Postoperative computed tomography of insufflated lung specimens obtained by video-assisted thoracic surgery: detection and margin assessment of pulmonary nodules / Tomografia computadorizada pós-operatória de espécimes pulmonares insuflados após cirurgia torácica videoassistida: detecção e avaliação de margens de nódulos pulmonares

Abstract Objective: To investigate the utility of computed tomography (CT) scans to detect and assess the margin status of pulmonary nodules that were insufflated after being resected by video-assisted thoracic surgery. Materials and Methods: This was a novel multicenter study conducted at two national referral centers for thoracic diseases. Patients suspected of having lung cancer underwent video-assisted thoracic surgery for the resection of pulmonary nodules, which were submitted to postoperative CT. Measurements from the CT scans were compared with the results of the histopathological analysis. Results: A total of 37 pulmonary nodules from 37 patients were evaluated. The mean age of the patients was 65 years (range, 36-84 years), and 27 (73%) were female. A CT analysis of insufflated specimens identified all 37 nodules, and 33 of those nodules were found to have tumor-free margins. The histopathological analysis revealed lung cancer in 30 of the nodules, all with tumor-free margins, and benign lesions in the seven remaining nodules. Conclusion: Postoperative CT of insufflated suspicious lung lesions provides real-time detection of pulmonary nodules and satisfactory assessment of tumor margins. This initial study shows that CT of insufflated lung lesions can be a valuable tool at centers where intraoperative histopathological analysis is unavailable.

Resumo Objetivo: Investigar a utilidade da tomografia computadorizada (TC) para a detecção e avaliação de margens de nódulos pulmonares que foram insuflados após ressecção por cirurgia torácica videoassistida. Materiais e Métodos: Um inédito estudo multicêntrico foi conduzido em dois centros de referência nacional para doenças torácicas. Nódulos foram ressecados por cirurgia torácica videoassistida de pacientes com suspeita de câncer de pulmão e submetidos a TC pós-operatória. As medidas radiológicas da TC foram comparadas com as da análise patológica. Resultados: Um total de 37 pacientes foi avaliado. A idade média foi de 65 anos (variação: 36-84 anos) e 27 indivíduos (73%) eram do sexo feminino. A análise por TC dos espécimes insuflados identificou todas as 37 lesões e 33 delas com margens livres. A análise patológica revelou 30 casos de câncer de pulmão, todos com margens livres, e sete lesões não malignas. Conclusão: A TC pós-operatória de lesões pulmonares insufladas com suspeita de malignidade provê detecção em tempo real de nódulos pulmonares e aceitável avaliação de margens tumorais. Este estudo inicial demonstra que a TC de lesões pulmonares insufladas pode ser uma ferramenta valiosa em centros em que a análise histopatológica intraoperatória é indisponível.

A Brazilian randomized study: Robotic-Assisted vs. Video-assisted lung lobectomy Outcomes (BRAVO trial) / Estudo brasileiro randomizado: desfechos da lobectomia pulmonar robótica vs. videoassistida (estudo BRAVO)

ABSTRACT Objective: To compare 90-day morbidity in patients undergoing lung lobectomy performed by either robotic-assisted thoracic surgery (RATS) or video-assisted thoracic surgery (VATS). Intraoperative complications, drainage time, length of hospital stay, postoperative pain, postoperative quality of life, and readmissions within 90 days were also compared. Methods: This was a two-arm randomized clinical trial including patients with lung lesions (primary lung cancer or lung metastasis) who were candidates for lung lobectomy. Patients with comorbidities that precluded surgical treatment were excluded. All patients followed the same postoperative protocol. Results: The overall sample comprised 76 patients (39 in the VATS group and 37 in the RATS group). The two groups were similar regarding gender, age, BMI, FEV1 in % of predicted, and comorbidities. Postoperative complications within 90 days tended to be more common in the VATS group than in the RATS group, but the difference was not significant (p = 0.12). However, when only major complications were analyzed, this tendency disappeared (p = 0.58). Regarding postoperative outcomes, the VATS group had a significantly higher number of readmissions within 90 days than did the RATS group (p = 0.029). No significant differences were found regarding intraoperative complications, drainage time, length of hospital stay, postoperative pain, and postoperative quality of life. Conclusions: RATS and VATS lobectomy had similar 90-day outcomes. However, RATS lobectomy was associated with a significant reduction in the 90-day hospital readmission rate. Larger studies are necessary to confirm such a finding. (ClinicalTrials.gov identifier: NCT02292914 [http://www.clinicaltrials.gov/])

RESUMO Objetivo: Comparar a morbidade em 90 dias de pacientes submetidos à lobectomia pulmonar por robotic-assisted thoracic surgery (RATS, cirurgia torácica robótica) ou por video-assisted thoracic surgery (VATS, cirurgia torácica videoassistida). Complicações intraoperatórias, tempo de drenagem, tempo de internação hospitalar, dor pós-operatória, qualidade de vida pós-operatória e reinternações em 90 dias também foram comparados. Métodos: Ensaio clínico randomizado, com dois braços, incluindo pacientes com lesões pulmonares (câncer de pulmão primário ou metástase pulmonar) candidatos à lobectomia pulmonar. Foram excluídos pacientes com comorbidades que impossibilitassem o tratamento cirúrgico. Todos os pacientes seguiram o mesmo protocolo pós-operatório. Resultados: A amostra total foi composta por 76 pacientes (39 no grupo VATS e 37 no grupo RATS). Os dois grupos foram semelhantes quanto a sexo, idade, IMC, VEF1 em % do previsto e comorbidades. Complicações pós-operatórias em 90 dias tenderam a ser mais frequentes no grupo VATS do que no grupo RATS, mas a diferença não foi significativa (p = 0,12). No entanto, quando analisadas apenas as complicações maiores, essa tendência desapareceu (p = 0,58). Quanto aos desfechos pós-operatórios, o grupo VATS apresentou um número significativamente maior de reinternações em 90 dias do que o grupo RATS (p = 0,029). Não foram encontradas diferenças significativas quanto a complicações intraoperatórias, tempo de drenagem, tempo de internação hospitalar, dor pós-operatória e qualidade de vida pós-operatória. Conclusões: A lobectomia por RATS e a lobectomia por VATS apresentaram desfechos em 90 dias semelhantes. No entanto, a lobectomia por RATS foi associada a uma redução significativa na taxa de reinternação hospitalar em 90 dias. Estudos maiores são necessários para confirmar esse achado. (Identificador ClinicalTrials.gov: NCT02292914 [http://www.clinicaltrials.gov/])

