Video-assisted Thoracoscopic Surgical Research Articles

Efficacy of video-assisted thoracoscopic surgical decortication for stage Ⅲ tuberculous empyema

Objective: To investigate the clinical efficacy, safety and feasibility of "double-portal" video-assisted thoracoscopic surgical(VATS) decortication among patients with stage Ⅲ tuberculous empyema, and then to evaluate the recovery of chest deformity. Method: This study was a single center retrospective study. A total of 49 patients with stage Ⅲ tuberculous empyema who underwent VATS pleural decortication at the Department of Thoracic Surgery, Public Health Clinical Center of Chengdu between June 2017 and April 2021 were enrolled, including 38 males, and 11 females, aged 13-60 (27.5±10.4) years. The safety and feasibility of VATS were further evaluated. The inner circumference of the chest on sternal and xiphoid planes on chest CT scans before and 1, 3, 6, 12months after decortication were collected through the measuring software of the CT. The samples in-pair test was used to compare the changes in the chest to reflect the recovery of the chest deformity. Results: In the 49 patients, The surgical time was (186±61) min, and the volume of blood loss was (366±267) ml. There were 8 cases (16.33%) with postoperative complications during the perioperative period. Constant air leak and pneumonia were the main postoperative complications. No relapse of empyema or dissemination of tuberculosis occured during the period of follow-up. Before surgery, the inner thoracic circumference of the thorax at the level of the carina plane was (655±54) mm, and the inner thoracic circumference of the thorax at the level of the xiphoid plane was (720±69) mm. Patients were followed for 12-36 months. The inner thoracic circumference of the thoracic cavity at the level of carina was (666±51), (667±47) and (671±47) mm at the 3rd, 6th and 12th months after operation, which were significantly larger than that at the level of carina before operation (all P<0.05). The inner thoracic circumference diameter of the thoracic cavity measured at the xiphoid level at the 3rd, 6th and 12th months after the operation was (730±65), (733±63) and (735±63) mm respectively(all P<0.05).The inner thoracic circumference of the thoracic cavity increased significantly than that before surgery (P<0.05). At 6 months after operation, there was significant difference in the improvement of the inner thoracic circumference of the carina plane in patients with age less than 20 years and FEV1% less than 80% (P=0.015, P=0.003). The improvement in the inner thoracic circumference of the carina plane in patients with pleural thickening≥8 mm compared with those with less than 8 mm was not statistically different(P=0.070). Conclusions: For some patients with stage Ⅲ tuberculous empyema, pleural decortication under thoracoscopy is safe and feasible, and can significantly restore the inner thoracic circumference of the patient's chest, improve the collapse of the patient's chest, and have significant clinical effect. The "double-portal VATS" surgical technology has the advantage of less trauma, wide operation field, large operation space and is easy to master, which is worth further exploring for clinical application.

Transcutaneous Electrical Acupoint Stimulation Improves Postoperative Cognitive Function in Senior Patients Undergoing Video-Assisted Thoracoscopic Surgery: A Randomized Controlled Trial.

To evaluate the effectiveness and safety of transcutaneous electrical acupoint stimulation (TEAS) for improving postoperative cognitive function in senior patients undergoing video-assisted thoracoscopic surgical (VATS). From January to December 2020, 97 participants were randomly assigned to the TEAS group (49 cases) and the control group (48 cases) by a random number table. The patients in the TEAS group received TEAS, at the bilateral Neiguan (PC 6) and Zusanli (ST 36) acupoints. The control group received sham TEAS. The stimulation was started from 30 min before surgery until the end of the operation. The primary outcome was the incidence of pstoperative cognitive dysfunction (POCD), diagnosed based on the changes in the Mini-Mental Status Examination (MMSE) and Montreal Cognitive Assessment (MoCA) scores. The secondary outcomes were plasma levels of S100β protein and neuron-specific enolase (NSE). The incidence of POCD on day 1 and 3 after surgery in the TEAS group was significantly lower than that in the control group [day 1 after surgery: 28.3% (13/46) vs. 52.3% (23/44), P=0.028; day 3 after surgery: 21.7% (10/46) vs. 40.9% (18/44), P=0.043]. Compared with baseline, the MMSE and MoCA scores decreased to various extents in both groups. The MMSE scores on day 1, 3, and 5 after surgery and MoCA scores on day 1, 3, 5, and 7 after surgery in the TEAS group were higher than those in the control group (all P<0.05) in both groups. Compared with baseline, the plasma levels of S100β and NSE were significantly increased at 4, 8, 12, 24 h after surgery (all P<0.05). Compared with the control group, the plasma levels of S100β and NSE were lower in the TEAS group at 4, 8, 12, and 24 h after surgery (all P<0.05). No obvious adverse events were found during the trial. Application of TEAS in senior patients after VATS could reduce incidence of POCD and improve postoperative cognitive function.

