Uniportal vs. triportal video-assisted thoracic surgery in the treatment of primary pneumothorax-a propensity matched bicentric study

Uniportal versus multiportal video-assisted thoracoscopic surgery for spontaneous pneumothorax

BACKGROUND

Multiportal video-assisted thoracic surgery (mVATS) is the standard approach for the surgical treatment of spontaneous pneumothorax. However, uniportal VATS (uVATS) has emerged as an alternative aiming to minimize surgical morbidity. This study aims to strengthen the evidence on the safety and efficiency of uVATS compared to mVATS.

METHODS

From January 2004 to December 2020, records of patients who had undergone surgical treatment for primary or secondary spontaneous pneumothorax were evaluated for eligibility. Patients who had undergone pleurectomy combined with bullectomy or apical wedge resection via uVATS or mVATS were included. Surgical characteristics and postoperative data were compared between patients who had undergone surgery via uVATS or mVATS. Univariable and multivariable analyses were performed to determine whether the surgical approach was associated with any complication (primary outcome), major complications (i.e., Clavien-Dindo ≥ 3), recurrence, prolonged hospitalization or prolonged chest drainage duration (secondary outcomes).

RESULTS

A total of 212 patients were enrolled. Patients treated via uVATS (n = 71) and mVATS (n = 141) were significantly different in pneumothorax type (secondary spontaneous; uVATS: 54 [76%], mVATS: 79 [56%]; p = 0.004). No significant differences were observed in (major) complications and recurrence rates between both groups. Multivariable analyses revealed that the surgical approach was no significant predictor for the primary or secondary outcomes.

CONCLUSIONS

This study indicates that uVATS is non-inferior to mVATS in the surgical treatment of spontaneous pneumothorax regarding safety and efficiency, and thus the uVATS approach has the potential for further improvements in the perioperative surgical care for spontaneous pneumothorax.

Mechanical and biological properties of poly-ε-caprolactone membrane for pleurodesis: A preclinical study in pigs

BACKGROUND/PURPOSE

Biomaterial implants are emerging as a treatment choice for pleurodesis; however, the optimal biomaterial and form for managing spontaneous pneumothorax, particularly post-video-assisted thoracic surgery, remain under investigation. This study evaluated the mechanical and biological properties of the poly-ε-caprolactone (PCL) membrane as a sclerosing agent for pleurodesis in Landrace pigs.

METHODS

Twenty-four Landrace pigs were split into two groups for mechanical abrasion and PCL membrane pleurodesis, with the latter group's PCL meshes inserted using video-assisted thoracic surgery. The mechanical and biological properties of the PCL membrane were assessed in pigs at three, six, and 12 months after the procedure. This assessment involved a range of techniques, such as the T-Peel test, macroscopic evaluation with a scoring scale, microscopic examination, and biomechanical and molecular weight analysis.

RESULTS

The PCL membrane group outperformed the traditional abrasion group, with stronger adhesions seen over longer implantation durations. This group also showed superior and more consistent results in both macroscopic and microscopic evaluations compared to the control group. The membrane-based method was easier and faster to perform than the control group's method, and importantly, no mortality occurred following membrane implantation.

CONCLUSION

This study is the pioneering effort to present long-term findings regarding the mechanical and biological properties of the PCL membrane in an in vivo animal model. The membrane demonstrated better adhesion ability than that of traditional abrasion and showed reassuring biocompatibility in both the pig model, suggesting its potential as treatment for patients with primary spontaneous pneumothorax. Further clinical studies are needed to support these observations.

Feasibility of tubeless thoracoscopic bullectomy in primary spontaneous pneumothorax patients

OBJECTIVES

Although early removal of postoperative chest drains can facilitate postoperative recovery, there are risks of undetected bleeding and a need for re-drainage to treat delayed pulmonary air leaks. In this study, we aimed to prospectively examine the feasibility of tubeless thoracoscopic bullectomy in primary spontaneous pneumothorax (PSP) patients.

METHODS

Between January 2021 and November 2021, 30 PSP patients were enrolled in this prospective study. The absence of air leakage was confirmed and radiographic evidence of lung expansion was acquired; the tube was then removed in the operating room. The primary endpoint was postoperative air leakage requiring re-drainage among patients who underwent tube removal in the operating room. The secondary endpoints were postoperative pain (numerical rating scale) on postoperative days (PODs) 1, 7, and 28, morbidity, and postoperative hospitalization time.

RESULTS

Four (13.3%) patients were excluded because of underlying pulmonary disease (n = 2) and air leaks (n = 2) detected in the operating room. Chest drainage tubes were removed in the operating room for the remaining 26 patients; none of them required re-drainage. The mean postoperative hospitalization time was 1.2 ± 0.4 days. The mean numerical rating scale scores were 4.2 ± 2 (median: 4.5), 1.6 ± 1.6 (median: 1), and 0.4 ± 0.8 (median: 0) on PODs 1, 7, and 28, respectively. Only one case of hemoptysis occurred as a postoperative complication.