Evaluation of pain and opioid consumption in local preemptive anesthesia and the erector spine plane block in thoracoscopic surgery: A randomized clinical trial / Avaliação da dor e consumo de opioides em anestesia preemptiva local e do plano eretor da espinha em cirurgia torácica videotoracoscópica: Um ensaio clínico randomizado

ABSTRACT Objective: assess pain and opioid consumption in patients undergoing anesthetic techniques of spinal erector plane block and local anesthetic block in video-assisted thoracic surgery in the immediate postoperative period. Methods: ninety-two patients undergoing video assisted thoracic surgery were randomized to receive ESPB or BAL before starting the surgical procedure. Using the numerical verbal scale, the primary outcome assessed was the patient's pain in the immediate postoperative period (POI). The secondary outcome comprises the assessment of opioid consumption in the IPP by quantifying the medication used in an equianalgesic dose of morphine expressed in milligrams, in the immediate post-anesthetic recovery period, 6h, 12h, and 24h after surgery. Results: the EVN scores in the LBA and ESPB group in the POI had a mean of 0,8 (±1,89) vs 0,58 (±2,02) in the post-anesthesia care room (REPAI), 1,06 (±2,00) vs 1,30 (±2,30) in 6 hours of POI, 0,84 (±1,74) vs 1,19 (±2,01) within 12 hours of POI and 0,95 (±1,88) vs 1 ( ±1,66) within 24 hours of POI, all with p>0.05. Mean opioid consumption in the BAL and ESPB groups in the POI was 12.9 (± 10.4) mg vs 14.9 (±10.2) mg, respectively, with p = 0.416. Sixteen participants in the ESPB group and seventeen in the BAL group did not use opioids during the first 24 hours of the PO analyzed. Conclusion: local anesthesic block and ESP block techniques showed similar results in terms of low pain scores and opioid consumption during the period evaluated.

RESUMO Objetivo: avaliar a dor e o consumo de opioides dos pacientes submetidos a técnicas anestésicas de bloqueio do plano eretor da espinha (ESPB) e bloqueio anestésico local (LBA) em cirurgia torácica vídeo assistida no período pós-operatório imediato (POI). Métodos: noventa e dois pacientes submetidos a cirurgia torácica videotoracoscópica foram randomizados aleatoriamente para receberem ESPB ou LBA antes do início do procedimento cirúrgico. O desfecho primário avaliado foi a dor do paciente no POI através da escala verbal numérica. O desfecho secundário avaliou o consumo de opioides através da quantificação da medicação usada em dose equianalgésica de morfina expressa em miligramas, no período de recuperação pós-anestésica imediata, 6h, 12h e 24h após a cirurgia. Resultados: os escores da Escala Verbal Numérica de dor (EVN) no grupo LBA e ESPB no POI, respectivamente, tiveram média de 0,8 (±1,89) vs 0,58 (±2,02) na sala de recuperação pós anestesia (REPAI), 1,06 (±2,00) vs 1,30 (±2,30) em 6 horas do POI, 0,84 (±1,74) vs 1,19 (±2,01) em 12 horas do POI e 0,95 (±1,88) vs 1 ( ±1,66) em 24 horas do POI, todos com p>0,05. O consumo médio de opioides no grupo LBA e ESPB foi de 12,9 (±10,4) mg vs 14,9 (±10.2) mg, respectivamente, com p=0.416. Dezesseis participantes do grupo ESPB e dezessete do grupo LBA não utilizaram opioides durante as primeiras 24 horas do PO. Conclusões: as técnicas de bloqueio LBA e ESPB apresentaram resultados semelhantes em termos de baixos escores de dor e consumo de opioides durante o período avaliado.

Lung nodule localization in hybrid room before minimally invasive thoracic surgery: series of 20 cases and literature review

ABSTRACT Objective To describe an experience in the preoperative localization of small pulmonary nodules and ground-glass lesions to guide minimally invasive thoracic surgery; in addition, a literature review was conducted, including the main advantages and disadvantages of the different agents used, and site marking in a hybrid operating room. Methods A retrospective search was conducted in a Interventional Radiology Department database, between March 2015 and May 2019, to identify patients undergoing preoperative percutaneous marking of lung injuries measuring up to 25mm. Results A total of 20 patients were included and submitted to descriptive analysis. All patients were marked in a hybrid room, at the same surgical-anesthetic time. Most often used markers were guidewire, Lipiodol® and microcoils. Despite one case of coil displacement, two cases of pneumothorax, and one case of hypotension after marking, all lesions were identified and resected accordingly from all patients. Conclusion Preoperative percutaneous localization of lung injuries in hybrid room is an effective and a safe technique, which can have decisive impact on surgical resection. The choice of marker and of the operating room scenario should be based on availability and experience of service. Multidisciplinary discussions with surgical teams, pathologists, and interventional radiologists are crucial to improve outcome of patients.