Clinical Analysis of Video-Assisted Thoracoscopic Surgery for Resection of Solitary Pulmonary Nodules and Influencing Factors in the Diagnosis of Benign and Malignant Nodules.

Purpose This is a retrospective research comparing the clinical outcomes of single-hole versus multi-hole video-assisted thoracoscopic surgical (VATS) resection for solitary pulmonary nodules (SPN) and examining the factors influencing the diagnosis of benign and malignant pulmonary nodules. Method We collected the clinical data, surgical status, outcomes, and corresponding imaging features of 317 patients with SPN who were surgically resected by VATS and diagnosed as benign or malignant by pathology in our hospital from January 2019 to December 2021. Result Among the 317 patients, 124 (39.12%) underwent single-port VATS and 193 (60.88%) underwent multiple-hole VATS. All patients were grouped according to the different surgical methods, and their postoperative indicators were statistically analyzed. The results showed that neither the single-port VATS group nor the multi-port VATS group had any serious adverse events such as death during the perioperative period. The average operation time, intraoperative blood loss, drainage tube indwelling time, and postoperative hospital stay were significantly lower in the two groups. Statistics of postoperative pathological diagnosis showed that 98 cases (30.91%) of all nodules were benign nodules and 219 cases (69.09%) were malignant nodules, and a further single-multivariate analysis showed that age, nodule maximum diameter, lobular sign, burr sign, vascular cluster sign, and pleural depression sign were independent relevant factors for the diagnosis of benign and malignant nodules. Conclusion VATS is less invasive and has fewer complications and is of great clinical value for both diagnosis and treatment of benign and malignant SPN. Age, maximum nodal diameter, lobar sign, burr sign, vascular set sign, and pleural depression sign were independent correlates affecting the diagnosis of benign and malignant SPN, which reminds that great attention should be paid to patients who are older and have risk factors on imaging, and early and timely active treatment or close follow-up should be carried out.

SAT-377 Case Series of Ectopic Parathyroid Gland

The prevalence of mediastinal parathyroid adenoma is unknown. Embryological origin and more extensive aberrant migration of the parathyroid glands result in ectopic glands found in the mediastinum. We report herein 4 cases of ectopic parathyroid adenoma causing primary hyperparathyroidism from three public hospitals in MalaysiaCase 1.A 70 year old lady with underlying diabetes mellitus, hypertension, chronic immune thrombocytopenic purpura and liver cirrhosis presented with incidental asymptomatic hypercalcemia during an admission for pneumonia. Her blood results revealed high corrected calcium of 2.93 mmol/L (2.02-2.60) and a low phosphate of 0.66 (0.81-1.45) mmol/L with an unsuppressed intact parathyroid hormone (iPTH) of 14.56 pmol/L (1.6-6.9). She had an equivocal urinary calcium excretion ratio of 0.01. Her bone mineral density confirmed severe osteoporosis at distal radius and neck of femur with a Tscore of -3.6 and -3.1 respectively. A hyperfunctioning ectopic parathyroid gland was seen in the Technetium Sestamibi scan which corelates with a mediastinal lymphadenopathy on CECT. The largest node measured 1.6 x 1.2 cm. Parathyroid gland was confirmed on HPE of the video-assisted-thoracoscopic surgical (VATS) excision of the mediastinal mass. Intraoperative iPTH (ioPTH) serially reduced from 8.87 to 1.94 to 1.03 pmol/L and she maintained a serum calcium levels of 2.4 mmol/L post surgery. She did not require any calcium or vitamin D supplementation. Case 2. A 36 year old male presented with generalized body weakness secondary to hypokalemia. His calcium was 3.07 mmol/l, phosphate 0.64 mmol/l and iPTH 11.53 pmol/L. Increase Technetium uptake seen at mediastinum. Post operatively, calcium normalized and remained stable 1 year later. Case 3.47 year old female presented with acute gallstone pancreatitis complicated with a pancreatic pseudocyst. She was found to have hypercalcemia of 2.77 mmol/L, phosphate 0.70 mmol/l and iPTH 21.87 pmol/L. Sestamibi scan revealed hyperfunctiong parathyroid tissue posterior to the left thyroid lobe and in the mediastinum. She is awaiting surgery. Case 4.Another asymptomatic 47 year old male who has history of post Radioactive-iodine hypothyroidism had an incidental finding of serum calcium of 2.69-2.84 mmol/L, phosphate 0.71-0.91 mmol/L and iPTH 9.89 pmol/L with urinary calcium excretion ratio of 0.019. His Sestamibi scan showed uptake at the superior mediastinum. Ectopic parathyroid gland is rarely encountered. With the advent of Technetium-Sestamibi scintigraphy, ectopic parathyroid adenoma can be localized easily. However, surgery poses a challenge due the location of the adenoma which may occasionally be near large vascular structures in the mediastinum. The availability of intraoperative PTH aids the decision for surgical exploration and completion.

