Minimally invasive surgery for clinical T4 non-small-cell lung cancer: national trends and outcomes

OBJECTIVES

Recent randomized data support the perioperative benefits of minimally invasive surgery (MIS) for non-small-cell lung cancer (NSCLC). Its utility for cT4 tumours remains understudied. We, therefore, sought to analyse national trends and outcomes of minimally invasive resections for cT4 cancers.

METHODS

Using the 2010-2019 National Cancer Database, we identified patients with cT4N0-1 NSCLC. Patients were stratified by surgical approach. Multivariable logistic analysis was used to identify factors associated with use of a minimally invasive approach. Groups were matched using propensity score analysis to evaluate perioperative and survival end points.

RESULTS

The study identified 3715 patients, among whom 64.1% (n = 2381) underwent open resection and 35.9% (n = 1334) minimally invasive resection [robotic-assisted in 31.5% (n = 420); and video-assisted in 68.5% (n = 914)]. Increased MIS use was noted among patients with higher income [≥$40 227, odds ratio (OR) 1.24; 95% confidence interval (CI) 1.01-1.51] and those treated at academic hospitals (OR 1.25; 95% CI 1.07-1.45). Clinically node-positive patients (OR 0.68; 95% CI 0.55-0.83) and those who underwent neoadjuvant therapy (OR 0.78; 95% CI 0.65-0.93) were less likely to have minimally invasive resection. In matched groups, patients undergoing MIS had a shorter median length of stay (5 vs 6 days, P < 0.001) and no significant differences between 30-day readmissions or 30/90-day mortality. MIS did not compromise overall survival (log-rank P = 0.487).

CONCLUSIONS

Nationally, the use of minimally invasive approaches for patients with cT4N0-1M0 NSCLC has increased substantially. In these patients, MIS is safe and does not compromise perioperative outcomes or survival.

Surgical Approaches to Pancoast Tumors

Pancoast tumors, also defined as superior sulcus tumors, still represent a complex clinical condition requiring high technical surgical skills within more articulated multimodality treatment. The morbidity and mortality rates after Pancoast tumor treatments range from 10 to 55% and 0 to 7%, respectively, and the 5-year survival rate has significantly improved in recent years thanks to the advancement of treatments. Although a multimodality approach combining chemotherapy, radiotherapy, and surgery allows for radical resection and effective local control in the vast majority of patients, many patients cannot receive surgical resection or complete the whole programmed therapeutic regimen. Systemic relapse, particularly cerebral recurrence, still poses a significant issue in this cohort of patients. Surgical resection still plays a pivotal role within the multimodality approach. Here, we focus on surgical approaches to both anterior and posterior Pancoast tumors: the anterior transclavicular approach (Dartevelle); the anterior transmanubrial approach (Grunenwald-Spaggiari); the anterior trap-door approach (Masaoka, Nomori); the posterior approach (Shaw-Paulson); the hemiclamshell approach; and hybrid approaches. Global clinical condition, tumor histology, and long-term perspectives should always be taken into consideration when embarking on such a demanding oncologic scenario.

Anatomic evaluation of Pancoast tumors using three-dimensional models for surgical strategy development

OBJECTIVE

Pancoast tumor resection planning requires precise interpretation of 2-dimensional images. We hypothesized that patient-specific 3-dimensional reconstructions, providing intuitive views of anatomy, would enable superior anatomic assessment.

METHODS

Cross-sectional images from 9 patients with representative Pancoast tumors, selected from an institutional database, were randomly assigned to presentation as 2-dimensional images, 3-dimensional virtual reconstruction, or 3-dimensional physical reconstruction. Thoracic surgeons (n = 15) completed questionnaires on the tumor extent and a zone-based algorithmic surgical approach for each patient. Responses were compared with surgical pathology, documented surgical approach, and the optimal "zone-specific" approach. A 5-point Likert scale assessed participants' opinions regarding data presentation and potential benefits of patient-specific 3-dimensional models.