Uniportal thoracoscopic decortication in the treatment of chronic tuberculous empyema / 中华胸心血管外科杂志

Objective:To investigate the surgical procedure and outcome of uniportal thoracoscopic decortication in the treatment of chronic tuberculous empyema.Methods:From March 2019 to December 2019, the clinical data of 53 patients with chronic tuberculous empyema, who underwent uniportal thoracoscopic decortication in the Surgical Department of Wuhan Pulmonary Hospital were retrospectively analyzed. There were 40 males and 13 females. Age ranged from 16 to 69, averaged 36 years old.36 cases were on the right side and 17 cases on the left side, 38 cases were complicated with pulmonary tuberculosis. All cases had been diagnosed as tuberculous empyema by pathogeny and pathology test in preoperative or postoperative, and received tuberculosis management treatment between 2 and 12 months prior to surgery.The surgical procedure and clinical efficacy of uniportal thoracoscopic decortication were expounded in treatment of chronic tuberculous empyema.Results:Among the 53 patients, 49(92.45%) cases underwent uniportal thoracoscopic decortication, and 4(7.55%) cases changed to thoracotomy. The duration of surgery was 100-370 min, mean(234.53±56.06)min. Intraoperative hemorrhage was 50-1 400 ml, median value 300(175.0, 402.5)ml. Catheter retention time was 3-22 days, median value 8(6.00, 11.25)days. The incidence of surgical complications was 1.89%(1/53), the cure rate was 92.45%(49/53).Conclusion:If the perioperative evaluation and treatment are appropriate, and the operator is experienced, the uniportal thoracoscopic decortication is feasible, safe and effective in the therapy of chronic tuberculous empyema.

La video mediastinoscopía en el oncotórax / The video mediastinoscopy in oncological thorax

RESUMEN Fundamento: el avance exponencial de la cirugía torácica tiene un desarrollo paralelo a las técnicas anestésicas e imagenológicas, desde la antigüedad se recogen en diferentes manuscritos los intentos de abordar este espacio corporal. Objetivo: describir la técnica de videomediastinoscopía así como las referencias anatómicas para su realización. Métodos: se realizó una descripción de la técnica de la videomediastinoscopía para la exéresis y biopsia de alteraciones mediastinales, basado en la experiencia personal y consulta bibliográfica. Se consultaron los repositorios internacionales: Ebsco, Medline y Cochrane para la obtención de las referencias relacionadas con el tema. Conclusiones: la videomediastinoscopía es una vía segura y útil para la estadificación del cáncer pulmonar la cual brinda además una clasificación patológica más exacta que las toracotomías convencionales al permitir el acceso a las zonas ganglionares superiores, aórticas y subcarinal según corresponda.

ABSTRACT Background: the exponential progress of thoracic surgery has a parallel development to anesthetic and imaging techniques; since ancient times, attempts to address this body space are collected in different manuscripts. Objective: to describe the technique of video-mediastinoscopy, as well as the anatomical references for its performance. Methods: a description of the technique of video-mediastinoscopy for the excision and biopsy of mediastinal alterations was made, based on personal experience and bibliographic consultation. The international repositories Ebsco, Medline and Cochrane were consulted to obtain references related to the subject. Conclusions: video-mediastinoscopy is a safe and useful route for lung cancer staging which also provides a more accurate pathological classification than conventional thoracotomies by allowing access to the upper, aortic and subcarinal ganglionic areas as appropriate.

Evolution of the surgical treatment of lung cancer at a tertiary referral center in Brazil, 2011-2018 / Evolução do tratamento cirúrgico do câncer de pulmão em uma instituição terciária de referência no Brasil, 2011-2018

ABSTRACT Objective: To evaluate the evolution of clinical and epidemiological data, as well as data related to diagnosis, staging, treatment, and survival, among patients undergoing curative surgery for lung cancer at a tertiary referral center in the city of São Paulo, Brazil. Methods: This was a retrospective study of cases in the International Association for the Study of Lung Cancer database. We selected only cases of patients undergoing curative surgery between January of 2011 and April of 2018. We determined overall and disease-free survival at 36 months and compared the data between two periods (2011-2014 and 2015-2018). Results: Comparing the two periods (N = 437 cases), we observed trends toward increases in the number of female patients, as well as in the proportions of former smokers (44.09% vs. 53.59%), of patients diagnosed with adenocarcinoma (52.21% vs. 59.72%), and of patients diagnosed at an earlier pathological stage, together with a decrease in 30-day mortality (4.05% vs. 2.39%). There were significant increases in the proportions of cases diagnosed at an earlier clinical stage (p = 0.002) or incidentally (p = 0.003). Although lobectomy was the main surgical technique employed, there was a proportional increase in segmentectomies (2.67% vs. 7.11%; p = 0.026). Overall and disease-free survival rates were 79.4% (95% CI: 74.0-83.9%) and 75.1% (95% CI: 69.1-80.1%), respectively. The difference in overall survival between the periods lost statistical significance when adjusted for pathological stage, the only factor that affected survival (log-rank: p = 0.038 to p = 0.079). Conclusions: The clinical and epidemiological evolution presented in this study corroborates global trends. The decrease in 30-day mortality was probably due to better patient selection and improved surgical techniques.