CONCLUSIONS

Tubeless thoracoscopic bullectomy for PSP is feasible and may reduce the postoperative hospitalization time; however, it does not significantly reduce pain on POD1.

Uniportal video-assisted thoracic surgery and perioperative pirfenidone for lung cancer and idiopathic pulmonary fibrosis: a case report

Patients with idiopathic pulmonary fibrosis (IPF) occasionally experience acute exacerbations after surgery for lung cancer. Several recent studies have revealed a prophylactic effect of perioperative pirfenidone treatment on postoperative acute exacerbations of IPF in patients with lung cancer. A 75-year-old woman consulted with her pulmonologist because of an IPF shadow detected by follow-up chest computed tomography 2 months after surgical treatment of biliary cancer. Another 7 months later, chest computed tomography showed a 23- × 14-mm nodule located in the right lower lobe with high accumulation of fluorodeoxyglucose detected by positron emission tomography, resulting in a radiological diagnosis of primary lung cancer with IPF. We administered perioperative pirfenidone treatment followed by right lower lobectomy using uniportal video-assisted thoracoscopic surgery after attaining a pathological diagnosis of adenocarcinoma. The patient developed no acute exacerbations of IPF during the postoperative period, and she had no recurrence of lung cancer for 15 months after surgery. We successfully used a combination of perioperative antifibrotic medication and minimally invasive surgery after lung cancer surgery in a patient with IPF.

A prospective comparative study of thoracoscopic transareolar and uniportal approaches for young male patients with primary spontaneous pneumothorax

OBJECTIVE

In this study, we introduce a novel approach, thoracoscopic transareolar bullectomy, for treating young male patients with primary spontaneous pneumothorax (PSP). This approach might be less invasive and cosmetically superior to existing methods. We also prospectively compared transareolar and uniportal approaches.

METHODS

Between April 2018 and July 2019, 40 patients were prospectively assigned to transareolar (n = 21) and uniportal (n = 19) groups. We compared patient characteristics and perioperative results. Approximately 1 week or 1 year after the operation, postoperative pain was evaluated using a numerical rating scale (NRS), and cosmetic satisfaction was graded on a four-point scale.

RESULTS

We found no significant between-group differences in patient characteristics or perioperative results. NRS scores did not differ on postoperative day (POD) 7 (transareolar, 1.8 ± 0.9 vs. uniportal, 1.6 ± 0.9; p = 0.62) or in postoperative month (POM) 12 (transareolar, 1.3 ± 0.5 vs. uniportal, 1.1 ± 0.5; p = 0.18). In terms of cosmetic satisfaction, the transareolar group was more satisfied on POD 7 (transareolar, 3.5 ± 0.6 vs. uniportal, 2.9 ± 0.9; p = 0.02) and in POM 12 (transareolar, 3.8 ± 0.5 vs. uniportal, 3.3 ± 0.9; p = 0.0065).

CONCLUSION

Although the perioperative results of the transareolar and uniportal approaches were similar, the former approach afforded a little better cosmetic satisfaction and might be useful option for young males with PSP.

Uniportal approach as an alternative to the three-portal approach to video-assisted thoracic surgery for primary spontaneous pneumothorax

Background

In recent years, uniportal video-assisted thoracic surgery (U-VATS) has been used for primary spontaneous pneumothorax (PSP). This study compared the perioperative outcomes of U-VATS and three-port VATS (3P-VATS) and sought to determine the risk factors for postoperative recurrence.

Methods

From October 2010 to February 2017, 232 patients with PSP undergoing surgical treatment were enrolled in this study. The patients were divided into two groups: U-VATS (n=161) and 3P-VATS (n=71) depending on the period of surgery. Retrospective analysis of the perioperative results and the risk factors for recurrence was performed.

Results

Both the operation time and duration of postoperative drainage were initially longer in the U-VATS group, but the difference gradually decreased such that ultimately there was no significant difference compared to the 3P-VATS group (P=0.10 and P=0.12, respectively). The duration of postoperative hospital stay and postoperative recurrence rate were not different between the two groups (P=0.084 and P=0.44, respectively). By multivariate analysis, the age (HR, 0.42, 95% CI: 0.24−0.72, P<0.01) and number of bullae (single vs. multiple: HR, 0.03, 95% CI: 0.002−0.54, P=0.02) were risk factors for recurrence.

Conclusions

The perioperative results and recurrence rate did not differ between the U-VATS and 3P-VATS groups, thereby demonstrating the non-inferiority of U-VATS. Postoperative risk factors for PSP recurrence were patient age and the number of bullae. Additional treatment may be needed to reduce recurrence in young patients with multiple bullae. Clinical registration number: The Institutional Review Board of Maebashi Red Cross Hospital (no. 2019-21).

