A simple and safe surgical technique for nonpalpable lung tumors: One-stop Solution for a nonpalpable lung tumor, Marking, Resection, and Confirmation of the surgical margin in a Hybrid operating room (OS-MRCH)

When performing thoracoscopic partial resections of nonpalpable lung tumors such as ground-glass opacities (GGOs) and small tumors, detecting the location of the lesion and assessing the resection margins can be challenging. We have developed a novel method to ease this difficulty, the One-stop Solution for a nonpalpable lung tumor, Marking, Resection, and Confirmation of the surgical margin in a Hybrid operating room (OS-MRCH), which uses a hybrid operating room wherein the operating table is seamlessly integrated with cone-beam computed tomography (CBCT). We performed the OS-MRCH method on 62 nodules including primary lung cancer presenting with GGO. Identification of the lesion and confirmation of the margin were performed in 58 of the cases, while nodules were detected in all. The frequency of computed tomography (CT) scans performed prior to resection was one time in 51 cases, two times in eight cases, and ≥3 times in three cases. Additional resection was performed in two cases. The median operative time was 85.0 minutes, and the median pathological margin was 11.0 mm. The key advantages of this method are that all surgical processes can be completed in a single session, specialized skill sets are not required, and it is feasible to perform in any facility equipped with a hybrid operating room. To overcome its disadvantages, such as longer operating time and limited patient positioning, we devised various methods for positioning patients and for CT imaging of the resected specimens. OS-MRCH is a simple, useful, and practical method for performing thoracoscopic partial resection of nonpalpable lung tumors.

Perioperative intravenous lidocaine in thoracoscopic surgery for improved postoperative pain control: a randomized, placebo-controlled, double-blind, superiority trial

Background

Pain, including associated pain management, remains a burden on patients after thoracic surgery. Our objective was to investigate whether perioperative intravenous administration of lidocaine reduces postoperative morphine consumption and pain intensity after video-assisted thoracoscopic surgery (VATS).

Methods

In this double-blind, placebo-controlled superiority trial, patients undergoing VATS with a planned duration of ≤90 minutes were randomized within an intention-to-treat setting. Patients received either intravenous lidocaine or placebo as a bolus of 1.5 mg/kg 30 minutes before incision, followed by a continuous infusion of 3.0 mg/kg/hour until 2 hours after skin closure. Pain and morphine consumption were evaluated when resting and when coughing 1, 2, 4, 8, 16, 24, and 48 hours after skin closure and in a follow-up 14, 90, and 180 days postoperatively.

Results

Twenty-eight patients were included in the lidocaine group, 24 in the placebo group. Patients' characteristics and preoperative pain scores were similar in both groups. When coughing, patients of the lidocaine group had less pain within 24 hours after skin closure than the placebo group (4.60±1.64 vs. 5.52±1.65; P=0.02). Morphine consumption was not statistically significantly lower in lidocaine group (18.22±12.87 vs. 21.26±9.39 mg; P=0.26). There were no significant differences between groups in secondary outcomes.

Conclusions

Our results suggest that perioperative intravenous lidocaine administration reduces pain scores after VATS. The beneficial clinical effects are limited. Nevertheless, intravenous lidocaine may be helpful as part of a multimodal analgesia protocol or with patients in whom the use of other analgesics is contraindicated.

Trial Registration

ClinicalTrials.gov NCT03677817.

Perioperative morbidity and 3-year survival in non-intubated thoracoscopic surgery: a propensity matched analysis

Background

Non-intubated thoracoscopic surgery with spontaneous breathing is rarely utilized, but may have several advantages over standard intubation, especially in those with significant cardiopulmonary comorbidities. In this study we evaluate the safety, feasibility, and 3-year survival of thoracoscopic surgery without endotracheal intubation for oncologic and non-oncologic indications.

Methods

All consecutive patients [2018-2022] selected for lung resection or other pleural space intervention under local anesthesia and sedation were compared to a cohort undergoing elective thoracoscopic procedures with endotracheal intubation. A propensity-score matched cohort was used to compare perioperative outcomes and 3-year overall survival.

Results

A total of 72 patients underwent thoracoscopic surgery without intubation compared to 1,741 who were intubated. Non-intubated procedures included 19 lobectomies (26.4%), 9 segmentectomies (12.5%), 25 wedge resections (34.7%), and 19 pleural or mediastinal resections (26.4%). Non-intubated patients had a lower average body mass index (BMI; 24.6 vs. 27.1 kg/m2, P<0.001) and a higher comorbidity burden. Primary lung cancer was the indication in 30 (41.7%) non-intubated patients. The non-intubated cohort had no operative or 30-day mortality. After propensity-score matching, there was no significant difference in pre-operative factors. In propensity-score matched analysis, non-intubated patients had shorter median total operating room time (109 vs. 159 min, P<0.001) and procedure time (69 vs. 119 min, P<0.001). Peri-operative morbidity was rare and did not differ between intubated and non-intubated patients. There was no significant difference in 3-year survival associated with non-intubation in the propensity-score matched cohorts (95% vs. 89%, P=0.10) or in a Cox proportional hazard model [hazard ratio (HR), 1.15; 95% confidence interval (CI): 0.36-3.67; P=0.81].

Conclusions

Non-intubated thoracoscopic surgery is safe and feasible in carefully selected patients for both benign and oncologic indications.

Evaluating postoperative recovery in uniportal versus needlescopic video-assisted thoracoscopic surgery for primary spontaneous pneumothorax: a comparable study

Objectives

Primary spontaneous pneumothorax (PSP) is a common disease in young and thin male. Operation has been regarded as definitive treatment for it. However, the operative methods for those patients are under dispute. This study aims to directly compare the outcomes of uniportal VATS vs. needlescopic VATS in the treatment of PSP, focusing on postoperative pain and safety outcomes.

Methods

From July 2013 to December 2017, the patients who underwent video-assisted thoracic surgery for pneumothorax in National Taiwan University Hospital were retrospectively collected. The preoperative condition, surgical results, and postoperative outcomes was analyzed.

Results

There were 60 patients undergoing needlescopic VATS and 91 undergoing uniportal VATS during the study period. There was no significant difference between the patients who underwent needlescopic VATS and those who underwent uniportal VATS in their demographic and clinical characteristics. The post-operative pain score was significantly lower in the uniportal VATS group compared to the needlescopic VATS group at day 1 (2.65 ± 1.59 vs. 1.74 ± 1.35, p = 0.001).

Conclusion

Uniportal VATS offers an effective, safe alternative for PSP treatment, with benefits including reduced post-operative pain. Our findings support the use of uniportal VATS, supplemented by a wound protector, as a viable option for PSP patients.

Comparison of safety and anxiety/depression in computed tomography-guided hook-wire localization versus electromagnetic navigation bronchoscopy-guided localization: a retrospective cohort study

Background

The utilization of computed tomography (CT)-guided localization and electromagnetic navigation bronchoscopy (ENB)-guided localization has gained significant traction in the localization of pulmonary nodules before video-assisted thoracoscopic surgery (VATS). This study aimed to ascertain the precision and safety of the two groups in the preoperative resection of isolated nodules in small peripheral lungs. Furthermore, we examined the subsequent outcomes pertaining to the decline in lung function and alterations in anxiety and depression following resection utilizing both localization techniques.

Methods

A total of 177 patients with small-sized pulmonary nodules, scheduled to undergo video-assisted thoracoscopic limited resection, were enrolled in this study. The study involved the examination and comparison of pertinent findings obtained through the utilization of CT-guided hook-wire or ENB injection techniques.

Results

The nodules were localized by ENB in 57 patients and by CT guidance in 120 patients. There were no significant complications in ENB-guided localization group (0/57). CT-guided hook-wire localization group had more complications (61/120, P<0.001). There was no disparity observed in pulmonary function decline 3 months post-operation between the two cohorts. The analysis of postoperative Hospital Anxiety and Depression Scale (HADS) scores indicated that the CT-guided localization group exhibited higher anxiety and depression scores on the initial day and 2 weeks following surgery.

Conclusions

ENB-guided and CT-guided localization can effectively identify solitary pulmonary nodules. ENB-guided localization has fewer complications, lower incidence of adverse events, and less impact on postoperative anxiety or depression, suggesting that this is a promising, safe, and feasible method for localization of solitary pulmonary nodules.

Agreement between observed and predicted postoperative forced expiratory volume in one second, forced vital capacity, and diffusing capacity for carbon monoxide after anatomic lung resection

Background

Despite its importance in clinical practice, clinical guideline pathway selection and as an outcome in clinical trials, little work has been undertaken to understand the agreement between expected lung function loss and actual observed values. This is particular pertinent in view of the unexpected findings of JCOG 0802 and CALBG 140503 demonstrating no clinically meaningful difference in lung function loss between the sub-lobar resection and lobectomy arm.

Methods

We performed a retrospective analysis on preoperative and postoperative forced expiratory volume in one second (FEV1), forced vital capacity (FVC) and diffusing capacity for carbon monoxide (DLCO) collated from 158 patients who underwent anatomical lung resection between January 2013 to July 2023. Patient's true preoperative and postoperative lung function was obtained via formal lung function testing while predicted postoperative lung function was derived using the 20-segment counting method. Longitudinal postoperative lung function analysis demonstrated sufficient stability over time. A formal testing of agreement between predicted and true postoperative lung function was undertaken using the Bland and Altman method and graphically demonstrated using scatter plots. We defined a deviation of more than 5% as a clinically minimally important difference.