RESUMO Objetivo: Avaliar a evolução de dados clínicos e epidemiológicos, assim como dados sobre diagnóstico, estadiamento, tratamento e sobrevida em pacientes submetidos a tratamento cirúrgico curativo de câncer de pulmão em uma instituição terciária na cidade de São Paulo (SP). Métodos: Estudo retrospectivo baseado nos casos inseridos no banco de dados da International Association for the Study of Lung Cancer submetidos à cirurgia curativa entre janeiro de 2011 e abril de 2018. Determinamos a sobrevida global e livre de doença em 36 meses e comparamos os dados em dois períodos (2011-2014 e 2015-2018). Resultados: Comparando-se os dois períodos (N = 437 casos), houve uma tendência de aumento no número de pacientes do sexo feminino, ex-tabagistas (44,09% vs. 53,59%), com diagnóstico de adenocarcinoma (52,21% vs. 59,72%) e em estádio patológico mais precoce, assim como queda da mortalidade em 30 dias (4,05% vs. 2,39%). Houve aumento significativo de casos em estádio clínico mais precoce (p = 0,002) e diagnosticados incidentalmente (p = 0,003). A lobectomia foi a principal técnica cirúrgica; entretanto, houve aumento de segmentectomias (2,67% vs. 7,11%; p = 0,026). As sobrevidas global e livre de doença foram de 79,4% (IC95%: 74,0-83,9%) e 75,1% (IC95%: 69,1-80,1%), respectivamente. Houve perda de significância estatística na sobrevida global entre os períodos quando ajustada por estadiamento patológico, o único fator a impactar a sobrevida (log-rank: p = 0,038 para p = 0,079). Conclusões: A evolução clínica e epidemiológica apresentada neste estudo corrobora tendências mundiais. A diminuição da mortalidade em 30 dias provavelmente ocorreu devido a melhor seleção de pacientes e melhora da técnica cirúrgica.

Uniportal surgical biopsy, without orotraqueal intubation, without thoracic drainage in intersticial pulmonary disease: initial results / Biópsia cirúrgica uniportal, sem intubação orotraqueal, sem drenagem torácica na doença pulmonar intersticial: resultados iniciais

ABSTRACT Objective: interstitial lung disease comprises a group of lung diseases with wide pathophysiological varieties. This paper aims to report the video thoracoscopic surgical biopsy in patients with interstitial lung disease through a single minimal chest incision, without orotracheal intubation, without chest drainage, and without the use of neuromuscular blockers. Methods: this study is a series of 14 cases evaluated retrospectively, descriptively, where patients underwent a pulmonary surgical biopsy from January 2019 to January 2020. The patients included in the study had diffuse interstitial lung disease without a defined etiological diagnosis. Results: none of the patients had transoperative complications, there was no need for chest drainage in the postoperative period, and the patients pain, assessed using the verbal scale, had a mode of 2 (minimum value of 1 and maximum of 4) in the post immediate surgery and 1 (minimum value of 1 and maximum of 3) at the time of hospital discharge. The length of hospital stay was up to 24 hours, with 12 patients being discharged on the same day of hospitalization. Conclusion: therefore, it is concluded in this series of cases that the performance of uniportal video-assisted thoracoscopic surgery procedures to perform lung biopsies, without orotracheal intubation, without chest drainage, and without the use of neuromuscular blockers, bring benefits to the patient without compromising his safety. Further larger studies are necessary to confirm the safety and efficiency of this method.

RESUMO Objetivo: a doença pulmonar intersticial compreende um grupo de doenças pulmonares com grandes variedades fisiopatológicas. Este trabalho objetiva relatar a biópsia cirúrgica videotoracoscópica em pacientes com doença pulmonar intersticial por meio de incisão torácica mínima única, sem intubação orotraqueal, sem drenagem torácica e sem uso de bloqueadores neuromusculares. Métodos: este estudo é uma série de 14 casos avaliados de forma retrospectiva, descritiva, onde no qual os pacientes foram submetidos a biópsia cirúrgica pulmonar no período de janeiro de 2019 a janeiro de 2020. Os pacientes incluídos na pesquisa, apresentavam doença pulmonar intersticial difusa sem diagnóstico etiológico definido. Resultados: nenhum dos pacientes apresentou complicações transoperatórias, não houve necessidade de drenagem torácica no período pós-operatório e a dor dos pacientes, avaliada por meio da escala verbal, teve moda de 2 (valores mínimos de 1 e máximo de 4) no período de pós-operatório imediato e 1 (valores mínimos de 1 e máximos de 3) no momento da alta hospitalar. O tempo de permanência hospitalar foi de até 24 horas, sendo que 12 pacientes receberam alta no mesmo dia da internação. Conclusão: conclui-se, assim, que nesta série de casos, a realização de procedimentos de cirurgia toracoscópica videoassistida uniportais para realização de biópsias pulmonares, sem intubação orotraqueal, sem drenagem torácica e sem uso de bloqueadores neuromusculares trazem benefícios para o paciente sem comprometer sua segurança. Estudos maiores são necessários para comprovar tanto a segurança quanto à eficácia deste método.

Modified strategy of anesthesia for thoracoscopic radical resection of lung cancer: serratus anterior plane block combined with general anesthesia / 中华麻醉学杂志