Severe Pulmonary Infection in a 20-Month-Old Female

Community-Acquired Pneumonia (CAP) is a common reason for hospitalization of a pediatric patient. We report a 20-month-old female admitted for suspected CAP. History included a week-long cough, fever, dyspnea, single occurrence of seizure-like activity, and a sick contact. Initial chest X-ray (CXR) showed left lower lobe pneumonia and parapneumonic effusion with a complex left pleural effusion. Ultrasound findings prompted the need for contrast-enhanced computed tomography (CT) of the chest. Contrast-enhanced CT of the chest confirmed a large pleural effusion with major atelectasis and mediastinal shift. The patient was treated with empiric antibiotics, video-assisted thoracoscopic surgical (VATS) decortication of empyema, and chest tube placement. Due to intraoperative complications, the VATS decortication was aborted and patient was transferred to the pediatric intensive care unit (PICU). A thoracentesis with culture failed to isolate a bacterial organism. Dexamethasone was started after repeat CXR showed persistent infiltrate. Subsequent contrast-enhanced CT of the chest showed a large collection of air and persistent consolidation. The patient received repeat VATS decortication and reinsertion of a chest tube. Repeat pleural fluid cultures failed to isolate a bacterial organism. Infectious disease (ID) consult recommended linezolid 140 mg Q8H for 4 weeks. Seven days after second VATS, a respiratory pathogen panel was positive for rhinovirus/enterovirus. With resolution of leukocytosis and clinical improvement, the patient was discharged with the chest tube in place and pediatric surgery outpatient follow-up. After three months, sequalae from both the infection and interventions presented .

Video‐assisted thoracoscopic surgery for ectopic mediastinal parathyroid adenoma

BackgroundPrimary hyperparathyroidism (PHPT), caused by an ectopic mediastinal parathyroid adenoma, is uncommon. In the past, when the adenoma was not accessible from the neck, median sternotomy was advocated for safe and successful parathyroidectomy. Video‐assisted thoracoscopic surgical (VATS) parathyroidectomy represents a modern alternative approach to this problem.MethodsInformation on patients undergoing VATS was obtained from a specific database, including clinical presentation, biochemistry, preoperative imaging, surgical approach and patient outcomes. A comprehensive literature review was undertaken to draw comparisons with other publications.ResultsOver a 2‐year period, nine patients underwent VATS parathyroidectomy for sporadic PHPT. Five patients had persistent PHPT following previous unsuccessful parathyroidectomy via cervicotomy, and four had had no previous parathyroid surgery. The median duration of surgery was 90 (range 60–160) min. Eight patients were cured biochemically, with no major complications. One patient required conversion to a median sternotomy for removal of a thymoma that had resulted in false‐positive preoperative imaging.ConclusionWith appropriate preoperative imaging, multidisciplinary input and expertise, VATS parathyroidectomy is an effective, safe and well tolerated approach to ectopic mediastinal parathyroid adenoma.

Chronic pain associated with costal margin rupture

A 60-year-old man presented to our clinic with a 5-year history of severe, chronic chest pain. His symptoms began in September 2013 when he had a prolonged upper respiratory illness...

Cryobiopsy versus open lung biopsy in the diagnosis of interstitial lung disease (COLDICE): protocol of a multicentre study

IntroductionTransbronchial lung cryobiopsy (TBLC) is a novel, minimally invasive technique for obtaining lung tissue for histopathological assessment in interstitial lung disease (ILD). Despite its increasing popularity, the diagnostic accuracy of...