Results

Scatter plots for effort-dependent measures suggested the tendency for underprediction (observed values were higher than predicted) for FEV1 and FVC but good agreement for DLCO. Formal agreement confirmed mean difference for FEV1 was -9.84% [95% confidence interval (CI): -39.33% to 19.65%], FVC -11.39% (95% CI: -50.14% to 27.36%) and DLCO -4.83% (95% CI: -25.59% to 15.92%).

Conclusions

Our study demonstrated that effort-dependent parameters of lung function including FEV1 and FVC tends to overestimate the amount of lung function loss after anatomic lung resection, clinicians should be cautious in using these measures to determine suitability of surgery based on current established guidelines. However, independent measures such as DLCO demonstrate good agreement suggesting that predicted lung tissue loss is consistent with a 20-segment lung model.

Surgical lung biopsy for suspected interstitial lung disease with video-assisted thoracoscopic surgery is safe, providing exact histological and disease specific diagnosis for tailoring treatment

Background

Surgical lung biopsy (SLB) is required for diagnosis in patients with suspected interstitial lung disease (ILD) if other less invasive diagnostic methods are non-conclusive. We evaluated the outcome of SLB by using centralized databases in a whole-nation patient-cohort.

Methods

A population-based retrospective study on 68 consecutive patients (mean age 58 years, 58.8% males) that underwent SLB in Iceland between the years 2008 and 2020. Patient information was obtained from patient charts and peri- and postoperative complications were registered together with 30- and 90-day mortality. Computed tomography (CT) scans, histological biopsies and spirometry results were reviewed, and overall survival (Kaplan-Meier) estimated. Mean follow-up was 61.3 months (range, 3-155 months).

Results

Out of 68 SLB-patients 41 (60.3%) had preoperatively undergone non-conclusive transbronchial biopsies (TBB) obtained with bronchoscopy. Spirometry showed forced vital capacity (FVC) 3.0 L and forced expiratory volume in 1 second (FEV1) 2.3 L, or 73.0% and 71.6% of predicted value, respectively. Video-assisted thoracoscopic surgery (VATS) technique was used in all cases and provided a histologic and disease specific diagnosis in 92.6% of cases; most often being nonspecific interstitial pneumonia (NSIP) (29.4%) and usual interstitial pneumonia (UIP) (23.5%). One patient (1.5%) sustained a major postoperative complication (excessive bleeding) and seven patients (10.3%) minor complications. Median chest tube time and length of stay was 1 and 2 days, respectively. No patients died <90 days postoperatively. Overall survival at 1 and 5 years was 95.6% and 73.5%, respectively, and 5-year survival for NSIP and UIP was 85% and 43.7%, respectively. Long-term mortality for UIP was four times higher when compared with NSIP and other diagnosis.

Conclusions

Lung biopsy with VATS-technique provided a definitive histological and disease specific diagnosis in majority of cases. The procedure is safe, reflected in low complication-rates and short hospital stay, and can therefore be used to diagnose and tailor treatment of ILD patients.

Influencing Factors on Intersegmental Identification Adequacy in Segmentectomy with Intraoperative Indocyanine Green (ICG) Intravenous Administration

Accurate identification of the intersegmental plane is essential in segmentectomy, and Indocyanine Green (ICG) assists in visualizing lung segments. Various factors, including patient-related, intraoperative, and technical issues, can influence boundary delineation. This study aims to assess the rate of unsuccessful intersegmental identification and identify the contributing factors. We analyzed cases of lung segmentectomy from April 2020 to March 2023, where intraoperative ICG was intravenously administered during robot-assisted or video-assisted thoracoscopic surgery. Cases where fluorescence extended beyond expected boundaries within 30 s were classified as the "unclear boundary group". This group was then compared to the "clear boundary group". The study encompassed 111 cases, 104 (94%) of which were classified under the "clear boundary group" and 7 (6%) under the "unclear boundary group". The "unclear boundary group" had a significantly lower DLCO (15.7 vs. 11.8, p = 0.03) and DLCO/VA (4.3 vs. 3.0, p = 0.01) compared to the "clear boundary group". All cases in the "unclear boundary group" underwent lower lobe segmentectomy. ICG administration effectively outlines pulmonary segments. Challenges in segment demarcation may occur in cases with low DLCO and DLCO/VA values, particularly during lower lobe segmentectomy.

Enhanced efficacy of a novel aspirator in uniportal video-assisted thoracoscopic mediastinal lymph node dissection: a non-randomized prospective clinical trial

Background

Video-assisted thoracoscopic surgery (VATS) is the standard approach in early-stage non-small cell lung cancer (NSCLC) and surgical aspirators play a crucial role. Traditional aspirators lack the ability to pull and lift tissue and cannot achieve optimal exposure. Therefore, we designed a new surgical aspirator that combined the function of thoracoscopic forceps. In this study, we aimed to validate the efficacy and safety of this new surgical aspirator.

Methods

We performed a prospective non-randomized intervention trial and enrolled 504 consecutive patients scheduled for uniportal VATS in early NSCLC requiring mediastinal lymph node dissection. A novel aspirator we developed with a clamping function via a front pliers-like structure was implemented in intervention group, whereas traditional aspirator was used in control group. Time spent for nodal dissection in No. 2/4R and No. 7R/L (No. 7 lymph nodes resected through right or left side) lymph nodes and perioperative adverse events related to lymph node dissection were recorded. Mann-Whitey U test was applied to analyze sex and pathological type, an independent-samples t-test was applied to analyze surgery time and age.

Results

In total, 250 of enrolled patients were allocated into traditional aspirator group and 254 of them were allocated into new aspirator group. Surgeons spent 544.71±120.80 (range, 332-917, median 541) seconds dissecting No. 2/4R lymph nodes with traditional aspirators and 507.54±100.00 (range, 348-702, median 520) seconds dissecting with new aspirators (P=0.008). The traditional aspirator group had an average surgery time of 507.11±104.61 (range, 310-785, median 510) seconds for No. 7R lymph nodes and 608.47±128.50 (range, 397-919, median 606) seconds for No. 7L lymph nodes, while that in the new aspirator group was 465.09±94.94 (range, 271-744, median 476) seconds (P=0.001) and 549.39±102.11 (range, 368-782, median 538) seconds (P<0.001). The new aspirator showed an efficacy advantage in mediastinal lymph node dissection in VATS, without additional risk.

Conclusions

This is the first report about a new suction device combining the functions of both traditional surgical aspirators and forceps, which can effectively shorten the time of mediastinal lymph node dissection and improve the efficiency of thoracoscopic surgery without increasing lymph node dissection-related adverse events.

Comparison of Quality of Life after Robotic, Video-Assisted, and Open Surgery for Lung Cancer

Post-operative quality of life (QOL) has become crucial in choosing operative approaches in thoracic surgery. However, compared to VATS and thoracotomy, QOL results post-RATS are limited. We compared QOL before and after RATS and between RATS, VATS, and thoracotomy. We conducted a retrospective review of lung cancer surgical patients from 2015 to 2020. Patients completed validated EORTC QOL questionnaires (QLQ-C30 and QLQ-LC13). Results were analysed using the EORTC Scoring Guide, with statistical analysis. A total of 47 (94%) pre- and post-RATS questionnaires were returned. Forty-two patients underwent anatomical lung resections. In addition, 80% of patients experienced uncomplicated recovery. All global and functional QOL domains improved post-operatively, as did most symptoms (13/19). Only four symptoms worsened, including dyspnoea (p = 0.017), with two symptoms unchanged. Of the 148 returned questionnaires for all approaches (open-22/VATS-79/RATS-47), over 70% showed a high pre-operative performance status. Most patients underwent anatomical lung resection, with only VATS patients requiring conversion (n = 6). Complications were slightly higher in RATS, with one patient requiring re-intubation. RATS patients demonstrated the highest global and functional QOL. Physical QOL was lowest after thoracotomy (p = 0.002). RATS patients reported the fewest symptoms, including dyspnoea (p = 0.046), fatigue (p < 0.001), and pain (p = 0.264). Overall, RATS results in a significantly better post-operative QOL and should be considered the preferred surgical approach for lung cancer patients.

Right upper lobe segmentectomy and subsegmentectomy guided by classification pattern of peripheral segmental veins

Background

Studies have analyzed the simplified branching pattern of peripheral segmental veins and developed a standardized approach for intersegmental vein identification in the right upper lobe (RUL). However, the identification approach of intersubsegmental veins has not been reported. This study aimed to supplement the identification approach of intersubsegmental veins and the classification pattern of peripheral segmental veins by using three-dimensional computed tomography bronchography and angiography (3D-CTBA).

Materials and methods

A total of 600 patients with ground glass opacity (GGO) who had undergone 3D-CTBA preoperatively at Hebei General Hospital between September 2020 and September 2022 were used for the retrospective study. We reviewed the anatomical variations of RUL veins in these patients using 3D-CTBA images.

Results

According to the anatomical position, the peripheral segmental veins structures of RUL were classified into five categories: "Iab type of anterior with central vein" (256/600, 42.7%), "Ib type of anterior with central vein" (166/600, 27.7%), "Central vein type" (38/600, 6.3%), "Anterior vein type" (81/600, 13.5%), "Right top pulmonary vein type" (57/600, 9.5%). The approach for intersegmental vein and intersubsegmental veins identification was divided into five types: anterior approach, posterobronchial approach, central vein approach, V2t approach, and intermediate bronchus posterior surface approach.

Conclusions

The classification pattern of peripheral segmental veins should find wide application. Further, approaches identifying intersegmental veins and intersubsegmental veins may help thoracic surgeons perform safe and accurate RUL segmentectomy.