Objective:To evaluate the modified efficacy of serratus anterior plane block (SAPB) combined with general anesthesia for thoracoscopic radical resection of lung cancer.Methods:Eighty-two patients of both sexes, aged 40-64 yr, with body mass index of 18-24 kg/m 2, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, scheduled for elective thoracoscopic radical resection of lung cancer, were divided into 2 groups ( n=41 each) using a random number table method: general anesthesia group (group G) and SAPB combined with general anesthesia group (group SG). Ultrasound-guided SAPB was performed before induction of general anesthesia in group SG.General anesthesia was induced with midazolam, etomidate, sufentanil and cis atracurium, and anesthesia was maintained with sevoflurane and remifentanil.Sufentanil was used for patient-controlled intravenous anesthesia (PCIA) after the end of operation.When visual analog scale score≥4, sufentanil 2.5 μg was injected intravenously for rescue analgesia.The intraoperative consumption of sevoflurane and remifentanil, extubation time, requirement for rescue analgesia within 48 h after operation, consumption of sufentanil, requirement for nicardipine and esmolol and occurrence of adverse events were recorded. Results:Compared with group G, the intraoperative consumption of remifentanil and sevoflurane, postoperative consumption of sufentanil, postoperative requirement for rescue analgesia, postoperative requirement for nicardipine and esmolol, postoperative incidence of nausea and vomiting, skin pruritus and urinary retention were significantly decreased, the extubation time was shortened, and the time of the first postoperative requirement for rescue analgesia was prolonged in group SG ( P<0.05). Conclusion:Compared with general anesthesia alone, SAPB combined with general anesthesia can not only significantly reduce intraoperative general anesthetics and opioid consumption, but also improve postoperative stress management, which is helpful for early postoperative outcome when used for thoracoscopic radical resection of lung cancer.

Thoracoscopic instruments do not interfere in the outcome of uncomplicated, experimental, video-assisted pulmonary lobectomy / Instrumentos toracoscópicos não interferem no desfecho da lobectomia pulmonar videoassistida experimental não complicada

ABSTRACT Objective: Since its first report, video-assisted thoracic surgery (VATS) lung lobectomy was carried out with the use of conventional surgical instruments, used in laparoscopy and open thoracotomy. These instruments are expensive, not standardized and there are a variety of models and manufacturers. The aim of this study was to determine the impact of the use of these instruments on the experimental pulmonary lobectomy. Methods: We used a modified surgical simulator that uses a porcine heart-lung block filled with tomato sauce, and tested specific (Group 1) and regular (Group 2) instruments. Each group includes 15 experiments. Results: The median total time, excluding the time spent to correct the lesions, was 45.08 and 45.81 minutes, respectively in Group 1 and Group 2. There was no statistical difference between the total times (p=0.58). The only statistically different was seen for partial times regarding the elapsed time to cut and suture of lung fissures (p=0.03 and 0.04, respectively). There were more direct lesions and indirect leaks in Group 2, but without statistical significance (p=1.000 and p=0.203, respectively). The mean time spent for the diagnosis and correction of these events was 1.77 minutes with a standard deviation of 1.18 for Group 1 and 2.72 ± 1.11 minutes for Group 2 (p=0.044). Conclusion: The use of minimally invasive instruments is not associated with time improvement spent with experimental video-assisted lung lobectomy and does not lead to a faster or safer surgery. The use of VATS instruments makes correction of adverse events faster when they occur.

RESUMO Objetivo: desde os primeiros registros, a lobectomia pulmonar por cirurgia torácica videoassistida (CTVA) foi feita usando instrumentos convencionais e de laparoscopia. Recentemente instrumentais específicos para CTVA surgiram. Esses instrumentais têm custo elevado, não são padronizados existindo uma variedade de modelos e fabricantes. Buscou-se determinar o impacto do uso desses instrumentais na realização da lobectomia pulmonar superior esquerda experimental. Métodos: foi usado simulador modificado com bloco de coração-pulmões preenchidos com molho de tomate para testar o uso de instrumental dedicado de CTVA e de cirurgia convencional (Grupo 1 e Grupo 2, respectivamente). Cada grupo inclui 15 experimentos. Resultados: a mediana do tempo total, excluído o tempo para corrigir vazamentos, foi de 45,8 e 45,81 minutos, respectivamente para o Grupo 1 e Grupo 2. Não houve diferença estatisticamente significante entre os tempos totais (p=0,58). Os únicos tempos parciais estatisticamente diferentes foram os para cortar e suturar a fissura pulmonar (p=0,03 e 0,04, respectivamente). Ocorreram mais lesões diretas e vazamentos indiretos no Grupo 2, mas sem significância estatística (p=1,000 e 0,203, respectivamente). A média de tempo gasto para diagnosticar e corrigir os eventos de lesão e vazamento foi de 1,77 minutos com desvio padrão de 1,18 para o Grupo 1 e 2,72±1,11 minutos para o Grupo 2 (p=0,044). Conclusão: o uso de instrumentos para CTVA não torna a cirurgia mais rápida, nem mais segura. O uso de instrumentos de CTVA permitiu uma correção mais rápida dos eventos adversos ocorridos.

The feasibility and effectiveness of thoracoscopic transdiaphragmatic approach for lung biopsy in rabbits. A randomized study

Abstract Purpose To assess the feasibility of thoracoscopic transdiaphragmatic approach for biopsy of all lung lobes and to determine the optimal intercostal space (ICS) for biopsy of each lung lobe. Methods Ten rabbits were positioned in dorsal recumbency. Total thoracoscopy lung biopsy was made combined transdiaphragmatic approach and right ICS approaches. A camera port was made in the transdiaphragmatic approach and the instrument port was made of ICS 7 and ICS 9. A pre tied loop ligature was placed to performed a caudal lung lobe biopsy and to simulate biopsies of the others lung lobes. Results Biopsy of the cranial aspect of the right caudal lung lobe was performed at ICS 9. Simulated biopsy of the accessory lung lobe was performed at ICS 9. Simulated lung biopsy of the right cranial and middle lung lobes was performed at ICS 7. The caudal and dorsal aspect of the right caudal lung lobe was not visualized by telescope at transdiaphragmatic approach, and biopsy was not performed. Conclusions Thoracoscopic transdiaphragmatic approach for lung lobes biopsies was a feasible technique, except for the caudal aspect of the right caudal lung lobe. An ideal intercostal port for biopsy of each right lung lobe was determined.

