SBLNs and underwent localization using the trans-scapular approach. The technical success of localization, together with complications and VATS, was assessed. Data on the 10 patients with 10 SBLNs were analyzed. Scapular puncture was successful in all patients (100%) with no incidence of complications near the scapula. SCN localization was also successful in 100% of patients. The average duration of SCN localization was 12.5 ±4.0 min, with 1 (10%) patient experiencing pneumothorax after localization. The WR success rate was also 100%. Three patients underwent additional lobectomy due to invasive adenocarcinoma. The VATS procedure lasted on average for 97.0 ±56.0 min with an average blood loss of 44.0 ±35.0 ml. Preoperative CT-guided SCN localization using the trans-scapular approach is safe, effective, and highly successful for VATS-guided WR of SBLNs.

Role of video-assisted thoracoscopic surgery in pulmonary metastasectomy.

There are sparse prospective studies investigating the role of video-assisted thoracoscopic surgery (VATS) in management of pulmonary metastasis. To prospectively investigate short-term surgical and pathological outcomes for PM patients operated on by VATS or open thoracotomy (OT) for management of lung secondaries. Between October 2017 and December 2020, patients undergoing pulmonary metastasectomy were recruited. Patients were assigned to undergo resection with either thoracotomy (group 1) or VATS (group 2) after multidisciplinary team discussions based on the number, size and location of pulmonary metastasis and underlying lung function. All related short-term surgical and pathologic outcomes for both groups were collected for analysis. Of 58 patients enrolled, 21 were in group 1 and 37 in group 2. Colorectal cancer primary represented 40% of the cases. Patients in the VATS group were more likely to have solitary lesions that are peripherally located and removed by wedge resection, as opposed to patients in the thoracotomy group, who had more anatomical lung resections. More new nodules were likely to be detected during surgery in thoracotomy than VATS cases (p = 0. 027). However, 8 (out of 15) of the newly detected lesions were not malignant. Operative time, blood loss and hospital stay were in favor of VATS procedures. In a highly selected cohort of pulmonary metastasis patients with favorable criteria (peripherally located, small, solitary/oligo-metastasis and cN0), VATS may provide acceptable onco-pathologic outcomes as compared to the standard open thoracotomy.

A CRYPTIC COUGH: A RARE CASE OF CRYPTOCOCCAL PNEUMONIA

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cryptococcal pneumonia is an opportunistic fungal infection caused by Cryptococcus neoformans. Many cases initially present in the lungs of those suffering from HIV/AIDS, diabetes, or on chronic immunosuppressants1. We present a case of a 28-year-old woman with no prior medical history who develops a severe case of cryptococcal pneumonia with factors of exposure or risk. CASE PRESENTATION: 28-year-old female with no prior medical history presents in the setting of a productive cough with yellow-brown sputum for 2 weeks that increased with frequency and severity. The patient presented to the emergency department and an initial computed tomography (CT) angiogram of the chest was performed that revealed a significant left lower lobe pneumonia, leading to her admission (Figure 1). The patient was initially started on levofloxacin and linezolid;however, MRSA, blood and sputum cultures, viral panel, HIV, and Covid-19 tests were all negative. A bronchoalveolar lavage was performed which also had negative cultures and cytology. The patient began to develop fevers, and a cryptococcal antigen was tested that was positive. The patient was started on fluconazole IV, and underwent a successful left video-assisted thoracoscopic surgery (VATS) with lower lobe resection, with the pathology revealing non-necrotizing and focal necrotizing granulomas. A GMS stain revealed numerous yeast forms with narrow based budding, morphologically consistent with Cryptococcus neoformans. The patient had a lumbar puncture that was negative for Cryptococcal antigen, and patient was discharged on oral fluconazole. The fungal culture from the BAL was eventually positive for C. neoformans, 2 weeks later. DISCUSSION: Cryptococcal pneumonia of this magnitude is incredibly rare in an immunocompetent patient, especially someone as young as this patient. The patient did not have any exposure nor risk factors, yet required a VATS procedure to confirm the infection. It would be expected with a cryptococcal pneumonia this severe would produce a more systemic response;however, multiple blood cultures and lumbar punctures were negative for any dissemination. The etiology in this case is still unknown, albeit a significant amount of the population has been exposed to Cryptococcus at some point as a child, especially those living in urban areas2. Our patient was fortunate and has responded quite well to fluconazole therapy, and continues to follow up outpatient without complications. CONCLUSIONS: Cryptococcal pneumonia caused by Cryptococcus neoformans is an opportunistic fungal infection, but has the ability to cause severe illness in those immunocompetent. Blood cryptococcal antigen, lumbar puncture, and at times surgical pathology may be required for those with severe illness, and early antifungal therapy may hasten recovery. REFERENCE #1: Perfect JR, Dismukes WE, Dromer F, et al. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of america. Clin Infect Dis. 2010;50(3):291-322. doi:10.1086/649858 REFERENCE #2: Goldman DL, Khine H, Abadi J, et al. Serologic evidence for Cryptococcus neoformans infection in early childhood. Pediatrics. 2001;107(5):E66. doi:10.1542/peds.107.5.e66 DISCLOSURES: No relevant relationships by Wahaaj Khan, source=Web Response No relevant relationships by Joseph Kim, source=Web Response No relevant relationships by Christian von Gizycki, source=Web Response No relevant relationships by Momina Zaman, source=Web Response