Computed tomography-guided hookwire localization and medical glue combined with methylene blue localization for pulmonary nodules before video-assisted thoracoscopic surgery: a single-center, retrospective study

Background

The aim of this study was to investigate the safety and efficacy of computed tomography (CT)-guided hookwire localization and new CT-guided medical glue combined with methylene blue (MGMB) localization before video-assisted thoracoscopic surgery (VATS) for solitary pulmonary nodules (SPNs) and to analyze the risk factors for complications after localization.

Methods

A total of 620 patients, comprising 727 SPNs, admitted to the Department of Thoracic Surgery of the First Hospital of the University of Science and Technology of China between December 2019 and July 2022 were retrospectively studied and case-control analyzed. According to the localization method, 620 patients were divided into the hookwire group (n=310) and MGMB group (n=310). The localization time, localization-to-surgery interval, operative time, length of hospitalization, and complication rate were compared between the 2 groups. Logistic regression was used to analyze the risk factors for the occurrence of complications in each group of localization methods.

Results

Compared to the hookwire group, the MGMB group had a shorter localization time (8.59±3.69 vs. 7.35±2.99 min; P<0.001), shorter hospital stay (5.60±2.13 vs. 6.73±2.86 days; P<0.001), and shorter operative time (103.48±54.11 vs. 98.59±49.92 min; P=0.33). The preoperative localization success rate was 99.4% (355/357) and 100% (370/370) in the hookwire group and MGMB group, respectively. No death or serious complications occurred during the localization process, but the overall complication rate was lower in the MGMB group (69/310, 22.3%) than in the hookwire group (105/310, 33.9%) (P<0.001). Logistic regression analysis showed that age, number of nodules, and localization time were risk factors for total complications, while localization technique was a protective factor for total complications [odds ratio =0.590; 95% confidence interval (CI): 0.405-0.860; P<0.05].

Conclusions

Both techniques could effectively locate SPNs before VATS; however, MGMB localization was found to be associated with a lower complication rate, shorter localization time, better safety, and higher potential clinical value and is thus worthy of clinical promotion.

Risk factors for the recurrence of primary spontaneous pneumothorax after video-assisted thoracoscopic surgery in patients younger than 40 years

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) is a standard primary spontaneous pneumothorax (PSP) procedure. However, its high recurrence rate compared to open thoracotomy is a problem. Therefore, various methods to prevent recurrence have been developed. The present study investigated the risk factors for postoperative recurrence of PSP after VATS.

METHODS

From January 2008 to November 2022, 207 patients younger than 40 years of age without underlying pulmonary disease underwent thoracoscopic bullectomy for PSP. Among them, 96 underwent staple line reinforcement with a polyglycolic acid (PGA) sheet and autologous blood spraying. Patient characteristics and surgical outcomes were analyzed to determine the prognostic factors for postoperative recurrence.

RESULTS

Twenty-seven patients (13.0%) experienced recurrences. A multivariate analysis using Cox regression analysis revealed that age younger than 20 years [P=0.039; hazard ratio (HR) =2.337; 95% confidence interval (CI): 3.283-17.287], history of contralateral pneumothorax (P<0.001; HR =7.533; 95% CI, 1.486-12.336), and no staple line reinforcement (P=0.007; HR =4.282; 95% CI, 1.043-5.236) were risk factors for recurrence after pneumothorax surgery.

CONCLUSIONS

Age younger than 20 years and history of contralateral pneumothorax were risk factors for postoperative recurrence of pneumothorax. Staple line reinforcement with a PGA sheet and spraying of autologous blood reduced the postoperative recurrence rate of PSP.

Preoperative CT-guided localization of pulmonary nodules with low-dose radiation

Background

Video-assisted thoracoscopic surgery (VATS) has been widely accepted for the treatment of pulmonary nodules. Prior to VATS, pulmonary nodules can be labeled by computed tomography (CT)-guided hook wire localization, but multiple scans are required, which increases the total radiation dose. We aimed to assess the effectiveness and risks of using low-dose radiation CT to locate lung nodules prior to VATS.

Methods

This study included 158 patients who underwent VATS resection after CT-guided hook wire localization. Based on the CT tube voltage, patients were split into two groups: the low-voltage group (Group A) received 80 kV, while the high-voltage group (Group B) received 120 kV. The two groups' image quality, radiation exposure, localization success and complication rates were compared. The frequencies of intraoperative complications and the types of lung nodules were also compared between the groups.

Results

Successful nodule mapping was obtained in 158 patients. There was no significant difference in age, sex ratio or BMI between the two groups. Subjective imaging quality in both groups met the requirements for location (≥2 points). The signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) in Group A were lower than those in Group B (P<0.05). Furthermore, the dose length product (DLP) and effective dose (ED) in Group A were lower than those in Group B (P<0.05).

Conclusions

Low-dose radiation CT-guided localization is safe and feasible for identifying uncertain pulmonary nodules before VATS, enabling a significant radiation dose reduction while maintaining mapping accuracy and not increasing complication risk.

Analyzing the impact of minimally invasive surgical approaches on post-operative outcomes of pneumonectomy and sleeve lobectomy patients

BACKGROUND

Some patients with non-small cell lung cancer (NSCLC) have superior short- and long-term outcomes with sleeve lobectomy rather than pneumonectomy. Originally sleeve lobectomy was reserved for patients with limited pulmonary function, however, the reported superior results allowed sleeve lobectomy to be performed in expanded patient populations. In a further attempt to improve post-operative outcomes surgeons have adopted minimally invasive techniques Minimally invasive approaches have potential benefits to patients such as decreased morbidity and mortality while maintaining the same caliber of oncologic outcomes.

METHODS

We identified patients at our institution who underwent sleeve lobectomy or pneumonectomy to treat NSCLC from 2007 to 2017. We analyzed these groups in respect to 30- and 90-day mortality, complications, local recurrence, and median survival. We included multivariate analysis to determine the impact of a minimally invasive approach, sex, extent of resection, and histology. Differences in mortality were analyzed using the Kaplan-Meier method using the log-rank test to compare the groups. A two-tailed Z test for difference in proportions was done to analyze complications, local recurrence, 30-day and 90-day mortality.

RESULTS

A total of 108 patients underwent sleeve lobectomy (n=34) or pneumonectomy (n=74) for treatment of NSCLC with 18 undergoing open pneumonectomy, 56 undergoing video-assisted thoracoscopic surgery (VATS) pneumonectomy, 29 undergoing open sleeve lobectomy, and 5 undergoing VATS sleeve lobectomy. There was no significant difference in 30-day mortality (P=0.064) but there was a difference in 90-day (P=0.007). There was no difference in complication rates (P=0.234) or local recurrence rates (P=0.779). The pneumonectomy patients had a median survival of 23.6 months (95% CI: 3.8-43.4 months). The sleeve lobectomy group had a median survival of 60.7 months (95% CI: 43.3-78.2 months) (P=0.008). On multivariate analysis extent of resection (P<0.001) and tumor stage (P=0.036) were associated with survival. There was no significant difference between the VATS approach and the open surgical approach (P=0.053).

CONCLUSIONS

When considering patients undergoing surgery for NSCLC sleeve lobectomy resulted in lower 90-day mortality and better 3-year survival compared to patients undergoing PN. Having a sleeve lobectomy rather than a pneumonectomy and having earlier-stage disease lead to significantly improved survival on multivariate analysis. Having a VATS operation leads to a non-inferior post-operative outcome compared to open surgery.

Analysis of bronchovascular patterns in the left superior division segment to explore the relationship between the descending bronchus and the artery crossing intersegmental planes

Background

A comprehensive understanding of the anatomical variations in the pulmonary bronchi and arteries is particularly essential to the implementation of safe and precise left superior division segment (LSDS) segmentectomy. However, no report shows the relationship between the descending bronchus and the artery crossing intersegmental planes. Thus, the purpose of the present study was to analyze the branching pattern of the pulmonary artery and bronchus in LSDS using three-dimensional computed tomography bronchography and angiography (3D-CTBA) and to explore the associated pulmonary anatomical features of the artery crossing intersegmental planes.

Materials and methods

The 3D-CTBA images of 540 cases were retrospectively analyzed. We reviewed the anatomical variations of the LSDS bronchus and artery and assorted them according to different classifications.

Results

Among all 540 cases of 3D-CTBA, there were 16 cases (44.4%) with lateral subsegmental artery crossing intersegmental planes (AX³a), 20 cases (55.6%) Without AX³a in the descending B³a or B³ type, and 53 cases (10.5%) with AX³a, 451 cases (89.5%) Without AX³a in the Without the descending B³a or B³ type. This illustrated that the AX³a was more common in the descending B³a or B³ type (P < 0.005). Similarly, there were 69 cases (36.1%) with horizontal subsegmental artery crossing intersegmental planes (AX^{1 + 2}c), 122 cases (63.9%) Without AX^{1 + 2}c in the descending B^{1 + 2}c type, and 33 cases (9.5%) with AX^{1 + 2}c, 316 cases (90.5%) Without AX^{1 + 2}c in the Without the descending B^{1 + 2}c type. Combinations of the branching patterns of the AX^{1 + 2}c and the descending B^{1 + 2}c type were significantly dependent (p < 0.005). The combinations of the branching patterns of the AX^{1 + 2}c and the descending B^{1 + 2}c type were frequently observed.

Conclusions

This is the first report to explore the relationship between the descending bronchus and the artery crossing intersegmental planes. In patients with the descending B³a or B³ type, the incidence of the AX³a was increased. Similarly, the incidence of the AX^{1 + 2}c was increased in patients with the descending B^{1 + 2}c type. These findings should be carefully identified when performing an accurate LSDS segmentectomy.