Are quality of life outcomes comparable following stereotactic radiotherapy and minimally invasive surgery for stage I lung cancer patients?

A best evidence topic in thoracic surgery was produced in accordance with published guidelines. The question addresses the effect of stereotactic ablative radiotherapy (SABR) and minimally-invasive anatomical lung resection on quality of life (QoL) in patients with stage I non-small-cell lung cancer. Altogether more than 428 papers were found using the reported search. Only one small RCT of 22 patients was identified that addressed the effect of SABR and surgery on QoL and found global health status to be statistically significantly worse for surgical patients when compared to SABR. Sixteen further studies provided some supporting evidence, but not directly compared QoL between the two treatment modalities. Consequently, there is no general consensus currently available from the literature. Among the nine SABR-only studies, only five specified the percentage of patients who were medically operable but refused surgery. None of the studies identified significant difference in most of the QoL domains 12 months after treatment. Within the surgical papers, patients recovered well after video-assisted thoracoscopic surgical (VATS) anatomical lung resection for stage-I NSCLC. Confirming previous evidence of open surgery, three studies demonstrated worsening of QoL domains from 8 weeks to 3 months and a return to baseline after 12 months. Emotional functioning (EF) showed an improvement across both treatments, often superseding baseline scores. Given the different population characteristics of all the available evidence, further appropriately powered and randomised studies are necessary to clarify this issue.

Preoperative localisation of pulmonary ground-glass opacity using medical adhesive before thoracoscopic resection.

To evaluate the safety and efficiency of computed tomography (CT)-guided medical adhesive, α-cyanoacrylate, for preoperative localisation of pulmonary ground-glass opacity (GGO) used for guiding the video-assisted thoracoscopic surgical (VATS) excision METHODS: The procedure was performed on 188 consecutive patients with solitary GGO (pure GGO = 90 cases; mixed GGO = 98 cases) prior to the thoracoscopic procedure. The complications and efficacy of this method were analysed. The resected GGO was analysed pathologically. The mean duration of the procedure was 16.3 ± 5.2 min. The preoperative localisation was 100% successful. All GGOs were successfully resected by VATS. Asymptomatic pneumothorax was developed in 16/188 patients (8.5%) and mild pulmonary haemorrhage occurred in 15 cases (7.9%) post-localisation. None of the patients required any further treatment for the complications. Preoperative localisation using CT-guided medical adhesive, α-cyanoacrylate, is a safe and short-duration procedure, with high accuracy and success rates with respect to VATS resection of GGO. • Preoperative localisation is crucial for successful resection of GGO by VATS. • Preoperative adhesive localisation provides an up to 100% successful localisation rate with few complications. • Preoperative adhesive localisation enabled VATS resection in 100% of the GGO. • Preoperative adhesive localisation is safe and effective for VATS resection of GGO.