RESULTS

Identification of tumor invasion of segmented neurovascular structures was more accurate with 3-dimensional physical reconstruction (2-dimensional 65.56%, 3-dimensional virtual reconstruction 58.52%, 3-dimensional physical reconstruction 87.50%, P < .001); there was no difference for unsegmented structures. Classification of assessed zonal invasion was better with 3-dimensional physical reconstruction (2-dimensional 67.41%, 3-dimensional virtual reconstruction 77.04%, 3-dimensional physical reconstruction 86.67%; P = .001). However, selected surgical approaches were often discordant from documented (2-dimensional 23.81%, 3-dimensional virtual reconstruction 42.86%, 3-dimensional physical reconstruction 45.24%, P = .084) and "zone-specific" approaches (2-dimensional 33.33%, 3-dimensional virtual reconstruction 42.86%, 3-dimensional physical reconstruction 45.24%, P = .501). All surgeons agreed that 3-dimensional virtual reconstruction and 3-dimensional physical reconstruction benefit surgical planning. Most surgeons (14/15) agreed that 3-dimensional virtual reconstruction and 3-dimensional physical reconstruction would facilitate patient and interdisciplinary communication. Finally, most surgeons (14/15) agreed that 3-dimensional virtual reconstruction and 3-dimensional physical reconstruction's benefits outweighed potential delays in care for model construction.

CONCLUSIONS

Although a consistent effect on surgical strategy was not identified, patient-specific 3-dimensional Pancoast tumor models provided accurate and user-friendly overviews of critical thoracic structures with perceived benefits for surgeons' clinical practices.

Bleeding during Learning Curve of Thoracoscopic Lobectomy: CUSUM Analysis Results

BACKGROUND

 The management of intraoperative bleeding during thoracoscopic lobectomy is challenging, especially for non-experienced surgeons. We evaluated intraoperative bleeding in relation to learning curve of thoracoscopic lobectomy, the strategies to face it, the outcomes, and the target case number for gaining the technical proficiency.

METHODS

 This was a retrospective single center study including consecutive patients undergoing thoracoscopic lobectomy for lung cancer. Based on cumulative sum analysis, patients were divided into early and late experience groups, and the differences on surgical outcomes, with particular focus on vascular injury, were statistically compared.

RESULTS

 Eight-three patients were evaluated. Cumulative sum charts showed a decreasing of operative time, blood loss, and hospital stay after the 49th, the 43th, and the 39th case, respectively. Early (n = 49) compared with late experience group (n = 34) was associated with higher conversion rate (p = 0.08), longer operative time (p <0.0001), greater blood loss (p <0.0001), higher transfusion rate (p = 0.01), higher postoperative air leak rate (p = 0.02), longer chest tube stay (p <0.0001), and hospitalization (p <0.0001). Six patients (7%) had intraoperative bleeding during early phase of learning curve, successfully treated by thoracoscopy in four cases. Patients with vascular injury (n = 6) compared with control group (n = 77) presented a longer operative time (p = 0.003), greater blood loss (p = 0.0001), and higher transfusion rate (p = 0.001); no significant differences were found regarding postoperative morbidity (p = 0.57), length of chest tube stay (p = 0.07), and hospitalization (p = 0.07).

CONCLUSION

 Technical proficiency was achieved after 50 procedures. All vascular injuries occurred in the early phase of learning curve; they were safely managed, without affecting surgical outcomes.

Combined video-assisted thoracoscopy surgery and posterior midline incision for en bloc resection of non-small-cell lung cancer invading the spine

OBJECTIVES

This article aims to evaluate the feasibility and safety of a hybrid video-assisted thoracic surgery (VATS) approach to achieve en bloc lobectomy and spinal resection for non-small-cell lung cancer (NSCLC).

METHODS

Between October 2015 and November 2020, 10 patients underwent VATS anatomical lobectomy and en bloc chest wall and spinal resection through a limited posterior midline incision as a single operation for T4 (vertebral involvement) lung cancer. Nine patients had Pancoast syndrome without vascular involvement and 1 patient had NSCLC of the right lower lobe with invasion of T9 and T10.

RESULTS

There were 5 men and 5 women. The mean age was 61 years (range: 47-74 years). Induction treatment was administered to 9 patients (90%). The average operative time was 315.5 min (range: 250-375 min). The average blood loss was 665 ml (range: 100-2500 ml). Spinal resection was hemivertebrectomy in 6 patients and wedge corpectomy in 4 patients. Complete resection (R0) was achieved in all patients. The average hospitalization stay was 14 days (range: 6-50 days). There was no in-hospital mortality. The mean follow-up was 32.3 months (range: 6-66 months). Six patients (60%) are alive without recurrence.