The detailed classification of the interlobar artery and the artery crossing intersegmental planes in the right upper lobe

Background

With the prevalence of three-dimensional computed tomography bronchography and angiography (3D-CTBA) and the development of anatomical segmentectomy, several studies have analyzed the branching patterns of peripheral segmental arteries in the right upper lobe (RUL). Nevertheless, the detailed classification of the branching patterns of the interlobar artery and the artery crossing intersegmental planes remains unknown. Thus, we conducted a retrospective study to analyze the variations of the interlobar artery and the artery crossing intersegmental planes in the RUL using 3D-CTBA.

Materials and methods

A total of 600 patients with ground-glass opacity (GGO) who had undergone 3D-CTBA preoperatively at Hebei General Hospital between September 2020 and September 2022 were used for the retrospective study. We reviewed the anatomical variations of the RUL arteries in these patients using 3D-CTBA images.

Results

The branching patterns of the RUL artery were classified into the following four categories: trunk superior (Tr. sup), Tr. sup + interlobar artery, Tr. sup + trunk inferior (Tr. inf), and Tr. sup + Tr. inf + interlobar artery. The branching patterns of the interlobar artery were subclassified into four subtypes: posterior ascending artery (A. pos), anterior ascending artery (A. ant), A. pos + A. ant, and ascending artery (A. asc). The artery crossing intersegmental planes contains two types: type A, anterior subsegmental artery crossing intersegmental planes (AX¹b); type B, recurrent artery crossing intersegmental planes (AX. rec).

Conclusion

The variation types of blood vessels in the RUL are complex. This study explored the detailed classification of the interlobar artery and the artery crossing intersegmental planes. It can help thoracic surgeons understand the anatomy variations, accurately locate lesions before surgery, and effectively plan surgeries.

Thoracoscopic resection of a cavernous haemangioma of anterior mediastinum: case report and literature review

Background

Mediastinal haemangioma is a rare type of tumour and accounts for ≤0.5% of all mediastinal tumours. Mediastinal haemangioma is often nonspecific upon examination by imaging. Mediastinal haemangioma diagnosis is difficult to confirm before surgery because the characteristic features of diagnostic imaging are poor, and these lesions are extremely rarely encountered in clinical practice.

Case Description

We herein report a case of thoracoscopic resection of a cavernous haemangioma in the anterior mediastinum. A 40-year-old man was referred to our hospital for a health examination. A chest computed tomography scan showed a mass with irregular contrast enhancement and a smooth surface. Using video-assisted thoracoscopic surgery, the tumour was completely extirpated and confirmed histologically to be a cavernous haemangioma. The patient recovered well, was discharged, he has since had no recurrences, and continues to be closely monitored as an outpatient.

Conclusions

Mediastinal haemangiomas, a rare type of mediastinal tumour, are typically benign and located in the anterior mediastinum, and lack specific symptoms and relevant imaging features. We found that minimally invasive thoracoscopic resection provided a satisfactory view and facilitated correct handling of a mediastinal cavernous haemangioma. Although such tumours are mostly benign and the prognosis is good, we recommend aggressive surgical management to avoid missing malignant lesions.

Preoperative umeclidinium/vilanterol or tiotropium improves postoperative FEV1 in lung cancer patients with comorbid untreated chronic obstructive pulmonary disease

Background

This study aimed to examine the effects of preoperative interventions in lung cancer patients with untreated chronic obstructive pulmonary disease (COPD). We evaluated the efficiency of preoperative interventions using tiotropium (TIO) or umeclidinium/vilanterol (UMEC/VI).

Methods

We conducted a two-center retrospective study. Perioperative forced expiratory volume in 1 second (FEV₁) was compared between a preoperative COPD intervention group and an untreated group. COPD therapeutic drugs were started 2 weeks before surgery and were continued until 3 months after surgery. Radical lobectomy was performed in patients with an FEV₁ of ≥1.5 L.

Results

A total of 92 patients were enrolled (untreated, 31 patients; intervention, 61 patients). In the intervention group, 45 (73.8%) patients were prescribed the UMEC/VI intervention and 16 (26.2%) received TIO. The intervention group showed a greater increase in FEV₁ than the untreated group (FEV₁: 120 vs. 0 mL, P=0.014). In the intervention group, the UMEC/VI group showed a greater increase in FEV₁ than the TIO group (FEV₁: 160 vs. 7 mL, P=0.0005). In 9 of 15 (60.0%) patients with an FEV₁ of <1.5 L before intervention, FEV₁ increased to ≥1.5 L after intervention. Postoperative FEV₁ in the intervention group was similar to that before intervention, unlike in the untreated group (-0.05 vs. -0.25 mL, P=0.0026). Moreover, the FEV₁ in the untreated group was similar to the preoperative predicted value, whereas that in the intervention group was significantly higher than the predicted value (+0.33 vs. +0.04 mL, P<0.0001).

Conclusions

In lung cancer patients with untreated COPD, active preoperative intervention improved respiratory function, expanded treatment options, and maintained respiratory function to a degree that exceeded preoperative predictions.

Uniportal vs. multiportal thoracoscopic segmentectomy: a north American study

Background

Uniportal video-assisted thoracoscopic surgery (VATS) segmentectomy is gaining worldwide acceptance, but experience in North America is still limited. We report a North American multicenter comparison of uniportal vs. multiportal VATS segmentectomy.

Methods

We performed an institutional review board-exempt retrospective chart review on prospectively collected databases at two North American centers, from January 2012 to December 2020. We included all VATS segmentectomy patients and excluded emergent cases (n=1), patients with incomplete records (n=2), and segmentectomy performed in conjunction with another type of lung resection (n=1). We recorded patient demographics, perioperative data, 30-day postoperative complications and compared outcomes between cohorts. We provided descriptive statistics for each group. We calculated propensity score matching and paired patients 1:1. We defined P values less than 0.05 as statistically significant.

Results

We performed a total of 423 VATS segmentectomies, 181 uniportal (42.7%) vs. 242 multiportal (57.2%). Indications for surgery were primary lung cancer (n=339), metastatic (n=41), benign disease (n=40), and other (n=3). We staged 85.1% of patients preoperatively with positron emission tomography-computed tomography (PET-CT) scan according to National Comprehensive Cancer Network (NCCN) guidelines. Propensity score matching generated 156 patients on each group. Operating time was significantly lower in the uniportal group compared to multiportal (130 vs. 161 min respectively, P<0.001). We found no difference in estimated blood loss, Clavien-Dindo class III-IV complications, conversion to thoracotomy, R0 resection rate, nodal upstaging, hospital length of stay, 30-day readmission or mortality.

Conclusions

Our experience from two North American centers indicates that, in experienced hands, postoperative outcomes after uniportal and multiportal VATS segmentectomy are comparable.

Chest tube-free video-assisted thoracoscopic surgery secured by quantitative air leak monitoring: a case series

Background

Although chest tube-omitted video-assisted thoracoscopic surgery (VATS) has been proven to be safe and efficacious, its universal application is precluded by a varying morbidity rate due to a lack of standardization. Since digital chest drainage has already shown improved accuracy and consistency in the management of postoperative air leak, we incorporated it in the strategy of intraoperative chest tube withdrawal, aiming to achieve better results.

Methods

We collected the clinical data of 114 consecutive patients who underwent elective uniportal VATS pulmonary wedge resection at the Shanghai Pulmonary Hospital from May 2021 to February 2022. Their chest tubes were withdrawn intraoperatively after an air-tightness test facilitated by digital drainage: the end flow rate had to be kept ≤30 mL/min for >15 s at the setting of -8 cmH₂O suctioning. The recordings and patterns of the air suctioning process were documented and analyzed as potential standards of chest tube withdrawal.

Results

The mean age of the patients was 49.7±11.7 years. The mean size of the nodules was 1.0±0.2 cm. The location of the nodules encompassed all lobes, and 90 (78.9%) patients received preoperative localization. The postoperative morbidity and mortality rates were 7.0% and 0%, respectively. Six patients had clinically overt pneumothorax and two patients had postoperative bleeding that required intervention. All of the patients recovered on conservative treatment except for one case of pneumothorax that required additional tube thoracostomy. The median length of postoperative stay was 2 days; and the median time of suctioning, peak flow rate, and end flow rate were 126 s, 210 mL/min, and 0 mL/min, respectively. The median numeric rating scale for pain was 1 on postoperative day (POD) 1 and 0 on the day of discharge.

Conclusions

Chest tube-free VATS assisted by digital drainage is feasible with minimal morbidity. Its strength of quantitative air leak monitoring produces important measurements for the prediction of postoperative pneumothorax and future standardization of the procedure.

Analysis of variations in the bronchovascular pattern of the lingular segment to explore the correlations between the lingular segment artery and left superior division veins

Background

With the development of anatomical segmentectomy, the thoracic surgeons must master the anatomical variations of the pulmonary bronchi and vessels. However, there are only a few reports showing anatomic variations of the lingular segment (LS) using three-dimensional computed tomography bronchography and angiography (3D-CTBA). Thus, the present study aimed to analyze the bronchovascular patterns of the LS and explore the correlation between the lingular segment artery (LSA) and left superior division veins (LSDV).

Materials and methods

The 3D-CTBA data of the left upper lobe (LUL) were collected from patients who had undergone lobectomy or segmentectomy at Hebei General Hospital between October 2020 and October 2022. We reviewed the clinical characteristics and variations in bronchi and pulmonary vessels and grouped them according to different classifications.