Simpatectomia torácica por videotoracoscopia: revisão da literatura / Video-assisted thoracic sympathectomy: literature review

RESUMO A simpatectomia toracoscópica mostrou-se eficaz no alívio da hiperidrose em diversos pacientes, com melhora da qualidade de vida. O conhecimento do quadro clínico de cada paciente, assim como, as possíveis complicações pós-operatórias, são fundamentais para a obtenção de bons resultados. Deste modo, foi realizada uma revisão na base de dados PubMed de artigos publicados entre 2005 e 2019 que apresentavam como temática principal a simpatectomia realizada por videotoracoscopia para o tratamento da hiperidrose, com o objetivo de avaliar o atual estado da arte referente à qualidade de vida pós-operatória, o tempo de cirurgia e as suas complicações. A partir desta análise, verificou-se a importância do nível de secção da cadeia ganglionar simpática em relação aos resultados. As complicações, apesar de ocorrerem, não reduziram o nível de satisfação e qualidade de vida pós-operatória dos pacientes.

ABSTRACT. Thoracic sympathectomy has been effective in relieving hyperhidrosis in several patients, with quality of life improvement. The knowledge of the clinical picture of each patient, as well as the possible postoperative complications, are fundamental to obtain good results. Thus, we performed a review of articles from the PubMed database published between 2005 and 2019 that presented, as the main topic, thoracoscopy sympathectomy for the treatment of hyperhidrosis, with the objective of evaluating the current state of art referring to postoperative quality of life, surgical time and its complications. From this analysis, we verified the importance of the level of sympathetic ganglion chain section in relation to results. The complication, although occurring, did not reduced the postoperative level of satisfaction or patients' quality of life.

Segmentectomia pulmonar anatômica robótica: aspectos técnicos e desfechos / Robotic anatomic pulmonary segmentectomy: technical approach and outcomes

RESUMO Objetivo: relatar nossa experiência inicial com a segmentectomia robótica, descrevendo a técnica operatória, a colocação preferencial dos portais, os resultados iniciais e desfechos. Métodos: dados clínicos de pacientes submetidos à segmentectomia robótica, entre janeiro de 2017 e dezembro de 2018, foram obtidos de um banco de dados prospectivo de cirurgia robótica. Todos os pacientes tinham câncer de pulmão, primário ou secundário, ou doenças benignas, e foram operados usando o sistema Da Vinci com a técnica de três portais mais uma incisão utilitária de 3cm. As estruturas hilares foram dissecadas individualmente e as ligaduras dos ramos arteriais e venosos, dos brônquios segmentares, assim como, a transecção do parênquima, realizadas com grampeadores endoscópicos. Dissecção sistemática dos linfonodos mediastinais foi realizada para os casos de câncer de pulmão não de pequenas células (CPNPC). Resultados: quarenta e nove pacientes, dos quais 33 mulheres, foram submetidos à segmentectomia robótica. A média de idade foi de 68 anos. A maioria dos pacientes tinha CPNPC (n=34), seguido de doença metastática (n=11) e doenças benignas (n=4). Não houve conversão para cirurgia aberta ou vídeo, ou conversão para lobectomia. A mediana do tempo operatório total foi de 160 minutos e do tempo de console foi de 117 minutos. Complicações pós-operatórias ocorreram em nove pacientes (18,3%), dos quais sete (14,2%) tiveram internação prolongada (>7 dias) devido à fístula aérea persistente (n=4; 8,1%) ou complicações abdominais (n=2; 4%). Conclusão: a segmentectomia robótica é um procedimento seguro e viável, oferecendo curto período de internação e baixa morbidade.

ABSTRACT Objective: to report our initial experience with pulmonary robotic segmentectomy, describing the surgical technique, the preferred positioning of portals, initial results and outcomes. Methods: we collected data, from a prospective robotic surgery database, on patients undergoing robotic segmentectomy between January 2017 and December 2018. All patients had lung cancer, primary or secondary, or benign diseases, and were operated on with the Da Vinci system, by the three portals technique plus one utilitarian incision of 3cm. We dissected the hilar structures individually and performed the ligatures of the arterial and venous branches, of the segmental bronchi, as well as a parenchymal transection, with endoscopic staplers. We carried out systematic dissection of mediastinal lymph nodes for non-small cell lung cancer (NSCLC) cases. Results: forty-nine patients, of whom 33 were women, underwent robotic segmentectomy. The average age was of 68 years. Most patients had NSCLC (n=34), followed by metastatic disease (n=11) and benign disease (n=4). There was no conversion to laparoscopic or open surgery, or to lobectomy. The median total operative time was 160 minutes, and the median console time, 117 minutes. Postoperative complications occurred in nine patients (18.3%), of whom seven (14.2%) had prolonged hospitalization (>7 days) due to persistent air fistula (n=4; 8.1%) or abdominal complications (n=2.4%). Conclusion: robotic segmentectomy is a safe and viable procedure, offering a short period of hospitalization and low morbidity.