Chronic chest pain and paresthesia after video-assisted thoracoscopy for primary pneumothorax

Background

This study aims to identify clinical and surgical risk factors for chronic chest pain and paresthesia after video thoracoscopic surgery for primary spontaneous pneumothorax.

Methods

We retrospectively collected the data of 1,178 consecutive patients <40-years-old undergoing video thoracoscopic surgery for primary spontaneous pneumothorax in 9 Italian centers in 2007–2017. Cases with <2-month follow-up were excluded, leaving 920 patients [80% male; median age: 21 (IQR, 18–27) years] for statistical analysis. The following risk factors for chronic chest pain and chronic paresthesia were assessed by univariable and multivariable Cox regression model: age, gender, cannabis smoking, video thoracoscopy ports number, pleurodesis technique (partial pleurectomy/pleural electrocauterization/pleural abrasion/talc poudrage), chest tube size (24/28 F), postoperative chest tube stay.

Results

Blebs/bullae resection with pleurodesis was performed in 732 (80%) cases; pleurodesis alone in 188 (20%). During a median follow-up of 68 (IQR: 42–95) months, chronic chest pain developed in 8% of patients, chronic chest paresthesia in 22%; 0.5% of patients regularly assumed painkillers. Chronic chest pain was independently associated with partial pleurectomy/pleura abrasion (P<0.001) and postoperative chest tube stay (P=0.019). Chronic chest paresthesia was independently associated with pleurodesis by partial pleurectomy (P<0.001), chest tube stay (P=0.035) and 28 F chest tube (P<0.001).

Conclusions

After video thoracoscopic surgery for primary spontaneous pneumothorax, the incidence of chronic chest pain and paresthesia was significantly lower when pleurodesis was performed by pleural electrocauterization or talc poudrage, and chest tube was removed early. A 24 F chest tube was associated with lower risk of chronic chest paresthesia.

Bio-artificial pleura using autologous dermal fibroblast sheets to mitigate air leaks during thoracoscopic lung resection

Lung air leaks (LALs) due to visceral pleura injury during surgery are a difficult-to-avoid complication in thoracic surgery (TS). Reliable LAL closure is an important patient management issue after TS. We demonstrated both safeties of transplantation of a cultured human autologous dermal fibroblast sheet (DFS) to LALs. From May 2016 to March 2018, five patients who underwent thoracoscopic lung resection met all the inclusion criteria. Skin biopsies were acquired from each patient to source autologous dermal cells for DFS fabrication. During the primary culture, fibroblasts migrated from the dermal tissue pieces and proliferated to form cell monolayers. These fibroblasts were subcultured to confluence. Transplantable DFSs were fabricated from these subcultured fibroblasts that were trypsinized and seeded onto temperature-responsive culture dishes. After 10 days of fabrication culture, intact patient-specific DFS were harvested. DFSs were analyzed for fibroblast cell content and tissue contaminants prior to application. For closing intraoperative LAL, mean number of transplanted autologous DFS per patient was 6 ± 2 sheets. Mean chest drainage duration was 5.0 ± 4.8 days. The two patients with major LAL had a drainage duration of more than 7 days. All patients currently have no LAL recurrence after discharge. DFSs effectively maintain LAL closure via remodeling of the deposited extracellular matrix. The use of autologous DFSs to permanently close air leaks using a patient-derived source is expected to reduce surgical complications during high-risk lung resections.

Uniport vs. multiport video-assisted thoracoscopic surgery for anatomical lung resection-which is less invasive?

Background

Video-assisted thoracoscopic surgery (VATS) has been recognized as a standard procedure, but whether uniport VATS (U-VATS) is a more effective and minimally invasive approach compared with multiport VATS (M-VATS) is controversial.

Methods

The medical records of 184 patients in the M-VATS group and 69 patients in the U-VATS group who underwent anatomical lung resection from April 2017 to July 2020 at our institution were retrospectively reviewed. Postoperative outcomes were compared among U-VATS and M-VATS. Multivariate analysis was performed to identify factors that reduce postoperative pain.

Results

The mean operation time was significantly shorter in U-VATS than in M-VATS (172±43 min in M-VATS vs. 143±43 min in U-VATS, P<0.0001). Duration of postoperative drainage (2.2±1.2 days in M-VATS vs. 1.6±1.0 days in U-VATS, P=0.0002) and hospitalization (4.0±1.6 days in M-VATS vs. 3.1±1.6 days in U-VATS, P=0.0003) were significantly shorter in U-VATS than in M-VATS. The rate of postoperative complications was not significantly different between the groups (P=0.732). The number of analgesic prescriptions over 10 days postoperatively was significantly less in U-VATS than in M-VATS [68 (37.0%) in M-VATS vs. 8 (11.6%) in U-VATS, P<0.0001]. A multivariate logistic regression model showed that U-VATS was the only significant predictor for reduction of postoperative pain (odds ratio =0.204, P=0.0001).