Invited Commentary

Dr Wolf and colleagues [1Wolf A. Liu B. Leoncini E. et al.Outcomes for thoracoscopy versus thoracotomy not just technique dependent: a study of 9,787 patients.Ann Thorac Surg. 2018; 105: 886-892Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar] add to an ever growing body of literature that compares outcomes between thoracotomy and a video-assisted thoracoscopic surgical (VATS) approach to lobar and sublobar resection. They hypothesized that there would be no relationship between VATS and outcomes after adequately controlling for selection bias. With the use of a New York State administrative database, they adjusted for potential confounding from patient, surgeon, and hospital factors and found that VATS was associated with lower rates of morbidity and mortality. Nearly a decade ago, our research team conducted a similar analysis with the use of the Surveillance, End-Results, and Epidemiology (SEER)-Medicare database and adjusted for patient, cancer, management, surgeon, and hospital factors. We found no relationship between VATS and operative mortality or long-term survival, except among low-volume surgeons whereby there was a trend toward lower long-term survival rates with VATS. Although our study findings are inconsistent, both research teams emphasize the importance of mitigating confounding bias arising from patient, cancer, surgeon, and hospital/health system factors. Our teams are also united in the view that randomization is the best way to mitigate known and unknown confounding, but there must be equipoise to conduct a randomized trial. Most retrospective and single-institution studies show an association between VATS and better short-term outcomes. However, Wolf and colleagues [1Wolf A. Liu B. Leoncini E. et al.Outcomes for thoracoscopy versus thoracotomy not just technique dependent: a study of 9,787 patients.Ann Thorac Surg. 2018; 105: 886-892Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar] provide citations for studies in which there is no association between VATS and short-term outcomes. In addition, a recent prospective study from Memorial Sloan-Kettering showed no evidence of a relationship between VATS and patient-reported health-related quality-of-life or pain scores at 12 months. Findings from a noninferiority randomized trial conducted in China—presented as a late-breaking abstract at The Society of Thoracic Surgeons 2017 annual meeting—showed no effect of VATS on length-of-stay or rate of morbidity or mortality. An objective view of the literature reveals uncertainty (ie, equipoise) about the purported benefits of VATS. Nonetheless, there is considerable belief that VATS is a superior incisional approach compared with thoracotomy. Yet, proof—rather than belief—will advance our field. If VATS is superior, then we should take steps to limit the care of early-stage lung cancer patients to only surgeons who competently perform VATS. If VATS is equivalent to a thoracotomy, then we can be liberated from the pressure to perform a minimally invasive operation—pressure that may arise from patients, surgical colleagues, referring physicians, market forces or a combination. VATS advocates may say it is impossible to randomly assign patients to VATS versus thoracotomy because the benefits are self-evident, but saying so may in fact be a self-fulfilling prophecy. Our colleagues in colorectal surgery have conducted several such studies published in high-profile journals (all which demonstrated equivalence). Thoracic surgeons should consider conducting a multicenter, noninferiority, pragmatic randomized trial of VATS versus thoracotomy among patients with suspected or confirmed clinical stage I lung cancer. Doing so would likely lay to rest recurring questions about VATS versus thoracotomy. Outcomes for Thoracoscopy Versus Thoracotomy Not Just Technique Dependent: A Study of 9,787 PatientsThe Annals of Thoracic SurgeryVol. 105Issue 3PreviewStudies reporting the benefits of video-assisted thoracoscopic surgery (VATS) lung cancer resection over thoracotomy have been subject to selection bias. We evaluated patient and hospital characteristics associated with type of surgery and the independent effect of VATS on outcomes. Full-Text PDF

CT-guided localization of pulmonary nodules in children prior to video-assisted thoracoscopic surgical resection utilizing a combination of two previously described techniques.

Pulmonary nodules in pediatric oncology patients can present a diagnostic and treatment dilemma. Imaging findings are often nonspecific and tissue diagnosis may be required for appropriate treatment. The smaller subpleural nodules may not be visualized and cannot be palpated during video-assisted thoracoscopic surgical (VATS) resection. Preoperative localization has been beneficial in obtaining an adequate pathological specimen. This study presents experience in a large pediatric hospital using CT-guided preoperative localization of pulmonary nodules combining two previously utilized techniques, hook wire and methylene blue blood patch localization. A search of the electronic medical record utilizing a medical record search application was performed to identify all patients who underwent preoperative lung nodule localization during a 12.5-year period (July 1999 through January 2012). A retrospective chart review of these patients was then performed. Pre- and postoperative imaging, interventional radiology procedural images and reports, surgical reports, and pathology reports were obtained and evaluated. Thirty-five patients, with 40 nodules, who underwent preoperative CT-guided lung nodule localization were identified. Patients ranged in age from 8months to 21years. The pulmonary nodules ranged in size from 1.4mm to 18mm. Twelve nodules were localized using a Kopans breast lesion localization needle with hook wire, 4 were localized using a methylene blue blood patch, and 24 were localized using the combination of these two techniques. The technical success rate of all procedures was 100%. A pathological diagnosis was determined in 39 patients (97.5%). There were 6 (15.0%) minor complications and no major complications. CT-guided lung nodule localization using the combined techniques of methylene blue blood patch and hook wire is safe, technically feasible and successful in children. Using this combination of techniques will consistently yield a pathological diagnosis, is currently the preferred technique at our tertiary pediatric hospital and could be considered the new best practice.