CONCLUSIONS

VATS is feasible and safe to achieve en bloc resection of NSCLC inviding the spine without compromising oncological efficacy. Further experience and longer follow-up are needed to determine if this approach provides any advantages over thoracotomy.

The Role of Surgery in Lung Cancer Treatment: Present Indications and Future Perspectives-State of the Art

Non-small cell lung cancers (NSCLC) are different today, due to the increased use of screening programs and of innovative systemic therapies, leading to the diagnosis of earlier and pre-invasive tumors, and of more advanced and controlled metastatic tumors. Surgery for NSCLC remains the cornerstone treatment when it can be performed. The role of surgery and surgeons has also evolved because surgeons not only perform the initial curative lung cancer resection but they also accompany and follow-up patients from pre-operative rehabilitation, to treatment for recurrences. Surgery is personalized, according to cancer characteristics, including cancer extensions, from pre-invasive and local tumors to locally advanced, metastatic disease, or residual disease after medical treatment, anticipating recurrences, and patients' characteristics. Surgical management is constantly evolving to offer the best oncologic resection adapted to each NSCLC stage. Today, NSCLC can be considered as a chronic disease and surgery is a valuable tool for the diagnosis and treatment of recurrences, and in palliative conditions to relieve dyspnea and improve patients' comfort.

Subxifoid versus transthoracic thoracoscopic lobectomy: Results of a retrospective analysis before and after matching analysis

Background

Here, we report our initial experience with subxifoid video‐assisted thoracoscopic surgery (SVATS) lobectomy for the management of primary lung cancer, and compared the outcomes of SVATS with those of conventional transthoracic VATS (CVATS) lobectomies to validate its feasibility and usefulness.

Methods

The clinical data of consecutive patients undergoing VATS lobectomy via SVATS or CVATS for lung cancer were retrospectively compared. The endpoints were to evaluate the statistical differences in surgical results, postoperative pain (measured with visual analog scale [VAS] scores at 8 hours, Day 1, Day 2, Day 3, at discharge, one month and three months after surgery) and paresthesia (measured at one‐ month, and three months after surgery). The two groups were compared before and after matching analysis.

Results

Our study population included 223 patients: 84 in the SVATS and 139 in the CVATS group. The two groups were not comparable for sex (P = 0.001), preoperative comorbidity as cardiopathy (P = 0.007), BMI value (P = 0.003), left‐sided procedure (P = 0.04), tumor stage (P = 0.04), and tumor size (P = 0.002). These differences were overcome by propensity score matching (PSM) analysis that yielded two well‐matched groups which included 61 patients in each group. Surgical outcomes including blood loss, hospital stay and complications were similar before and after matching analysis, but SVATS compared to CVATS was associated with longer operative time before (159 ± 13 vs. 126 ± 6.3, P < 0.0001), and after matching analysis (161 ± 23 vs. 119 ± 8.3; P < 0.0001) and significant reduction of postoperative pain during the different time‐points (P < 0.001), and paresthesia at one (P = 0.001), and three months (P < 0.0001).

Conclusions

SVATS lobectomy is a feasible and safe strategy with surgical outcomes similar to CVATS lobectomy but with less postoperative pain and paresthesia.

Key points

Significant findings of the study

Subxifoid thoracoscopic lobectomy is a feasible and safe procedure, with potential benefits in terms of postoperative pain and paresthesia compared to conventional thoracoscopic lobectomy

Our results showed that surgical outcomes including blood loss, hospital stay, morbidity and mortality are similar but subxifoid thoracoscopy was associated with significant reduction of postoperative pain and paresthesia.

What this study adds

Subxifoid thoracoscopy is a safe procedure; compared to conventional transthoracic thoracoscopy, it avoids intercostal incisions, and spares nerve trauma, resulting in a reduction of postoperative pain and paresthesia.