Conclusions

U-VATS shortened the operation time, postoperative drainage duration, and hospitalization compared with conventional M-VATS, and it significantly reduced the use of analgesics. There were no differences in perioperative results such as blood loss and the postoperative complication rate. U-VATS can be said to be a safe and minimally invasive surgical procedure.

Feasibility of thoracoscopic pulmonary bullectomy using a transareolar approach for treatment of primary spontaneous pneumothorax

Background

Primary spontaneous pneumothorax (PSP) is a common disease among young patients, particularly men. While the most common thoracoscopic approach is triportal, the transareolar approach is rare. In this study, we prospectively investigated the feasibility of thoracoscopic pulmonary bullectomy using a transareolar approach for treatment of PSP.

Methods

Ten patients with PSP who underwent thoracoscopic transareolar pulmonary bullectomy were prospectively enrolled in this study between September 2017 and March 2018. For all 10 patients, we evaluated the perioperative outcomes, postoperative complications, recurrence, wound-related pain, and cosmetic satisfaction regarding the surgical wound.

Results

The mean patient age was 18.9±4.2 years; three patients were affected on the right side and seven patients were affected on the left side. Bullae and blebs were localized at the apex of the affected lung in all patients. All procedures were completed using a transareolar approach without additional ports or conversion to thoracotomy in any patient. The mean operative time was 39.8±8.6 min. The mean volume of blood lost during surgery was extremely small in all patients. The duration of postoperative drainage was 1 day, while the length of postoperative hospital stay was 2 days in all patients. No morbidities or recurrence of PSP occurred during the study period. The mean cosmetic satisfaction scores of the surgical wound were 3.3 and 3.2 on postoperative day (POD) 7 and at postoperative month (POM) 12. The mean NRS score was 1.5 on POD 7. All patients were pain-free at POM 12.

Conclusions

Transareolar thoracoscopic pulmonary bullectomy for treatment of PSP is feasible and safe, with a high degree of satisfaction for postoperative pain and cosmetics. This new approach could be a novel option for surgical treatment of PSP.

Next-day discharge following small uniportal thoracoscopic bullectomy assisted with an anchoring suture

Objective

Manipulating the instruments during uniportal video-assisted thoracoscopic surgery (U-VATS) bullectomy requires a relatively large incision. This study aimed to investigate the feasibility of next-day discharge following U-VATS bullectomy using an anchoring suture.

Methods

A stapler and a scope were inserted through a single incision in the anchoring group. The bullae were retracted by the suture, which was inserted from outside of the chest wall into the thorax, and then bullectomy was performed. For those in the control group, resection of the bullae was performed with the assistance of a grasping forceps.

Results

The length of the incision of the patients in the anchoring group ([13.2 ± 2.2] mm) was significantly smaller than in the control group ([26.2 ± 3.9] mm). In addition, the number of staplers used in the anchoring group was significantly less than in the control group ([1.2 ± 0.4] vs. [1.4 ± 0.5]). Furthermore, 36 (92.3%) cases in the anchoring group were uneventfully discharged within 24 hours after bullectomy.

Conclusion

Next-day discharge after U-VATS bullectomy through a small incision assisted with an anchoring suture is safe and feasible.

Minimally invasive approach to pneumothorax: Single port or two ports?

Background

This study aims to compare the effectiveness of single-port and two-port video-assisted thoracoscopic surgery in patients with pneumothorax.

Methods

Between June 2016 and December 2018, a total of 44 patients (39 males, 5 females; mean age 27.0±9.5 years; range, 15 to 60 years) who underwent video-assisted thoracoscopic surgery due to the spontaneous pneumothorax in our center were retrospectively evaluated. The study population was divided into two groups as the single-port (n=29) and two-port (n=15) procedure according to the number of port entries applied during the operation. Age, gender, number of days of drainage, length of hospitalization, number of days of air leak, the indication of operation, pneumothorax side, type of pneumothorax, duration of operation, and complications were compared between the groups.

Results

Twenty-two patients (50%) were operated on the right side and 22 patients (50%) on the left side. The mean operation time was 81.1±19.2 min, indicating no significant difference between the groups (p=0.053). No significant difference was observed in the number of days of drainage, the length of hospitalization, and number of days of air leak between the two groups. Complications developed in eight patients (27.6%) in the single-port group and five patients (33.3%) in the two-port group, indicating no significant difference between the groups (p=0.475).

Conclusion

Our study results show that video-assisted thoracoscopic surgery for the treatment of pneumothorax can be successfully performed via a single-port approach.