Self-Appraised Readiness of Senior and Graduating General Surgery Residents to Perform Thoracic Surgery

General surgeons perform up to 50% of noncardiac thoracic surgery (TS). Although data show consistent TS case volume during general surgery (GS) residency it is unknown whether this operative trend will persist given potentially limited subspecialty exposure. We sought to determine if certain aspects of residency programs and resident characteristics were associated with trainees' perceived comfort in performing certain basic TS procedures. An anonymous survey was distributed to GS residents regarding program characteristics, presence of a TS residency, and intent to pursue thoracic surgical training, and estimated case volumes of individual procedures. Comfort levels for performing video-assisted thoracoscopic surgical (VATS) procedures, open lobectomy, elective thoracotomy, and sternotomy were attained through a 5-point Likert-type scale. This survey was administered at 50 training programs with responses recorded via an online form. Fourth- and fifth-year GS residents in the United States. Of 272 respondents 58% were fourth-year residents, 62% of residents trained at university-affiliated programs, and 64% reported a TS residency program at their institution and 16% stated intent to pursue TS. Fifth-year residents performed significantly more cases than fourth-year residents despite no difference in median comfort levels. Residents intending to pursue TS performed significantly more cases and were more comfortable performing a thoracotomy, sternotomy, VATS wedge resection/biopsy, and VATS decortication/pleurodesis (p = 0.044, <0.001, 0.045, 0.025). No characteristics were associated with comfort performing a lobectomy via thoracoscopic or open (thoracotomy) approaches. Most senior or graduating GS residents state they are comfortable performing certain thoracic procedures with those pursuing additional thoracic surgical training more comfortable overall. No characteristics were associated with comfort performing a lobectomy. These findings may advise residency curriculum design to ensure continued thoracic surgical exposure and recommend against non-fellowship trained surgeons performing a pulmonary lobectomy.

Postoperative pulmonary complications and rehabilitation requirements following lobectomy: a propensity score matched study of patients undergoing video-assisted thoracoscopic surgery versus thoracotomy†.

: Video-assisted thoracoscopic surgical (VATS) lobectomy is increasingly used for curative intent lung cancer surgery compared to open thoracotomy due to its minimally invasive approach and associated benefits. However, the effects of the VATS approach on postoperative pulmonary complications (PPC), rehabilitation and physiotherapy requirements are unclear; our study aimed to use propensity score matching to investigate this. Between January 2012 and January 2016 all consecutive patients undergoing lobectomy via thoracotomy or VATS were prospectively observed. Exclusion criteria included VATS converted to thoracotomy, re-do thoracotomy, sleeve/bilobectomy and tumour size >7 cm diameter (T3/T4). All patients received physiotherapy assessment on postoperative day 1 (POD1), and subsequent treatment as deemed appropriate. PPC frequency was measured daily using the Melbourne Group Scale. Postoperative length of stay (LOS), high dependency unit (HDU) LOS, intensive therapy unit (ITU) admission and in-hospital mortality were observed. Propensity score matching (PSM) was performed using previous PPC risk factors (age, ASA score, body mass index, chronic obstructive pulmonary disease, current smoking) and lung cancer staging. Over 4 years 736 patients underwent lobectomy with 524 remaining after exclusions; 252 (48%) thoracotomy and 272 (52%) VATS cases. PSM produced 215 matched pairs. VATS approach was associated with less PPC (7.4% vs 18.6%; P < 0.001), shorter median LOS (4 days vs 6; P < 0.001), and a shorter median HDU LOS (1 day vs 2; P = 0.002). Patients undergoing VATS required less physiotherapy contacts (3 vs 6; P < 0.001) and reduced therapy time (80 min vs 140; P < 0.001). More patients mobilized on POD1 (84% vs 81%; P = 0.018), and significantly less physiotherapy to treat sputum retention and lung expansion was required ( P < 0.05). This study demonstrates that patients undergoing VATS lobectomy developed less PPC and had improved associated outcomes compared to thoracotomy. Patients were more mobile earlier, and required half the physiotherapy resources having fewer pulmonary and mobility issues.

P1.08-038 VATS Sub-Lobar Anatomical Pulmonary Resections: Indications and Outcomes in Thoracic Oncological Practice