Is video-assisted thoracoscopic lobectomy associated with higher overall costs compared with open surgery? Results of best evidence topic analysis

Thoracoscopic lobectomy has become the preferred approach for surgical management of early stage lung cancer, but the potential higher operative costs limit its widespread use. Theoretically, higher direct costs may be significantly counterbalanced by lower indirect costs, resulting in lower overall costs for thoracoscopic than for open lobectomy. To support this hypothesis, we reviewed the literature until May 2020, analyzing all papers comparing the cost of thoracoscopic versus open lobectomy.A total of 20 studies provided the most applicable evidence to evaluate this issue. In all the studies apart from one, thoracoscopic lobectomy was associated with higher operative costs due to the increased use of disposable instruments, and prolonged operative time. By contrast, in 17 studies the increased operative costs were significantly offset by indirect costs which were lower in thoracoscopic than in open lobectomy due to fewer postoperative complications, faster recovery, and lower readmission rates. It translated into lower overall costs for thoracoscopic than for open lobectomy in 10 studies, similar costs in seven, and higher in three, despite the lower hospitalization costs. The low bed fees and high prices of disposable instruments in these three studies may explain the discordance. The careful use of disposable instruments, and the minimizing hospitalization costs can reduce the total costs of thoracoscopic lobectomy to levels similar or to below those of open lobectomy. The worry that video‐assisted thoracoscopic surgery lobectomy (VATSL) might be associated with an increased overal cost is thus not warranted, and should not be used as an excuse against the use of VATS in surgery for early stage lung cancers.

The use of Transcollation Technology for Video-Assisted Thoracic Surgery lobectomy

Background

Video-Assisted Thoracic Surgery (VATS) lobectomy is now considered the preferred approach at many centers for early stage lung cancer. However, it needs an adequate learning curve, and it may be challenging in non-expert hands. The aim of this study was to evaluate the effectiveness of Transcollation Technology over Traditional Electrocautery to perform hilar and mediastinal dissection during VATS lobectomy.

Methods

This is a single-center retrospective study including consecutive patients undergoing VATS lobectomy for lung cancer. Patients were divided in two groups based on whether Transcollation Technology (TT Group) or Traditional Electrocautery (TE Group) was used for hilar and mediastinal lymphadenectomy. Operative time and surgical outcome, including number of transfusions, length of chest drainage, length of hospital stay, morbidity and mortality were registered, and the inter-group differences were statistically analyzed.

Results

53 patients were included in the final analysis. The TT Group (n = 24) compared to the TE Group (n = 29) showed significant shorter operative time (75.2 ± 25.8 min versus 98.1 ± 33.3 min; p = 0.023), and reduction of length of chest tube stay (4.7 ± 0.8 days vs. 6.8 ± 1.1 days, p = 0.013) and length of hospital stay (5.3 ± 1.9 days vs. 6.8 ± 1.1 days, p = 0.007). No intraoperative or major postoperative complications were observed in either groups.

Conclusions

Transcollation Technology represents a valid alternative to standard electrocautery instruments during VATS lobectomy. It contributes to reduce the operative time and length of hospital stay. Further larger prospective studies are required to confirm our data.

Does the length of uniportal video-assisted thoracoscopic lobectomy affect postoperative pain? Results of a randomized controlled trial

BACKGROUND

Uniportal video-assisted thoracoscopic surgery (VATS) lobectomy has become a common approach for the treatment of early stage lung cancer. Here, we aimed to establish whether the length of uniportal incision could affect postoperative pain and surgical outcomes in consecutive patients undergoing uniportal VATS lobectomy for early stage lung cancer.

METHODS

This was a unicenter Randomized Control Trial (NCT03218098). Consecutive patients undergoing uniportal VATS lobectomy for Stage I lung cancer were randomly assigned to a Small Incision group or Long Incision group in 1:1 ratio based on whether patients received a 4 cm or 8 cm incision. The endpoints were to compare the intergroup difference regarding (i) postoperative pain measured by brief pain inventory (BPI) questionnaire (first endpoint); (ii) operative time; (iii) length of chest drainage; (iv) length of hospital stay; (v) postoperative complications; and (vi) pulmonary functional status (secondary endpoints).

RESULTS

A total of 48 patients were eligible for the study. Four patients were excluded; the study population included 44 patients: 23 within the Small Incision group, and 21 within the Long Incision group. The 11 BPI scores between the two groups showed no significant difference. Small Incision group presented higher operative time than Long Incision group (138.69 vs. 112.14 minutes; P = 0.0001) while no significant differences were found regarding length of hospital stay (P = 0.95); respiratory complications (P = 0.92); FEV1% (P = 0.63), and 6-Minute Walking Test (P = 0.77).

CONCLUSIONS

A larger incision for uniportal VATS lobectomy significantly reduced the operative time due to better exposure of the anatomical structures without increasing postoperative pain or affecting the surgical outcome.