Evaluation of Newborn Infants with Prenatally Diagnosed Congenital Pulmonary Airway Malformation: A Single-Center Experience

PURPOSE: Congenital pulmonary airway malformation (CPAM)—a rare developmental anomaly—affects the lower respiratory tract in newborns. By comparing the reliability of diagnostic tools and identifying predictive factors for symptoms, we provide comprehensive clinical data for the proper management of CPAM. METHODS: We reviewed the medical records of 66 patients with prenatally diagnosed CPAM delivered at Severance Children's Hospital between January 2005 and July 2017. RESULTS: We enrolled 33 boys and 33 girls. Their mean gestational age and birth weight were 38.8 weeks and 3,050 g, respectively. Prenatal ultrasonography and postnatal radiography, lung ultrasonography, and chest computed tomography (CT) showed inconsistent findings. Chest CT showed superior sensitivity (100%) and positive predictive value (90%). Among the 66 patients, 59 had postnatally confirmed CPAM, three had pulmonary sequestration, one had cystic teratoma, and one had a normal lung. Of the 59 patients with CPAM, 21 (35%; mean age, 23.4 months) underwent surgery, including 15 who underwent video-assisted thoracoscopy. Twenty-five and 12 patients exhibited respiratory symptoms at birth and during infancy, respectively. Apgar scores and mediastinal shift on radiography were significantly associated with respiratory symptoms at birth. However, none of the factors could predict respiratory symptoms during infancy. CONCLUSION: Radiography or ultrasonography combined with chest CT can confirm an unclear or inconsistent lesion. Apgar scores and mediastinal shift on radiography can predict respiratory symptoms at birth. However, symptoms during infancy are not associated with prenatal and postnatal factors. Chest CT combined with periodic symptom monitoring is important for diagnosing and managing patients with prenatally diagnosed CPAM and to guide appropriate timing of surgery.

Planting Seeds into the Lung: Image-Guided Percutaneous Localization to Guide Minimally Invasive Thoracic Surgery

Image-guided localization materials are constantly evolving, providing options for the localization of small pulmonary nodules to guide minimally invasive thoracic surgery. Several preoperative methods have been developed to localize small pulmonary lesions prior to video-assisted thoracic surgery. These localization techniques can be categorized into 4 groups according to the materials used: localization with metallic materials (hook-wire, microcoil, or spiral coil), localization with dye (methylene blue or indigo carmine), localization with contrast agents (lipiodol, barium, or iodine contrast agents), and radiotracers (technetium-99m). However, the optimal localization method has not yet been established. In this review article, we discuss the various localization techniques and the advantages and disadvantages of localization techniques as well as the available safety and efficacy data on these techniques.

Comparison of the effect of two different surgical approaches for thymoma under thoracoscopy / 中国基层医药

Objective@#To compare the effects of video assisted thoracoscopic surgery(VATS) of intercostal surgery and by subxiphoid surgical treatment for early thymoma, to investigate the feasibility and clinical application value of VATS subxiphoid surgical treatment for thymoma.@*Methods@#From January 2014 to January 2017, 30 thymoma patients who met the diagnostic criteria of the Masaoka stageⅠ~Ⅱ in the People's Hospital of Jingshan County were selected, and were divided into two groups according to the different surgical methods.The observation group (12 patients) received VATS underwent subxiphoid surgery, 18 patients in the control group were treated with VATS intercostal surgery.The operation time, blood loss, drainage time, length of stay, degree of pain, antibacterial time, incidence rate of complication and patients' satisfaction were compared between the two groups.@*Results@#The preoperative general data between the two groups had no statistically significant differences(all P>0.05). The operation time, intraoperative bleeding volume, postoperative drainage time, antibacterial time, postoperative hospitalization time in the observation group were (102.2±26.6)min, (105.9±29.4)mL, (3.8±1.4)d, (6.8±0.3)d, (8.5±1.6)d, respectively, which in the control group were (124.6±35.1)min, (255.6±82.8)mL, (5.2±1.2)d, (9.3±0.8)d, (14.4±1.8)d, respectively, there were statistically significant differences between the two groups(t=1.516, 2.517, 2.857, 4.462, 3.327, all P<0.05). The incidence rate of complications (8.33% vs.16.67%), satisfaction(82% vs.59%) between the two groups had statistically significant differences(χ2=4.013, 4.427, all P<0.05). During the follow-up period, there was no recurrence or metastasis in the two groups.@*Conclusion@#Compared with VATS intercostal surgery, VATS subxiphoid approach for surgical treatment of thymoma can reduce surgical trauma and reduce the incidence of complications, reduce the pain of patients, shorten the hospitalization time, its curative effect is more significant.

Clinical analysis of video-assisted thoracoscopic surgery in 65 patients with early non-small cell lung cancer / 中国基层医药

Objective@#To study the clinical effect of video-assisted thoracoscopic surgery in the treatment of early non-small cell lung cancer(NSCLC).@*Methods@#130 cases with early NSCLC were selected.According to random number table, the patients were divided into the observation group and the control group, 65 cases in each group.The observation group was treated with video-assisted thoracoscopic surgery, while the control group was treated with thoracotomy.The perioperative period of the two groups was compared, 24h before operation and 24h after operation, the changes of T lymphocyte subsets(CD3+ , CD4+ , CD4+ /CD8+ ) were measured, and the postoperative complications were recorded.The patients were followed up for one year, the survival rate and recurrence rate were recorded.@*Results@#There was no statistically significant difference in the number of lymph node dissection between the two groups(t=1.023, P>0.05). The operation time of the observation group was significantly longer than that of the control group(t=6.479, P<0.05), the amount of bleeding of the observation group was significantly less than that of the control group, the postoperative drainage time and ambulation time of the observation group were significantly shorter than those of the control group, the pain score of the observation group was lower than that of the control group, the differences were statistically significant(t=17.081, 16.040, 39.443, 21.237, all P<0.05). After operation, the CD3+ , CD4+ , CD4+ /CD8+ in the two groups were significantly reduced compared with before operation(observation group: t=5.591, 5.300, 4.300; the control group: t=10.450, 10.735, 4.883, all P<0.05), the CD3+ , CD4+ , CD4+ /CD8+ of the observation group were significantly higher than those of the control group[(58.95±7.58)% vs.(52.42±7.52)%, (34.83±3.75)% vs.(30.07±3.12)%, (1.21±0.17) vs.(1.15±0.13), t=4.931, 7.867, 2.260, all P<0.05]. The incidence rate of complications of the observation group was significantly lower than that of the control group[6.15%(4/65) vs.18.46%(12/65), χ2=4.561, P<0.05]. The patients were followed up for 1 year, there were no statistically significant differences in survival and recurrence between the two groups(χ2=0.367, 0.208, all P>0.05).@*Conclusion@#Video-assisted thoracoscopic surgery is well for early NSCLC patients, with advantages of small trauma, quick recovery, and it can help to protect the immune function of the organism, the clinical value is high.