Results

Among all 540 cases of 3D-CTBA, the branching patterns of LSA included 369 (68.3%) cases with the interlobar origin, 126 (23.3%) cases with the interlobar and mediastinal origin, and 45 (8.3%) cases with the mediastinal origin. The branching pattern of LSDV could be classified into three forms: Semi-central vein type (345/540, 63.9%), Non-central vein type (76/540, 14.1%), and Central vein type (119/540, 22.0%). There were 51 cases (9.4%) with Non-central vein type, 50 cases (9.3%) with Central vein type, 268 cases (49.6%) with Semi-central vein type in the interlobar type, and 7 cases (1.3%) with Non-central vein type, 9 cases (1.7%) with Central vein type, 29 cases (5.4%) with Semi-central vein type in the mediastinal type. Moreover, the Non-central vein type, the Central vein type, and the Semi-central vein type accounted for 18 (3.3%), 60 (11.1%), and 48 (8.9%) in the interlobar and mediastinal type. Combinations of the branching patterns of the LSA and LSDV were significantly dependent (p < 0.005). The combinations of the interlobar and mediastinal type with the Central vein type, and the interlobar type and the mediastinal type with the Semi-central vein type were frequently observed.

Conclusions

This study found the relationship between the LSA and LSDV and clarified the bifurcation patterns of the bronchovascular in the LS. Our data can be used by thoracic surgeons to perform safe and precise LS segmentectomy.

Role of subxiphoid uniportal video-assisted thoracoscopic surgery in pulmonary metastasectomy

Optimal management for patients with pulmonary metastasis is still debated. True survival benefit from widely practiced pulmonary metastasectomy (PM) is yet to be proved from high-quality randomized controlled trials. The ideal surgical approach for PM is also not generally agreed. VATS offers enhanced recovery and superior functional outcomes but at the expense of less detection of lung nodules and higher possibility of narrow/positive resection margins. The subxiphoid uniportal VATS (uVATS) approach is an evolving new approach with potential advantages including simultaneous access to both lung fields, less pain and faster rehabilitation. These advantages make it a favorable approach for PM, particularly in the setting of bilateral metastases. However, its use is still limited to case reports of a small number of patients. There is room for improvements in subxiphoid uVATS due to reported technical challenges and limitations. Herein, we aim to publicize a comprehensive review of literature on applications of subxiphoid uVATS in PM.

Current perspective on uniportal and multiportal video-assisted thoracic surgery during lobectomy for lung cancer

Non-small cell lung cancer (NSCLC) is the most typical type of lung cancer, and it is the leading cancer-related mortality globally. Lobectomy for early-stage NSCLC has been characterized in the previous decade using a wide range of methodologies. The development of video-assisted thoracoscopic surgery (VATS) allowed surgeons first to reduce the thoracotomy size, which is generally anterior, limiting it to trocar incisions or a single portal approach. This review aimed to describe current perspectives on operative outcomes, lymph node removal, oncologic outcomes, and advantages for surgeons performing uniportal VATS (uVATS) and multiportal (mVATS) lobectomy. The advantages of uVATS include comfortable operating for surgeons with a direct view and safety, and for patients more favourable operative outcomes. Also, the uVATS approach has previously been demonstrated to be effective and safe, with positive outcomes not just with respect to cosmetics but also in terms of a speedy recovery. Oncological uVATS clearance is comparable to multiportal VATS with respect to early mid-term survivability as well as nodal staging, as per retrospective comparison studies. However, the interpretation of outcomes must be made cautiously due to selection bias as well as lack of long-term follow-up; the choice of which VATS approach to utilize for patients' treatment following pulmonary resection is largely based on the preferences of the surgeon. As a result, it is difficult to say if one VATS method is better than another.

The improved success rate and reduced complications of a novel localization device vs. hookwire for thoracoscopic resection of small pulmonary nodules: a single-center, open-label, randomized clinical trial

Background

In our previous study, we developed a 4-hook claw-suture localization device for pulmonary nodule resection, which acheived satifisfactory results. Following this, we conducted this single-center, open-label, randomized clinical trial to compare the success rate and complication rate of this novel localization device and currently widely-used hookwire.

Methods

Patients with small pulmonary nodules (0.4-1 cm) who received preoperative localization and thoracoscopic resection at Shanghai Chest Hospital were randomly assigned (1:2 ratio, via computer-generated randomized numbers) to undergo localization using either a novel claw-suture system (claw group) or classical (hookwire group) localization device. The primary endpoint of this study was localization success rate, and the secondary endpoints included complications, localization-related time, and pain.

Results

A total of 411 patients were randomly assigned to the claw group (n=136) or the hookwire group (n=275) before thoracoscopic resection of small pulmonary nodules and analyzed. Compared with the hookwire group, the claw group had a significantly higher success rate (133/136, 97.8% vs. 254/275, 92.4%, P=0.027), less asymptomatic hemorrhage (16.9% vs. 37.5%, P=0.003) and pleural reaction (0% vs. 5.1%, P=0.017), as well as better pain alleviation 10 min after localization (measured using the difference between two visual analog scale scores, 0.84±0.98 vs. 0.35±0.79, P<0.001). In contrast, the hookwire group was associated with a shorter localization procedure duration than the claw group (7.2±2.9 vs. 14.4±6.6 min, P<0.001). In the multiple localization subgroup, the claw group compared to the hookwire group also achieved higher success (32/33, 97.0% vs. 70/86, 81.4%) and less pleural reaction (0% vs. 16.3%).

Conclusions

The new claw-suture localization device is superior to traditional hookwire, with a higher success rate, fewer complications, and better patient tolerance for preoperative localization of small pulmonary nodules.

Trial Registration

Chinese Clinical Trial Registry ChiCTR1900027346.

Management of descending necrotizing mediastinitis with severe thoracic empyema using minimally invasive video-assisted thoracoscopic surgery: a case report

BACKGROUND

Descending necrotizing mediastinitis (DNM) is a rare but serious complication of odontogenic or pharyngeal infection spreading into the mediastinum. Very few childhood cases of DNM have been described.

CASE DESCRIPTION

We report a case of DNM complicated with severe thoracic empyema in a previously healthy 6-year-old girl who was successfully treated using minimally invasive video-assisted thoracoscopic surgery (VATS). The patient presented with odynophagia and dental pain, followed by rapid clinical deterioration including high fever, tachypnea, and left chest pain. As chest computed tomography (CT) revealed features of DNM, she was transferred from the local hospital to our hospital for intensive care. Empirical treatment was started with meropenem and linezolid. However, her tachypnea and dyspnea progressed rapidly. An ultrasound-guided left-sided thoracentesis drained 80 mL of brown sticky pus and the pus culture yielded Streptococcus constellatus. A contrast-enhanced CT scan demonstrated large mediastinal abscess and severe thoracic empyema. We performed debridement and drainage of the mediastinum and pleura using VATS. She recovered and was discharged on hospital day 18.

CONCLUSIONS

Early diagnosis by cervicothoracic CT and multidisciplinary approaches including intensive care, broad-spectrum antibiotics, and aggressive surgical intervention are crucial to reducing morbidity and mortality. VATS is a minimally invasive and appropriate treatment strategy for children with DNM, especially complicated with thoracic empyema.

Efficacy of the intraoperative opioid-sparing anesthesia on quality of patients' recovery in video-assisted thoracoscopic surgery: a randomized trial

Background

We aimed to explore the impact of opioid-sparing anesthesia on patients' quality of recovery after video-assisted thoracoscopic surgery (VATS). We tested the primary hypothesis that our predefined opioid-sparing anesthesia provides better quality of patients' recovery compared to routine anesthesia in VATS.

Methods

Patients between 18 and 70 years, scheduled for elective VATS, had an American Society of Anesthesiologists (ASA) class I-III under general anesthesia, were randomly allocated to: routine anesthesia group and opioid-sparing anesthesia group. Patients in the opioid-sparing anesthesia group were mainly given preoperative thoracic paravertebral blockade with intraoperative withholding longer acting opioids. Patients in routine anesthesia group received opioid-based anesthesia. The primary outcome was the Quality of Recovery-15 scale (QoR-15) at 6 hours after surgery. The secondary outcomes included QoR-15 at 24 and 48 hours after surgery, Overall Benefit of Analgesia Score Satisfaction with pain treatment (OBAS) and acute pain intensity at 6, 24 and 48 hours after surgery, and clinical outcomes of recovery after surgery.

Results

A total of 159 patients were included in final analysis. The median difference in QoR-15 between opioid-sparing anesthesia and routine anesthesia was 4 (95% CI: 1-6) at 6 hours, 8 (95% CI: 4-12) at 24 hours and 4.7 (95% CI: 1-6) at 48 hours after surgery respectively; 73.4% of patient showed good recovery in opioid-sparing anesthesia group, compared to 53.8% in routine anesthesia group at 24 hours after surgery (P=0.01). Patients demonstrated lower OBAS in opioid-sparing anesthesia group compared to routine anesthesia at all time points after surgery (P<0.05). The pain at most was significantly lower in opioid-sparing anesthesia group compared to routine anesthesia at 6 and 48 hours after surgery (P<0.05). Patients exhibited faster recovery with opioid-sparing anesthesia on time to mobilize and time to first flatus (P<0.01).

Conclusions

Our intraoperative opioid-sparing anesthesia cannot improve patients' recovery at 6 hours after VATS lung surgery, but it demonstrates better outcomes at 24 hours after surgery compared to routine anesthesia, reaching to a clinically important difference.

Trial Registration

This study is registered in the Chinese Clinical Trial Registry, ChiCTR2000031609.

Efficacy of ultrasound-guided erector spinae plane block versus paravertebral block for postoperative analgesia in single-port video-assisted thoracoscopic surgery: a retrospective study

BACKGROUND

Thoracic paravertebral block (TPVB) is an analgesic method recommended in the enhanced recovery after surgery (ERAS) protocol and proven successful in thoracoscopic surgery. The study aimed to investigate whether the erector spinae plane block (ESPB) administered single-injection in uniportal video-assisted thoracoscopic surgery (VATS) can be an alternative to TPVB as an analgesic method.