KEY POINTS

A larger incision for uniportal VATS lobectomy significantly reduced the operative time due to better exposure of the anatomical structures without increasing postoperative pain or affecting the surgical outcome. To perform a larger incision could be a valuable strategy, particularly in nonexpert hands or when the patient's anatomy or tumor size make exposure of anatomic structures through smaller incisions difficult.

Preventive skin analgesia with lidocaine patch for management of post-thoracotomy pain: Results of a randomized, double blind, placebo controlled study

Background

To evaluate whether pre‐emptive skin analgesia using a lidocaine patch 5% would improve the effects of systemic morphine analgesia for controlling acute post‐thoracotomy pain.

Methods

This was a double‐blind, placebo controlled, prospective study. Patients were randomly assigned to receive lidocaine 5% patch (lidocaine group) or a placebo (placebo group) three days before thoracotomy. Postoperative analgesia was induced in all cases with intravenous morphine analgesia. The intergroup differences were assessed in order to evaluate whether the lidocaine patch 5% would have effects on pain intensity when at rest and after coughing (primary end‐point) on morphine consumption, on the recovery of respiratory function, and on peripheral painful pathways measured with N2 and P2 laser‐evoked potential (secondary end‐points).

Results

A total of 90 patients were randomized, of whom 45 were allocated to the lidocaine group and 45 to the placebo group. Lidocaine compared with the placebo group showed a significant reduction in pain intensity both at rest (P = 0.013) and after coughing (P = 0.015), and in total morphine consumption (P = 0.001); and also showed a better recovery of flow expiratory volume in one second (P = 0.025) and of forced vital capacity (P = 0.037). The placebo group compared with the lidocaine group presented a reduction in amplitude of N2 (P = 0.001) and P2 (P = 0.03), and an increase in the latency of N2 (P = 0.023) and P2 (P = 0.025) laser‐evoked potential.

Conclusions

The preventive skin analgesia with lidocaine patch 5% seems to be a valid adjunct to intravenous morphine analgesia for controlling post‐thoracotomy pain. However, our initial results should be corroborated/confirmed by larger studies.

Uniportal Thoracoscopic Thoracic Duct Clipping in Poirier's Triangle for Postoperative Chylothorax

Postoperative chylothorax is a rare but potentially life-threatening complication. Conservative treatment is usually unsuccessful in patients with high-output chylothorax, for whom early surgical thoracic duct ligation has been advocated to minimize morbidity and mortality. This report describes left uniportal thoracoscopic closure of persistent high-output chylothorax through Poirier's triangle in a patient undergoing thoracoscopic thymectomy. After resection of pleural adhesions, the mediastinal pleura was resected at the level of the aortic arch, left subclavian artery, and vertebral column, the anatomic limits of Poirier's triangle. The thoracic duct was then isolated from the esophagus and successfully clipped along its path.

Resection of esophageal diverticulum through uniportal video-assisted thoracoscopic surgery

Open surgery remains the standard strategy for management of esophageal diverticulum in symptomatic patients. However, in the last years an increasing number of minimally invasive approaches have been proposed for this issue in order to reduce the surgical trauma and favor a fast return to daily activity. Herein, we describe a novel technique as uniportal video-assisted thoracoscopic surgery (VATS) for performing resection of esophageal diverticulum. This procedure was successfully carried out in three consecutive patients with giant mid-esophageal diverticulum (mean size: 6.5±0.5 cm). The mean post-operative time was 121±10 minutes. The chest drain was removed 48 hours later in all cases and the mean length of hospital stay was 9±1 days. No intraoperative neither postoperative complications were found in all patients but one. He had a small fistula 15 days later that was successfully treated with stent insertion. No recurrence of diverticulum was seen in all cases. Uniportal VATS is a feasible procedure that in theory could reduce the surgical trauma compared to standard open approach. However, future prospective studies should corroborate our impression before it can be recommended as acceptable therapy.

Uniportal thoracoscopy combined with laparoscopy as minimally invasive treatment of esophageal cancer

A 67-year-old man was referred to our attention for management of esophageal adenocarcinoma, localized at the level of the esophagogastric junction and obstructed the 1/3 of the esophageal lumen. Due to the extension of the disease (T3N1M0-Stage IIIA), the patient underwent neo-adjuvant chemo-radiation therapy and he was then scheduled for a minimally invasive surgical procedure including laparoscopic gastroplasty, uniportal thoracoscopic esophageal dissection and intrathoracic end-to-end esophago-gastric anastomosis. No intraoperative and post-operative complications were seen. The patient was discharged in post-operative day 9. Pathological study confirmed the diagnosis of adenocarcinoma (T2N1M0-Stage IIB) and he underwent adjuvant chemotherapy. At the time of present paper, patient is alive and well without signs of recurrence or metastasis. Our minimally approach compared to standard open procedure would help reduce post-operative pain and favours early return to normal activity. However, future experiences with a control group are required before our strategy can be widely used.