A Diaphragmic Traction Suture Increases Pleural Cavity Volume and Surgical Field Overview During Video-Assisted Thoracoscopic Surgery.

An elevated hemidiaphragm may impair surgical field overview during video assisted thoracoscopic surgery (VATS) and may consequently jeopardize a safe surgical procedure or prolong the duration of surgery. The aim of this study was to evaluate if tension applied to a diaphragmatic suture improves the surgical field overview. Following informed consent and at the surgeon's discretion during elective VATS procedures, a single stitch was placed at the posterior tendinous border of the diaphragm and retracted through the camera port. The surgical field overview was evaluated using a numeric rating scale (1-10) by the surgeon before and after applying tension during the procedure, and later by 9 VATS surgeons (> 10years' experience) using video recordings. During a 4-month period, 43 patients scheduled for elective VATS by two surgeons gave informed consent to participate. The hemidiaphragm was elevated to such an extent in 27 patients that the surgeon placed a diaphragmatic stitch suture. When tension was applied to the suture, surgical field overview improved significantly (p < 0.001). A diaphragmatic traction suture improves surgical field overview in selected patients with elevation of the hemidiaphragm. This simple procedure may facilitate VATS in patients with impaired surgical field overview and consequently improve safety during VATS. CLINICAL TRIAL NUMBER: http://ClinicalTrials.gov (No. NCT04837950).

The Importance of Culture Change Associated With Novel Surgical Approaches and Innovation: Does Perioperative Care Transcend Technical Considerations for Pulmonary Lobectomy?

Robotic thoracic surgery for pulmonary lobectomy was introduced at our unit in 2015, along with enhanced perioperative patient care pathways. We evaluated the effect of this practice change on short-term outcomes. Data on all adult patients who underwent a lobectomy in our unit between 2015 and 2019 were obtained retrospectively from our surgical database. Patients fell into three groups: conventional open surgery via thoracotomy, video-assisted thoracoscopic surgery (VATS), and robot-assisted thoracoscopic surgery (RATS). Survival was defined as survival to discharge. Our cohort included 722 patients. Three hundred and ninety-two patients (54.3%) underwent an open operation, 259 patients (35.9%) underwent VATS surgery, and 71 patients (9.8%) underwent a robotic procedure. Comparing these surgical approaches, there was no statistically significant difference in the overall incidence of post-operative complications (p = 0.15) as well as the incidence of wound infections, arrhythmias, prolonged air leaks, respiratory failure, or ICU readmissions. Additionally, there was no statistically significant difference in survival to discharge (p = 0.66). However, patients who had a VATS procedure were less likely to develop a post-operative chest infection (p = 0.01). Evaluating our practice over time, we found a decrease in the overall incidence of post-operative complications (p = 0.01) with an improvement in survival to discharge (p = 0.02). In our experience, VATS lobectomy was associated with a lower incidence of post-operative chest infections. However, the limitations of our study must be considered; factors such as patient selection that may have had a substantial impact. The culture change associated with adoption of a VATS and robotic surgical programme appears to have corresponded with an improved survival to discharge for all lobectomy patients, irrespective of surgical approach. Perioperative care may therefore have a more significant impact on outcomes than technical considerations.

Video-assisted thoracoscopic surgery in the treatment of empyema: a case series

Background: Empyema is a condition that can be treated depending on the etiology of the empyema and the phase of empyema development. Open thoracotomy surgery is a conventional technique commonly used in empyema that has greater risk and more extended postoperative hospital stay. This case series aims to evaluate Video-Assisted Thoracoscopic Surgery (VATS) to shorten postoperative hospital stay and lower the risk during the surgery.Case Presentation: We describe a case series of empyema in five patients, each with a different presentation, clinical course, and outcome. All of our patients were performed VATS procedures under General Anesthesia and evaluated for postoperative hospital stays and complications that occur after the surgery. Most of the patients experienced tolerable pain on the site of surgery and only need 3 – 4 days post-operation hospital stays after VATS before being discharged. Only one patient with a poor prognosis after VATS in this case series caused the patient to be admitted to the Intensive Care Unit and using a mechanical ventilator.Conclusion: In this case series, VATS has a promising result for the patient and can become a choice of treatment for empyema.