In patients with limited pulmonary reserve, sub-lobar anatomic pulmonary resection (SLAPR) may have reduced perioperative morbidity and mortality and additionally may better preserve long-term pulmonary function compared to lobectomy. SLAPR may also mitigate the oncological deficiencies of wedge resection. However, the safety and oncological efficacy of video assisted thoracoscopic surgical (VATS) SLAPR has not been well described. We therefore audited our recent experience of VATS SLAPR to evaluate: indications, safety, and oncological outcomes. We retrospectively reviewed a prospectively maintained database to identify all consecutive patients who underwent planned VATS SLAPR with curative intent. Demographics, co-morbidities, indications and treatment outcomes were retrieved, with supplemental chart review where necessary. Seventy seven VATS SLAPRs were performed between December 2010 and May 2016. Median age of patients was 67 (44-83) years and 57% (44/77) were male. The majority (47/77; 61%) of SLAPRs were undertaken for resection of NSCLC. Indications for SLAPR in NSCLC patients included: inadequate pulmonary reserve (DLCO <60% or predicted post-operative DLCO <40%) in 21/47 (44%), excessive (≥2 major) comorbidities in 18/47 (38%), advanced age (≥75 years) in 13/47 (27%) or a combination of these factors precluding lobectomy. In patients with metastatic 22(28%) and benign 8(10%) nodules, indications included proximity to vascular structures or inability to palpate lesion precluding simple wedge resections. Superior segmentectomy (22/77; 28%) and lingula sparing left upper lobectomy (17/77; 22%) were the commonest SLAPRs performed. Seventy one (92%) were completed via VATS. Emergency conversion occurred in one case. Morbidity rate was 30% (23/77) and 30 day mortality rate was 2.5% (2/77). Pre-operative DLCO was not associated with post-operative pulmonary complication (P=0.7) or length of hospital stay (P=0.20). In the NSCLC sub group, all patients were clinically stage I; R0 resection was achieved in 100%. Median of 12(4-27) nodes were excised with a nodal upstaging rate of 25% (12/47) and pathological stage was I in 65%. Median disease free survival (DFS) was 40 months and median overall survival (OS) was not reached. Loco regional recurrence rate was zero. Pre-operative DLCO dichotomized using median did not correlate with OS (P=0.8) or DFS (P=0.29). A variety of VATS SLAPRs may be performed safely with acceptable morbidity and mortality in high risk patients. Complete microscopic resection and adequate nodal dissection can be achieved. Although larger studies and longer follow is needed, our findings suggest that VATS SLAPR achieves comparable oncological outcomes in high risk patients to formal lobectomy.

Video-Assisted Thoracoscopic Lobectomy Is the Preferred Approach Following Induction Chemotherapy.

A video-assisted thoracoscopic surgical (VATS) resection, after induction chemotherapy, has long been considered a relative contraindication. We report our experience with VATS lobectomy after induction chemotherapy for patients with nonsmall cell lung cancer (NSCLC), with propensity-matched group of patients, who underwent an open approach, to determine safety and oncological outcome. A retrospective review of a prospective database (2002-2014) was performed to identify patients undergoing potentially curative lobectomy for NSCLC after induction therapy. Propensity score matching (age, gender, and clinical stage) was performed (1:2) to obtain a balanced cohort of patients undergoing VATS resection and thoracotomy. A total of 285 patients underwent lobectomy after induction therapy, 114 were propensity matched (VATS, n = 40, thoracotomy, n = 74). There were no differences in the clinicopathological factors or type of induction therapy (conventional versus targeted) between VATS and thoracotomy groups. Similarly, no differences were found in the number of lymph nodes resected (12 versus 15, P = .94), the number of stations sampled (4 for each, P = .68), or in the rate of R0 resection (95% versus 96%, P = .81) between VATS and thoracotomy groups. Five VATS cases were converted to an open approach because of adhesions. VATS resection was associated with less estimated blood loss (EBL), shorter length of stay (LOS), and a trend toward fewer postoperative complications. There was no difference in 5 years disease-free survival (DFS) between VATS and thoracotomy groups (73% versus 48%, P = .09). Similarly, for patients who presented with cN2, there were no differences between thoracotomy and VATS groups in DFS (P = .37). On multi-variable analysis (MVA), only the clinical N1/2 status [Hazard ratio (HR): 4.86, P < .001] independently predicted poor DFS. A VATS lobectomy is a feasible, safe, and oncologically sound approach after induction therapy for NSCLC. When compared with thoracotomy, VATS lobectomy is associated with lower EBL, shorter LOS, and a trend toward fewer postoperative complications.