Is it appropriate to perform video-assisted thoracoscopic surgery for advanced lung cancer?

Video-assisted thoracoscopic surgery (VATS) has showed benefits in terms of pain, hospital stay and accomplishment of adjuvancy therapy versus open surgery in early stage of non-small-cell lung cancer. Over the last years, the indication of VATS technique has been expanded to advanced lung cancer. In this article, we discuss the definition of VATS and advanced lung cancer, and the safety and feasibility of VATS technique for the resection of advanced tumors.

Thoracoscopic anatomic lung resections for cancer in patients with previous cardiac surgery

We reported the feasibility of thoracoscopic anatomical resections for lung cancer in four consecutive patients undergoing previous cardiac surgeries as coronary artery by-pass graft (CABG) using left internal mammary artery (LIMA) graft (n=1), cardiac transplantation (n=2), and mitral valve replacement (n=1). A three-port approach was used in all patients but one where an uniportal approach was adopted. Lobectomy was carried out in two patients; left upper three-segmentectomy and upper bilobectomy in the other two. All procedures were successfully performed without needing conversion. No intra-operative, post-operative morbidity and mortality were recorded. At last follow-up, all patients were alive without recurrence but one who had cerebral metastasis. Thoracoscopic lung resection after cardiac surgery is a feasible but complex procedure that should be performed in centres having a cardiac surgery team ready to operate in case of cardiac complications.

Prognostic value of soluble major histocompatibility complex class I polypeptide-related sequence A in non-small-cell lung cancer - significance and development

Soluble major histocompatibility complex class I polypeptide-related sequence A (sMICA) is a useful marker in surveillance of lung cancer. High serum sMICA level in patients with non-small-cell lung cancer (NSCLC) seems to be a poor prognostic factor being correlated with poor differentiation and advanced stage. However, the low specificity limits its role as a single prognostic marker of NSCLC, but its evaluation, in addition to standard serum markers, could improve the staging of NSCLC. Despite promising, all current studies are insufficient to assess the real efficiency of sMICA as a prognostic marker of NSCLC, and hence, future studies are required to validate it.

Uniportal video-assisted lobectomy through a posterior approach

We propose a technique of uniportal VATS lobectomy using a posterior approach. The main differences of our technique versus standard anterior uniportal VATS are the following: (I) the surgical incision is performed in the auscultatory triangle instead of in the posterior axillary line and (II) the surgeon is placed posteriorly to the patient rather than anteriorly. For thoracic surgeons who are familiar with posterolateral thoracotomy, our technique allows to replicate the same maneuvers performed in the open approach. This strategy was applied with success in 19 consecutive patients for anatomical resection of neoplastic (n=17) and benign (n=2) diseases.

Management of Lung Cancer Invading the Superior Sulcus

Superior sulcus tumors have posed a formidable therapeutic challenge since their original description by Pancoast and Tobias in the early twentieth century. Initial therapeutic efforts with radiotherapy were associated with high rates of relapse and mortality. Bimodality therapy with complete surgical resection in the 1960s paved the way for trimodality therapy as the current standard of care in the treatment of superior sulcus tumors. The evolution of treatment approaches over time has provided outcomes that come increasingly closer to rivaling those of similarly staged nonapical lung cancer.

Bilateral single-port thoracoscopic extended thymectomy for management of thymoma and myasthenia gravis: case report

Background

Video-assisted thoracoscopy is become a widely accepted approach for the resection of anterior mediastinal masses, including thymoma. The current trend is to reduce the number of ports and minimize the length of incisions to further decrease postoperative pain, chest wall paresthesia, and length of hospitalization. Herein, we reported an extended resection of thymoma in a patient with myasthenia gravis through an uniportal bilateral thoracoscopic approach.