METHODS

In this study, American Society of Anesthesiologists (ASA) physical status class I-II-III patients aged between 18-70 years who underwent thoracoscopic wedge resection surgery were analyzed retrospectively; 136 patients in the ESPB group and 114 patients in the TPVB group were included in the study. Postoperative cumulative morphine consumption numerical rating scale (NRS) scores were compared at 1, 6, 12, and 24 hours after surgery at rest and during coughing between the groups. Also, rescue analgesia requirements, postoperative nausea, vomiting and other complications were evaluated.

RESULTS

The mean cumulative morphine consumption in the postoperative 24 hours was 20.06 mg in the ESPB group and 11.35 mg in the TPVB group. A statistically significant difference was observed between groups in terms of total morphine consumption in the postoperative 24 hours (P<0.001). NRS score was significantly lower in the TPVB group at postoperative 6th and 24th hours during coughing (P=0.003 and P=0.034, respectively) and at 24th hour at rest (P=0.008) than ESPB group. Median NRS scores at rest were low (<4) in both groups. There was no significant difference between the groups in terms of postoperative pulmonary complications as atelectasis and length of hospital stay (LOS) (P=0.643 and P=0.867 respectively).

CONCLUSIONS

Ultrasound (US)-guided single-injection TPVB provided superior analgesia in patients undergoing single-port VATS than ESPB. In addition to this, TPVB showed more opioid sparing by reducing morphine consumption.

Efficacy and safety of video-assisted thoracoscopic surgery and thoracotomy in the treatment of pulmonary hydatid disease in the Tibetan Plateau: a retrospective study

Background

Although video-assisted thoracoscopic surgery (VATS) plays an increasingly significant part in treating thoracic disease, the role of thoracotomy is not replaced in cystic echinococcosis. The aim of this study was to demonstrate the application of VATS and traditional thoracotomy in the treatment of pulmonary hydatid disease in Shigatse of the Tibet Plateau and to compare the clinical safety and efficacy of these two surgical approaches.

Methods

A total of 53 patients with pulmonary hydatid who received thoracoscopic cystectomy with needle aspiration from January 2015 to December 2020 were enrolled in the study, and 126 patients who received thoracotomy during the same period were matched as the control group. The clinical characteristics, operative time, incidence of perioperative complications, length of stay, and hospitalization cost of the VATS and thoracotomy groups were analyzed to compare the safety and efficacy. Patients were followed up through telephone and outpatient service. In order to balance potential confounding baseline factors, propensity-score matching (PSM) was applied to establish a 1:1 VATS to thoracotomy group ratio.

Results

There were statistically significant differences between the VATS group and the thoracotomy group in operative time, blood loss, drainage volume, and postoperative hospital stay (P<0.05), with the VATS group being superior to the thoracotomy group. There were no significant differences in postoperative complications, adverse imaging outcomes, or recurrence rates between the 2 groups. In terms of complications, there was no significant difference in the incidence of postoperative air leakage, atelectasis, or other common complications between the 2 groups, while the frequency of postoperative fever and incision infection in the thoracotomy group was significantly higher than that in the VATS group (P<0.05). Moreover, the postoperative recurrence rate between the 2 groups showed no significant difference after a 3-year follow-up.

Conclusions

Compared to traditional thoracotomy, VATS had acceptable efficacy and safety and it could further accelerate postoperative recovery and reduce the cost in the treatment of pulmonary hydatid disease in the Tibetan Plateau. Thus, VATS should be promoted more widely to other Tibetan regions.

Surgical lung biopsy for interstitial lung diseases-a single center study of 129 patients

Background

According to guidelines for the diagnosis and treatment of interstitial lung diseases (ILDs), a diagnostic surgical lung biopsy should be used to obtain the differential diagnosis of an ILD in patients with ILDs, which are difficult to distinguish clinically. However, the risk of developing postoperative complications such as postoperative pulmonary fistula or acute exacerbation is a concern. The purpose of this study was to evaluate the safety of surgical lung biopsy for the differential diagnosis of ILDs.

Methods

From October 2007 to July 2019, 129 patients thought to have ILD underwent a surgical lung biopsy at Toho University Omori Medical Center. We conducted a retrospective study on the diagnosis and safety of surgical lung biopsy for patients with ILD.

Results

The 30- and 60-day mortality was 0%. Postoperative complications occurred in 13 of 129 (10.1%) patients. The complications included pneumothorax in 8 (6.2%) patients after removal of the chest tube, postoperative pneumonia in 2 (1.0%), and acute exacerbation in 1 (0.8%). Postoperative pneumothorax was observed in 4 of 13 patients (30.7%) who underwent a biopsy of the apex of the lung (right S1, left S1+2), which was a significantly higher rate of postoperative pneumothorax than seen for patients undergoing biopsy at other sites (P=0.0086).

Conclusions

Surgical lung biopsy for the differential diagnosis of an ILD was performed safely. However, biopsy sites for ILDs need to be carefully selected to avoid postoperative complications.

Uniportal video-assisted thoracoscopic surgery (UVATS) right lower lobectomy for a giant T4 squamous cell lung tumour

Video-assisted thoracoscopic surgery (VATS) is one of the unique methods that have revolutionized the discipline of minimally-invasive thoracic surgery in the last two decades. Previously, double-port VATS lobectomy has been used for the resection of T4 tumours. This current case report presents a 68-year-old male that presented with a productive cough of 3 months' duration, associated with fever, chest pain and loss of body weight. He was haemodynamically stable. The patient underwent surgery under general anaesthesia using a uniportal VATS (UVATS) approach. A 2-cm incision was made in the mid-axillary line through the right 5th intercostal space with no rib spreading. The tumour was put into a specimen bag, cut into pieces and then removed via the mouth of the bag using a grasper. After good haemostasis, a single chest drain was placed and the small incision was sutured in layers. The postoperative course was uneventful and no complications were observed. On the 6th day postoperative, the patient was discharged home. This current case demonstrated that UVATS resection for T4 tumours might be a viable approach in the hands of skilled surgeons. It should also provide decreased postoperative pain, faster recovery and shorter hospitalization.

Missing lung nodule? Intra-operative contingency plan with O-arm imaging: a case report

Despite the availability of various modalities to locate small non-palpable pulmonary nodules during minimally invasive thoracoscopic surgery, precise lung nodule resection remains a challenge. Pre-operative localization techniques add additional time, expense, and complication rate. Intra-operative localization methods, such as ultrasound, may be a real-time solution, but challenges remain with visualizing deep parenchyma lesions and operator-dependent use. Many thoracoscopic wedge resections are performed using a combination of pre-operative imaging and intra-operative landmarks. Although usually cost and time-efficient, the problem occurs when a wedge resection is performed, and the nodule is not within the specimen. This case report describes the use of the O-arm Surgical Imaging System, a full-rotation imaging system that provides three-dimensional cone-beam imaging, in an 81-year-old male patient with a solid 8 mm left lower lobe lung nodule. After two unsuccessful wedge resections, we used the O-arm and finally resected the nodule with a negative surgical margin. The O-arm provided instant feedback regarding the nodule status, allowing a standard thoracoscopy room to function as a hybrid operating room without the need to reposition the patient. Rather than convert to a thoracotomy, proceed to a larger resection, or experience a missed nodule, the O-arm proved to be a helpful intra-operative tool to find a missing lung nodule.

Simultaneous Comparison of Subxiphoid and Intercostal Wound Pain in the Same Patients Following Thoracoscopic Surgery

There is a lack of data comparing postoperative pain after subxiphoid and intercostal video-assisted thoracoscopic surgery (VATS). Pain is an individual’s subjective experience and, therefore, difficult to compare between different individuals subjected to either procedure. This study assessed reported pain at six postoperative time points in the same patients receiving both subxiphoid and intercostal incisions for thoracic disease. Data from 44 patients who received simultaneous combined intercostal and subxiphoid VATS were retrospectively analyzed from August 2019 to July 2021. All patients received the same length of subxiphoid and intercostal incisions with or without drain placements. A numerical pain rating scale was administered on postoperative days (POD)-1, POD-2, POD-Discharge, POD-30, POD-90, and POD-180. Bilateral uniportal VATS was performed in 11 patients, and unilateral multiportal VATS was performed in 33 patients. In the unilateral VATS group, there were no differences in pain reported for both incisions in the early postoperative period. However, in the bilateral VATS group, subxiphoid wounds resulted in significantly higher pain scores on POD-1, POD-2, and POD-Discharge (p = 0.0003, 0.001, and 0.03, respectively). Higher late (3 and 6 months) postoperative pain was associated with intercostal incisions in both groups, as previously reported, whereas higher early (day 1, 2, and discharge) postoperative pain was more associated with subxiphoid incisions than intercostal incisions in the bilateral VATS group.

Factors Associated with Nodal Upstaging in Clinical T1a-bN0M0 Non-Small Cell Lung Cancers

Nodal upstaging of lung adenocarcinoma occurs when unexpected pathological lymph node metastasis is found after surgical intervention, and may be associated with a worse prognosis. In this study, we aimed to determine the predictive factors of nodal upstaging in cT1a-bN0M0 primary lung adenocarcinoma. We retrospectively reviewed a prospective database (January 2011 to May 2017) at National Taiwan University Hospital and identified patients with cT1a-bN0M0 (solid part tumor diameter ≤ 2 cm) lung adenocarcinoma who underwent video-assisted thoracoscopic lobectomy. Logistic regression models and survival analysis were used to examine and compare the predictive factors of nodal upstaging. A total of 352 patients were included. Among them, 28 (7.8%) patients had nodal upstaging. Abnormal preoperative serum carcinoembryonic antigen (CEA) levels, solid part tumor diameter ≥ 1.3 cm, and consolidation-tumor (C/T) ratio ≥ 0.50 on chest computed tomography (CT) were significant predictive factors associated with nodal upstaging, and patients with nodal upstaging tended to have worse survival. Standard lobectomy is recommended for patients with these predictive factors. If neither of the predictive factors are positive, a less invasive procedure may be a reasonable alternative. Further studies are needed to verify these data.