Single-port videoscopic splanchnotomy for palliation of refractory chronic pancreatitis

Interrupting the afferent signals that travel through the splanchnic nerves by multiportal thoracoscopic splanchnotomy can offer effective palliation in chronic pancreatitis. However, obtained results weaken after time, possibly necessitating repeat procedures. Given the palliative nature of this procedure, potential for iatrogenic damage should be kept at a minimum. So, in order to minimize invasiveness while optimizing repeatability, we sought to create an easily reproducible single-access port operative strategy. Four patients suffering from intractable pain due to chronic pancreatitis for >10 years (12.8 ± 5.9) underwent a single-port unilateral R5-R11 splanchnotomy. Postoperative recovery was uneventful. No operative complications were observed. All 4 patients experienced excellent pain relief with a significant improvement of Visual Analogue Scale pain scores (8.8 ± 1.0 preoperatively to 3.0 ± 1.2 postoperatively, P = 0.003). We report the first series of single-port video-assisted thoracoscopic surgical (VATS) splanchnotomy for palliation of intractable pain due to chronic pancreatitis. From this small study, single-port VATS splanchnotomy seems to be a safe and effective alternative to multiportal or open procedures.

Video Assisted Thoracoscopic Surgical Enucleation of a Giant Esophageal Leiomyoma Presenting with Persistent Cough.

Esophageal leiomyoma is a relatively rare tumor of esophagus but it is the most common benign neoplasm of the esophagus. Small esophageal leiomyoma can be observed but larger ones and those producing symptoms should be excised. As observed for other esophageal tumors, dysphagia is its main symptom. Traditionally, open thoracotomy and enucleation are its main treatment but in the last few years video assisted thoracoscopic surgical (VATS) enucleation is gaining recognition with proven advantages of minimally invasive surgery. Herein we present our experience with patient presenting with cough rather than dysphagia as a main symptom, who was diagnosed to be having giant esophageal leiomyoma. VATS guided enucleation was accomplished successfully. Size of lesion was 16 × 4 × 3 cm. Postoperative recovery was uneventful and patient is not having any signs of recurrence, after three years during follow-up period.

CT-guided localization of small pulmonary nodules using adjacent microcoil implantation prior to video-assisted thoracoscopic surgical resection.

To describe and assess the localization of small peripheral pulmonary nodules prior to video-assisted thoracoscopic surgical (VATS) resection using the implantation of microcoils. Ninety-two patients with 101 pulmonary nodules underwent computed tomography (CT)-guided implantation of microcoils proximal to each nodule. Patients were randomly assigned to undergo entire microcoil or leaving-microcoil-end implantations. The complications and efficacy of the two implantation methods were evaluated. VATS resection of lung tissue containing each pulmonary lesion and microcoil were performed in the direction of the microcoil marker. Histopathological analysis was performed for the resected pulmonary lesions. CT-guided microcoil implantation was successful in 99/101 cases, and the placement of microcoils within 1 cm of the nodules was not disruptive. There was no difference in the complications and efficacy associated with the entire implantation method (performed for 51/99 nodules) versus the leaving-microcoil-end implantation method (performed for 48/99 nodules). All nodules were successfully removed using VATS resection. Asymptomatic pneumothorax occurred in 16 patients and mild pulmonary haemorrhage occurred in nine patients. However, none of these patients required further surgical treatment. Preoperative localization of small pulmonary nodules using a refined percutaneous microcoil implantation method was found to be safe and useful prior to VATS resection. • An increasing number of small, indeterminate pulmonary lesions need to be characterized. • Entire microcoil and leaving-microcoil-end implantation methods were described for nodule localization. • Adjacent microcoil localization prior to video-assisted thoracoscopic surgical resection involved minimal intervention. • Preoperative microcoil localization facilitates the definitive resection of small pulmonary nodules.

VATS versus open surgery for lung cancer resection: moving beyond the incision.

Surgery remains the primary therapy in the treatment of early-stage lung cancer. Traditionally, anatomic resection via open thoracotomy has been the conventional approach, but as experience with minimally invasive lung surgery has increased, video-assisted thoracoscopic surgical (VATS) lobectomy is being performed more commonly for treatment of lung cancer. Proponents of VATS have argued that thoracoscopic resection for lung cancer is not only safe but is also superior to the open approach. VATS enthusiasts even have proposed that this approach should be the standard of care and a metric for quality in lung cancer surgery. Such zeal for promoting a "preferred" technique, however, obscures focus from other time-proven, but perhaps less fashionable, factors that have a tremendous impact on quality and lung cancer outcomes, namely cancer staging and quality of cancer surgery. Rather than debate incisions, thoracic surgeons should advocate for specialty care and surgical quality that assures the best short- and long-term outcomes for patients, regardless of the surgical approach.