Case presentation

A 74 years old woman with myasthenia gravis was referred to our attention for management of a 3.5 cm, well capsulate, thymoma. All laboratory and cardio-pulmonary tests were within normal; thus, she was scheduled for thymoma resection through an uniportal bilateral thoracoscopic approach. Under general anaesthesia and selective intubation, the patient was placed in a 60° right lateral decubitus. A 3 cm skin incision was performed in the fourth right intercostal space and, through that a 30° video-camera and working instruments were inserted without rib spreading. After complete dissection of the thymus and mediastinal fat, the contralateral pleura was opened, and, through that the specimen was pushed into the left pleural cavity. Then, the patient was placed in the left lateral decubitus. Similarly to the right side procedure, a 3-cm incision was performed in the fourth left intercostal space to complete thymic dissection and retrieve the specimen. No intraoperative and post-operative complications were found. The patient was discharged four days later. Pathological examination revealed a type A thymoma (Masaoka stage I). No recurrence was found at 18 months of follow-up

Conclusions

Bilateral single-port thoracoscopy is an available procedure for management of thymoma associated with myasthenia gravis. The less post-operative pain, the reduction of hospital stay and the better esthetic results are all potential advantages of this approach over traditional technique. Obviously, our impression should be validated by larger studies in terms of long-term oncological outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/s13019-016-0547-3) contains supplementary material, which is available to authorized users.

VATS lobectomy combined with limited Shaw-Paulson thoracotomy for posterolateral Pancoast tumor

Purpose

Several techniques have been proposed for the challenging surgical resection of Pancoast tumors. We describe a hybrid approach that combines video-assisted thoracic surgery (VATS) lobectomy and limited Shaw-Paulson thoracotomy.

Methods

We report a case of Pancoast tumor in a 57-year-old man, staged as cT3N0M0, that was treated with induction chemoradiotherapy prior to the hybrid surgical approach. After thoracoscopic pleural cavity inspection, an upper right VATS lobectomy by a 3-port standard approach was performed. The chest wall was resected through a limited paravertebral incision, allowing the extraction of the lobe together with the rib segments. The posterior chest wall defect was repaired with a synthetic patch.

Results

The postoperative period was uneventful and the pain never exceed a score of 3 on a visual analogue scale. Pathological examination revealed nonvital tumor cells in the specimen (ypT0N0M0). The patient is disease free at 6 months’ follow-up.

Conclusions

With this approach we experienced excellent access to both the apical and hilar structures. Further experiences are needed to validate the role of VATS lobectomy in the multidisciplinary management of posterior Pancoast tumor.

A Comparative Study of Video-Assisted Thoracic Surgery with Thoracotomy for Middle Lobe Syndrome

OBJECTIVES

The aim of this study is to evaluate the feasibility and safety of video-assisted thoracic surgery (VATS) for the treatment of middle lobe syndrome (MLS) through comparison with thoracotomy during the same period.

METHODS

We retrospectively reviewed all consecutive patients with MLS who underwent lobectomy or lingular segmentectomy between December 2005 and November 2015 in a single institute. Thirty patients were enrolled and divided into two groups: VATS group (n = 19) and thoracotomy group (n = 11). Data regarding the patients' demographics, medical history were collected and statistically compared.

RESULTS

All patients received successful middle lobe resection or lingular segmentectomy. In terms of operation time, blood transfusion, chest drainage amount, duration of chest drainage and postoperative complications, no significant differences were found between the two groups (p > 0.05). The mean intraoperative blood loss of VATS group was less than thoracotomy group (79.0 ± 63.9 vs. 165 ± 94.9 ml, p = 0.04). In VATS group, the mean length of postoperative hospital stay was 6.0 ± 2.4 days, shorter than that in group thoracotomy (9.0 ± 3.5 days, p = 0.01).

CONCLUSIONS

VATS was a feasible and safe method for the surgical treatment of MLS in selected patients when no severe calcified lymph nodes surrounding hilus pulmonis was observed by preoperative chest CT scan.

Is VATS lobectomy standard of care for operable non-small cell lung cancer?