Abordagem vídeo-toracoscópica, sem sutura, das perfurações do esôfago torácico diagnosticadas tardiamente / Video-thoracoscopic approach, without suture, of late thoracic esophageal perforations

RESUMO Objetivos: avaliar a utilização da vídeo-toracoscopia, no tratamento das perfurações tardias do esôfago torácico, sem sutura ou ressecção do órgão. Métodos: análise retrospectiva de pacientes com diagnóstico tardio (>12 horas) de perfuração do esôfago torácico tratados por vídeo-toracoscopia, sem sutura ou ressecção do órgão, num período de 15 anos. Resultados: foram operados 16 pacientes, sendo dez homens e seis mulheres, com idades entre 48 e 66 anos e com tempo entre o diagnóstico da perfuração e a cirurgia variando entre 16 e 26 horas. Todos os pacientes foram submetidos a vídeo-toracoscopia, com decorticação pulmonar, abordagem das loculações pleurais, abertura da pleura mediastinal junto ao local da perfuração e desbridamento dos tecidos desvitalizados, seguido por dupla drenagem da cavidade pleural. Não foi realizada sutura ou ressecção esofagiana, e os pacientes evoluíram com fechamento completo das lesões, sem óbitos. Conclusão: a abordagem cirúrgica vídeo-toracoscópica mostrou-se capaz de controlar a infecção pleural, a expansão pulmonar e possibilitar a completa regeneração do esôfago com perfuração diagnosticada tardiamente.

ABSTRACT Objectives: to evaluate the use of video-thoracoscopy, in the treatment of late perforations of the thoracic esophagus, without suture or organ resection. Methods: retrospective analysis of patients with late diagnosis (> 12 hours) of thoracic esophageal perforation treated by video-thoracoscopy, without suture or organ resection, over a 15-year period. Results: sixteen patients were operated on, ten men and six women, aged between 48 and 66 years, with time between the diagnosis of the perforation and the surgery ranging from 16 to 26 hours. All patients underwent video-thoracoscopy, with pulmonary decortication, pleural loculations approach, opening of the mediastinal pleura near the perforation site and debridement of the devitalized tissues, followed by double drainage of the pleural cavity. No esophageal suture or resection was performed, and the patients evolved with complete closure of the lesions, without deaths. Conclusion: the video-thoracoscopic surgical approach was able to control pleural infection, pulmonary expansion and enable complete regeneration of the esophagus with late-diagnosed perforation.

Anatomic pulmonary resection via video-assisted thoracic surgery: analysis of 117 cases at a referral center in Brazil / Ressecções pulmonares anatômicas por cirurgia torácica videoassistida: experiência de 117 casos em um centro de referência no Brasil

ABSTRACT Objective: To describe our experience with video-assisted thoracic surgery (VATS) for anatomic pulmonary resection at a referral center for thoracic surgery in Brazil. Methods: All patients who underwent anatomic pulmonary resection by VATS between 2010 and 2015 were included. Clinical and pathological data, as well as postoperative complications, were analyzed. Results: A total of 117 pulmonary resections by VATS were performed, of which 98 were lobectomies and 19 were anatomic segmentectomies. The mean age of the patients was 63.6 years (range, 15-86 years). Females predominated (n = 69; 59%). The mean time to chest tube removal was 2.47 days, and the mean length of ICU stay was 1.88 days. The mean length of hospital stay was 4.48 days. Bleeding ≥ 400 mL occurred in 15 patients. Conversion to thoracotomy was required in 4 patients. Conclusions: Our results are similar to those published in major international studies, indicating that VATS is an important strategy for pulmonary resection. They also show that VATS can be safely performed with adequate training. This technique should be used more often for the treatment of lung diseases in Brazil.

RESUMO Objetivo: Relatar a experiência com cirurgia torácica videoassistida (CTVA) para ressecções pulmonares anatômicas em um centro nacional de referência de cirurgia torácica no Brasil. Métodos: Foram incluídos todos os pacientes tratados com ressecções pulmonares anatômicas por CTVA entre 2010 e 2015 e analisados dados clínicos e patológicos, assim como complicações pós-operatórias. Resultados: Foram realizadas 117 ressecções pulmonares por CTVA, sendo 98 lobectomias e 19 segmentectomias anatômicas. A média de idade foi de 63,6 anos (variação, 15-86 anos), sendo a maioria mulheres (n = 69; 59%). A média de tempo de permanência com dreno foi de 2,47 dias e a de estada em UTI foi de 1,88 dias. A média de tempo de internação foi de 4,48 dias. Sangramento ≥ 400 ml ocorreu em 15 pacientes. Houve conversão para toracotomia em 4 pacientes. Conclusões: Nossos resultados vão ao encontro de publicações em grandes séries internacionais, corroborando que a CTVA é uma importante via de execução de ressecções pulmonares e que pode ser realizada com segurança quando há treinamento adequado, devendo ser mais utilizada no Brasil para o tratamento das doenças pulmonares.