Effects of preoperative pulmonary function on short-term outcomes and overall survival after video-assisted thoracic surgery lobectomy

Background

Preoperative pulmonary function tests are a necessary preoperative assessment tool for non-small cell lung cancer (NSCLC) patients awaiting surgery. We studied the effects of preoperative pulmonary function on short-term outcomes and overall survival (OS).

Methods

A retrospective cohort study was undertaken with adult NSCLC patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy between May 2016 and April 2017. The primary exposure variables were the percentage of predicted peak expiratory flow (PEF%), the percentage of predicted forced vital capacity (FVC%), and the percentage of predicted forced expiratory volume in 1 s. The observation outcomes were postoperative pulmonary complications (PPCs), acute kidney injury (AKI), in-hospital mortality, readmission within 30 days, and OS. Univariate and multivariate analyses were performed.

Results

Of the 548 patients, postoperative pneumonia was observed in 206 (37.6%). The results of the binary logistics regression analysis showed that relative to the moderate PEF% group, the risk of postoperative pneumonia was significantly increased in the marginal PEF% [odds ratio (OR) 2.076; 95% confidence interval (CI): 1.211–3.558; P=0.008] and excellent PEF% (OR 1.962; 95% CI: 1.129–3.411; P=0.017) groups. Relative to the good FVC% group, the risk of postoperative pneumonia was significantly increased in the marginal FVC% (OR 2.125; 95% CI: 1.226–3.683; P=0.007) and moderate FVC% (OR 2.230; 95% CI: 1.298–3.832; P=0.004) groups. The OS analysis did not reveal any correlations among the pulmonary function parameters and OS in this cohort.

Conclusions

Preoperative PEF% and FVC% are associated with postoperative pneumonia in NSCLC patients undergoing VATS lobectomy. Preoperative PEF% is as important as FVC% in pulmonary function assessment before lung surgery.

Persistent hyperparathyroidism secondary to ectopic parathyroid adenoma in lung: Case report

Primary hyperparathyroidism (PHPT) is the most prevalent cause of hypercalcemia, affecting 0.3% of the population. The only curative procedure is parathyroidectomy. Persistent PHPT occurs in 4.7 percent of patients, even in the most skilled hands. Ectopic adenomas are challenging to localize before and during surgery and frequently result in persistent PHPT. We presented a case with persistent PHPT due to lung parathyroid adenoma that was successfully resected with video-assisted thoracoscopic surgery. A 55-year-old female patient was admitted to our endocrinology clinic with persistent PHPT after four neck explorations over 16 years. The last ⁹⁹m Tc-MIBI scintigraphy with SPECT showed nothing suggestive of parathyroid adenoma, neither in the neck nor the mediastinum, but a solitary nodule as an incidental finding was reported in the lower lobe of the right lung, which was highly probable for a parathyroid adenoma in a fluorodeoxyglucose PET scan. Pathological examination ruled out parathyromatosis and lung malignancy; despite its location outside the anticipated embryonic pathway, pathology revealed the presence of an ectopic parathyroid adenoma. After the surgery, serum parathyroid hormone and calcium levels decreased, and hypoparathyroidism was corrected with calcium carbonate and calcitriol.

A randomized clinical trial: optimal strategies of paravertebral nerve block combined with general anesthesia for postoperative analgesia in patients undergoing lobectomy: a comparison of the effects of different approaches for serratus anterior plane block

BACKGROUND

To observe the analgesic effect of different ultrasound-guided methods of serratus anterior plane block (SAPB) after surgery in patients who have undergone thoracoscopic lobectomy with general anesthesia combined with thoracic paravertebral nerve block.

METHODS

A total of 120 patients aged 18-65 years old scheduled for video-assisted thoracoscopic surgery (VATS) were selected. Patients were randomly divided into 3 groups: patient-controlled intravenous analgesia (PCIA) group, serratus anterior plane block (SPB) group and continuous serratus anterior plane block (CSPB) group (n=40 each). All patients were treated with general anesthesia combined with double-point (T4, T7) thoracic paravertebral block. The SPB group received an ultrasound-guided single serratus plane block. The CSPB group underwent the same procedure as the SPB group, with an epidural catheter inserted. Both the PCIA and SPB groups received PCIA after surgery. Patients in the CSPB group were connected to a continuous serratus block automatic analgesia pump after surgery.

RESULTS

There were no significant differences among the 3 groups in terms of the general condition. Compared with the PCIA group, the resting and exercise VAS pain scores at T2, T3, T4, and T5, cortisol level at T1, T4 and T5 in SPB group and CSPB group were lower (P<0.05), the times of the first analgesia were significantly prolonged, and the times of pressing the PCA pump and opioid use were significantly less in the SPB and CSPB groups, and the CSPB group used no opioids (P<0.05), the SPB group and CSPB group had shorter times of the first postoperative activity, longer mobilization distance and the total number of days in hospital was significantly lower (P<0.05). Postoperative complications in the SPB and CSPB groups were significantly less and the CSPB group had an even lower incidence of postoperative complications (P<0.05). Compared with the SPB group, active VAS pain scores at T4 and T5 were higher in the CSPB group (P<0.05). Compared with the PCIA group, the total QoR-40 score at T6 was significantly higher in the SPB and CSPB groups, and compared with the SPB group, this data was higher in the CSPB group (P<0.05).

CONCLUSIONS

Single ultrasound-guided SAPB combined with PCIA can provide a better analgesic effect, improve the quality of early postoperative recovery, and accelerate ERAS.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2000041350.

Effectiveness of rehabilitation for postoperative pain after surgery for spontaneous pneumothorax in young adults

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) has been established as a standard therapeutic approach for pneumothorax; however, patients may experience pronounced pain during the postoperative period, and the optimization of analgesic approaches during the postoperative period is necessary. The aim of this study was to determine for the first time the effect of a physical therapist-guided exercise program on pain perception and analgesic use in the postoperative period after VATS for spontaneous pneumothorax.

METHODS

This retrospective study included 73 patients aged ≤40 years (mean age is 21, range is 15 to 40) with spontaneous pneumothorax treated with VATS that were divided in exercise-based rehabilitation (n=23) and no rehabilitation (n=50) groups. Postoperative pain perception and the use of analgesics were investigated in patients who did or did not undergo an aerobic exercise postoperatively.

RESULTS

In patients who underwent an exercise-based postoperative rehabilitation program, the pain control was more effective the mean numeric rating scale (NRS) scale was lower than without rehabilitation patients (25.46/42.31, P=0.002) and the dose of analgesic medications was lower than in the patients who did not undergo rehabilitation (P=0.008).

CONCLUSIONS

Overall, our findings suggest for the first time that exercise-based postoperative rehabilitation may be a viable option for pain reduction after VATS for spontaneous pneumothorax in young adults.

Three-dimensional reconstruction facilitates thoracoscopic anatomical partial lobectomy by an inexperienced surgeon: a single-institution retrospective review

Background

This study aimed to evaluate the effect of three-dimensional (3D) interactive quantitative surgical planning on the outcome of video-assisted thoracoscopic surgery (VATS) anatomical partial lobectomy (APL), and to investigate the learning curve of 3D reconstruction-assisted VATS APL assisted.

Methods

We retrospectively analyzed 156 cases of solitary pulmonary ground-glass opacity (GGO) lesions in patients who underwent 3D interactive quantitative VATS APL. Digital imaging and communications in medicine data were recorded for each patient. We used Materialise 3-Matic software to make 3D reconstructed images. All surgeries were performed by the same thoracic surgeon at the Cardiothoracic Surgery Department of Yichang Central People’s Hospital between February 28, 2018, and April 20, 2020. The learning curve was evaluated using operative time and the cumulative sum (CUSUM) value of operative time in all cases.

Results

VATS APL was performed in every patient successfully, and there were no conversions to thoracotomy or lobectomy. The median surgical margin distance was 2.2 (range, 2.0–2.8) cm. All patients had an R0 complete cancer resection on histology. The histological subtypes of the segmental lesions included 69 cases of minimally invasive adenocarcinoma (MIA), 61 cases of adenocarcinoma, one case of squamous cell carcinoma, 16 cases of adenocarcinoma in situ (AIS), and nine cases of atypical adenomatous hyperplasia (AAH). The median operation time was 119 (range, 57–245) min, and median intraoperative blood loss was 37 (range, 15–247) mL. The median duration of thoracic drainage tube insertion was 2.3 (range, 1–23) days after surgery. The median length of postoperative hospital stay was 3.7 (range, 3–25) days. There were no cases of perioperative death. During the median postoperative follow-up period of 11 (range, 2–26) months, no tumor recurrence or postoperative death was observed. 3D interactive quantitative surgical planning facilitates safe and efficient VATS APL with a learning curve of 30 cases.

Conclusions

3D interactive quantitative surgical planning for VATS APL is a feasible option for inexperienced surgeons, with acceptable safety and complications.

Targeted Near-Infrared Fluorescence Imaging With Iodized Indocyanine Green in Preoperative Pulmonary Localization: Comparative Efficacy, Safety, Patient Perception With Hook-Wire Localization

Background

Precise preoperative localization is of great importance to improve the success rate and reduce the operation time of VATS surgery. This study aimed to assess the efficacy, safety, patient perception between CT-guided indocyanine green (ICG) preoperative localization of lung nodule and hook-wire localization.