Video-Assisted Thoracic Surgery (VATS) for treatment of lung cancer is being increasingly applied worldwide in the last few years. Since its introduction, many publications have been providing strong evidences that this minimally invasive approach is feasible, safe and oncologically efficient; offering to patients several advantages over traditional open thoracotomy, particularly for early-stage disease (I and II). The application of VATS for locally advanced disease treatment has also been largely described, but probably requires a further level of experience, which is more likely to be found in reference centers, with skilled experts. Although a large multi-institutional prospective randomized-controlled trial is the best way to confirm the superiority of one technique over another, such study comparing VATS versus open lobectomy for lung cancer is unlikely to ever come out. And in this scenario, retrospective data remains as the most reliable source of scientific information. Based on a literature review, the main objective of this article is to discuss to what extent VATS lobectomy can be considered the gold standard in the surgical treatment of lung cancer, taking into account the most important comparison aspects between the minimally invasive approach and open thoracotomy technique. This review addresses questions regarding lymph node dissection, oncologic efficacy, extended resections beyond standard lobectomy, post-operative complications/pain/quality of life, survival rates and the present limits of indication (and contraindication) for VATS, in order to define the real role of this technique on the surgical treatment of lung cancer in a minimally invasive, but safe and effective manner.

Superior sulcus tumors (Pancoast tumors)

Superior Sulcus Tumors, frequently termed as Pancoast tumors, are a wide range of tumors invading the apical chest wall. Due to its localization in the apex of the lung, with the potential invasion of the lower part of the brachial plexus, first ribs, vertebrae, subclavian vessels or stellate ganglion, the superior sulcus tumors cause characteristic symptoms, like arm or shoulder pain or Horner's syndrome. The management of superior sulcus tumors has dramatically evolved over the past 50 years. Originally deemed universally fatal, in 1956, Shaw and Paulson introduced a new treatment paradigm with combined radiotherapy and surgery ensuring 5-year survival of approximately 30%. During the 1990s, following the need to improve systemic as well as local control, a trimodality approach including induction concurrent chemoradiotherapy followed by surgical resection was introduced, reaching 5-year survival rates up to 44% and becoming the standard of care. Many efforts have been persecuted, also, to obtain higher complete resection rates using appropriate surgical approaches and involving multidisciplinary team including spine surgeon or vascular surgeon. Other potential treatment options are under consideration like prophylactic cranial irradiation or the addition of other chemotherapy agents or biologic agents to the trimodality approach.

Bilateral thoracoscopic extended thymectomy versus sternotomy

Background

Complete open surgical resection is the standard treatment for thymoma and myasthenia gravis. We evaluated the feasibility of bilateral video-assisted thoracoscopic extended thymectomy, and compared it to surgery via sternotomy.

Methods

From 2011 to 2014, 43 patients undergoing thymectomy were divided into 2 groups: 23 underwent video-assisted thoracoscopic extended thymectomy, and 20 had thymectomy via sternotomy. The primary outcomes were postoperative pain score (visual analog scale) at 6, 12, 24, 48, and 72 h, and 1-month postoperatively, and morphine consumption in the first 48 h. Secondary outcomes were surgical and clinical results.

Results

There were no significant differences between the 2 groups in terms of demographics and preoperative clinical data. Compared to the sternotomy group, the video-assisted thoracoscopic thymectomy group had lower pain scores and morphine consumption at all time points, significantly less operative blood loss and chest drainage volume, and shorter hospital stay. The rates of improvement in myasthenia gravis were 85% and 86% in the video-assisted thoracoscopic thymectomy and sternotomy groups, respectively. No recurrence of thymoma was found in either group (median follow-up 27 months).

Conclusions

Our results seem to confirm that in selected cases, video-assisted thoracoscopic thymectomy allows complete resection of thymus and perithymic tissue, similar to sternotomy but with the known advantages of minimally invasive surgery including less pain and a good cosmetic result.

Reconstruction with a pectoralis major myocutaneous flap after left first rib and clavicular chest wall resection for a metastasis from laryngeal cancer

We presented a case of recurrent metastasis from epidermoid cancer that occurred in the left clavicle of a patient with a history of laryngeal cancer treated on April 2005 with extended hemilaryngectomy, neck dissection and chemoradiation therapy. On September 2008, he developed a left clavicular metastasis. The disease was initially well controlled by chemoradiotherapy but it recurred 17 months later. The optimal treatment plan was established by several multidisciplinary meetings and the patient subsequently underwent an en bloc resection of the left clavicle, first rib and all the other involved structures. Coverage of the thoracic defect was achieved using pectoralis major myocutaneous flap. The patient had a successful surgical outcome. At 1-year follow-up, he had no evidence of disease, a good cosmetic result and returned to normal daily activity. He died for bone metastasis with an overall 21 months post-surgical survival.