Methods

65 patients with 85 clinically suspicious pulmonary nodules underwent ICG preoperative localization in this study, and 92 patients with 95 nodules localized by conventional hook-wire served as controls. Both hook-wire localization and ICG injection were performed under CT guidance. Successful targeting rate, success rate in the operative field, incidence rate of complications and respiratory pain score were recorded and compared.

Results

The successful targeting rate for both groups is 100%, however, due to hook-wire dislodgement, the success rate in the VATS operation field of the hook-wire group (95.6%) is lower than that of the ICG group (100%), with no significant difference(p=0.056). The overall complication rate of the hook-wire group (37.0%) is significantly higher than the ICG group (35.4%) (p=0.038). The mean respiratory pain score of the hook-wire group is 3.70 ± 1.25, which is significantly higher than that of the ICG group (2.85 ± 1.05) (p<0.001).

Conclusions

ICG composed with contrast mixture are superior to the conventional hook-wire preoperative lung nodule localization procedure, with a lower complication rate, lower pain score, and relatively higher success rate. ICG is a promising alternative method for pulmonary nodule preoperative localization.

Pulmonary Metastasectomy in Pediatric Patients: A Comparison of Open and Thoracoscopic Approaches

Background: Although the use of video-assisted thoracoscopic surgery (VATS) for resection of lung metastases has increased, surgeons still advocate for open resection as it permits palpation of lesions that may be missed on imaging. This study aimed to compare the utilization of open thoracotomy versus VATS over time and determine if the use of VATS changes perioperative outcomes. Methods: Using the Kids' Inpatient Database (2006, 2009, 2012, 2016), we identified children (age ≤20) with a diagnosis of secondary lung cancer with either lobectomy or sublobar resection coded during the same admission. Utilization was compared across years for the overall cohort and for patients with primary bone and connective tissue (PBCT) cancers. We defined prolonged length of stay (LOS) as LOS ≥75th percentile (LOS ≥7 days). Univariable and multivariable analyses compared in-hospital complication rates and LOS for open and VATS approaches. Results: Of the 1316 children (539 female) undergoing pulmonary resection, VATS was utilized in 374 (28.4%). Utilization increased rapidly from 2006 to 2009 (P < .001 for trend), but stabilized thereafter (P = .622). Metastatic PBCT cancers were the most common indication for resection (n = 496, 38%), but open and VATS approaches were used nearly equally (P = .368). Overall, 352 (26%) patients had complications. On multivariable analysis, the open approach remained independently associated with increased complications (odds ratio [OR] 1.48, 95% confidence interval [CI] [1.04-2.11]). Median LOS increased for open cases (5 versus 3 days, P < .001). Furthermore, open metastasectomy was associated with prolonged LOS (OR 1.50, [1.07-2.10]) after controlling for age, sex, primary cancer, reporting year, resection extent, obesity, complications, and nonoperative intubation. Conclusion: VATS approach to pulmonary metastasectomy resulted in fewer complications and shorter LOS in a nationwide sample of children. Despite these advantages, the use of VATS has plateaued. While this study cannot comment on oncologic safety or long-term outcomes, future studies should evaluate whether indications for VATS pulmonary metastasectomy can be expanded.

Electromagnetic bronchoscopy guided microwave ablation for early stage lung cancer presenting as ground glass nodule

Background

Patients with early-stage lung cancer are sometimes medically inoperable, and for patients with multiple primary lung cancers, surgical resection alone sometimes proves to be impractical. Local treatments like microwave ablation (MWA) are investigational alternatives for these patients. Most reported MWA procedures for lung cancers are performed percutaneously under CT guidance. MWA navigated by electromagnetic bronchoscopy (ENB) has been limitedly studied. In this study, we aimed to evaluate the safety and feasibility of MWA under ENB guidance in patients with inoperable early-stage lung cancers or multiple primary lung cancers which cannot be completely resected.

Methods

From June 2019 to December 2020, preliminary attempts of ENB-guided MWA were made in five medically inoperable patients with a single early-stage lung cancer and ten patients with multiple primary lung cancers which were difficult to resect at the same time. For patients with concomitant pulmonary nodules which needed surgical resection, thoracoscopic resections were performed following ENB-guided MWA. The safety, feasibility, and technique effectiveness of treatments were evaluated.

Results

ENB-guided MWA for 15 ground glass nodules (GGNs) in 15 patients was completed in accordance with the planned protocol. Biopsy of 13 GGNs showed malignancy. Five patients received simple ENB-guided MWA without simultaneous surgical resection and ten patients received simultaneous surgical resection for 13 concomitant pulmonary nodules. CT scan by the first postoperative week showed technique effectiveness of ablation for 11 nodules indicated for MWA. Four patients had mild complications after the procedure and recovered shortly after treatment.

Conclusions

For medically inoperable patients with a single GGN manifesting early-stage lung cancer and patients with multiple primary early-stage lung cancers which cannot be resected at the same time, ENB-guided MWA might be a safe and feasible alternative local treatment, whether combined with surgical resection or not. However, large, prospective, randomized, multicenter studies are needed to confirm its role in the treatment of early-stage lung cancer.

Short-term analysis of uniport video-assisted thoracoscopic surgery via the subxiphoid approach without chest tube drainage for anterior mediastinal tumors: a comparative retrospective study

Background

Uniport video-assisted thoracoscopic surgery (VATS) via the subxiphoid approach has emerged as a safe and effective treatment for anterior mediastinal tumors. However, there is limited evidence of the necessity of chest tubes and the comparative efficacy with other approaches.

Methods

A total of 141 patients with anterior mediastinal tumors receiving VATS were enrolled in this retrospective study. The patients were divided into the lateral approach (LA) group, the uniport subxiphoid approach (USA) group, and the three-port subxiphoid approach (TSA) group. Short-term analysis including operation time, chest tube rates, drainage duration, visual analogue scale (VAS) score, and hospital stay were compared. Postoperative CT scans were analyzed to evaluate the amount of pleural effusion.

Results

There was no significant difference in demographic and baseline characteristics among the three groups (all P>0.05). The operation time, blood loss, and hospital stay of the subxiphoid approach group were significantly lower than the LA group (P<0.001). The postoperative CT scans demonstrated that the USA group had a similar amount of pleural effusion as the other groups (P=0.1605). The postoperative VAS score of the USA group was significantly lower than the other groups (P<0.001). There was no significant difference in complications, in-hospital death, and conversion to thoracotomy among the three groups (all P>0.05).

Conclusions

VATS via the subxiphoid approach is less invasive, equally safe, and same effective for anterior mediastinal tumors than the LA. The chest tube could be omitted for the USA.

Examination on the necessity of pericardial fat tissue resection in extended thymectomy for myasthenia gravis

Background

Extended thymectomy with pericardial fat tissue resection has been a mainstay in the treatment for myasthenia gravies (MG), but few studies have examined the necessity of the pericardial fat tissue resection in extended thymectomy.

Methods

We pathologically examined the distribution of germinal centers in the resected thymus including the thymus-surrounding fat tissue. Patients who underwent extended thymectomy using subxiphoid thoracoscopy for generalized MG or thymoma with anti-acetylcholine receptor antibody (anti-AchR Ab) positivity from March 2015 to January 2021 were included in this study.

Results

A total of 20 patients underwent extended thymectomy (generalized nonthymomatous MG, n=5; generalized MG with thymoma, n=6; thymoma with anti-AchR Ab positivity, n=9). The resected specimens were divided to 6 parts and were pathologically examined to investigate the distribution of the geminal centers in all lesions. The number and distribution of germinal centers in the thymus varied depending on the patient, and no germinal centers were identified in the right or left pericardial fat tissues.

Conclusions

It is necessary to resect the pericardial fat tissue in patients whose preoperative images show the presence of pericardial fat tissue hyperplasia or ectopic thymoma. However, extensive pericardial fat tissue resection might not be necessary for all MG patients who undergo extended thymectomy with opening of the bilateral pleural by video-assisted or robot-assisted thoracoscopic surgery (RATS) via a subxiphoid approach.

Electromagnetic navigation bronchoscopy localization of lung nodules for thoracoscopic resection

Background

Thoracoscopic localization of small peripheral pulmonary nodules is a concern. Failure can lead to larger parenchymal resection or conversion to thoracotomy. This study evaluates our experience in preoperative electromagnetic navigation bronchoscopy-guided localization of small peripheral lung lesions.

Methods

From January 2017 to March 2020 clinical, radiographic, surgical, and pathological data of patients who underwent electromagnetic navigation bronchoscopy (ENB)-guided methylene blue pleural marking of highly suspected pulmonary lesions before a full thoracoscopic resection were evaluated. Localization was performed for solid or mixed subpleural nodules measuring <10 mm, solid nodules measuring <20 mm located at more than 1 cm from the pleura and any pure ground glass opacity. Successful localization was defined as successful identification and thoracoscopic resection of target lesions.

Results

Forty-eight patients were included: 30 solid nodules (63%), 12 pure GGO (25%) and 6 mixed (13%). The median largest diameter at CT-scan was 11 mm (IQR, 9-14 mm) while the median distance from the pleural surface was 12 mm (IQR, 6-16 mm). The median ENB length was 25 min (19-33 min). Localization procedure was successful in 45 cases (94%). No procedural-related complications were reported.

Conclusions

ENB is a safe and accurate preoperative procedure to localize small lung peripheral lesions. The high successful rate, the absence of related complications, the possibility of performing the procedure in the same operating room with a single general anesthesia, make ENB-guided dye marking an advantageous tool for thoracoscopic pulmonary resection.