The uniportal VATS in the treatment of stage II pleural empyema: a safe and effective approach for adults and elderly patients-a single-center experience and literature review.

BACKGROUND: Pleural empyema (PE) is a frequent disease, associated with a high morbidity and mortality. Surgical approach is the standard of care for most patients with II-III stage PE. In the last years, the minimally invasive surgical revolution involved also thoracic surgery allowing the same outcomes in terms of safety and effectiveness combined to better pain management and early discharge. The aim of this study is to demonstrate through our experience on uniportal-video-assisted thoracoscopy (u-VATS) the effectiveness and safety of its approach in treatment of stage II PE. As secondary endpoint, we will evaluate the different pattern of indication of u-VATS in adult and elderly patients with literature review. METHODS: We retrospectively reviewed our prospectively collected database of u-VATS procedures from November 2018 to February 2022, in our regional referral center for Thoracic Surgery of Regione Molise General Surgery Unit of "A. Cardarelli" Hospital, in Campobasso, Molise, Italy. RESULTS: A total of 29 patients underwent u-VATS for II stage PE. Fifteen (51.72%) patients were younger than 70 years old, identified as "adults," 14 (48.28%) patients were older than 70 years old, identified as "elderly." No mortality was found. Mean operative time was 104.68 ± 39.01 min in the total population. The elderly group showed a longer operative time (115 ± 53.15 min) (p = 0.369). Chest tube was removed earlier in adults than in elderly group (5.56 ± 2.06 vs. 10.14 ± 5.58 p = 0.038). The Length of Stay (LOS) was shorter in the adults group (6.44 ± 2.35 vs. 12.29 ± 6.96 p = 0.033). Patients evaluated through Instrumental Activities of Daily Living (IADL) scale returned to normal activities of daily living after surgery. CONCLUSION: In addition, the u-VATS approach seems to be safe and effective ensuring a risk reduction of progression to stage III PE with a lower recurrence risk and septic complications also in elderly patients. Further comparative multicenter analysis are advocated to set the role of u-VATS approach in the treatment of PE in adults and elderly patients.

[Application and Research Progress of Video Double-lumen Tube in Thoracic Surgery].

The rapid development and promotion of minimally invasive thoracic surgery represented by video-assisted thoracoscopy surgery has gradually replaced traditional thoracic surgery technique as the primary choice for the treatment of pulmonary nodules, including early lung cancer. With the clinical application of double-lumen bronchial catheters, the realization of one-lung ventilation technology not only provides a solid anesthesia foundation for the popularization of minimally invasive thoracic surgery, but also provides a guarantee for the rapid and smooth implementation of the operation. However, compared with single-lumen bronchial catheters, the diameter of the double-lumen bronchial catheter is thicker, and the tube body is hard and difficult to shape, which brings inconvenience to anesthesia intubation. The bronchial structure is different, and the incidence of dislocation during anesthesia intubation is also high. With the gradual clinical use of video double-lumen tube (VDLT), it has become a hot spot in thoracic surgery in recent years. This article reviews the application and research progress of VDLT in thoracic surgery.
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Early outcomes of lung resections in non-small cell lung cancer after COVID-19 pneumonia.

OBJECTIVE: There is limited literature on patients with a history of COVID-19 pneumonia who underwent anatomical lung resection for non-small cell lung cancer (NSCLC). This study was aimed to share the early postoperative outcomes in patients who underwent lung resection after COVID-19 pneumonia. MATERIALS AND METHODS: We retrospectively evaluated 30 patients who underwent lobectomy with thoracotomy and systematic mediastinal lymph node dissection due to NSCLC in a single center between November 2018 and September 2021. The patients were divided into two groups regarding COVID-19 pneumonia history; the COVID-19 group consisted of 14 patients (46.7%) and the non-COVID-19 group 16 (53.3%) patients. The patients' age, gender, comorbidity, Charlson Comorbidity Index (CCI) score, forced expiratory volume in 1 s (FEV1) value, tumor type and size, resection type, postoperative air leak duration, total drainage volume, drain removal time, postoperative complications, and length of stay (LOS) were recorded. RESULTS: 9 (30%) patients were female, and 21 (70%) were male. The mean age was 62.1 ± 8.91 years. Our comparison of postoperative air leak duration, total drainage volume, time to drain removal, postoperative complications, and LOS between the COVID-19 and non-COVID-19 groups revealed no statistically significant difference. CONCLUSION: Anatomical lung resection can be performed safely in NSCLC patients with a history of COVID-19 pneumonia without significant difference in early postoperative morbidity and mortality.

Life-Threatening Cardiac Tamponade Secondary to COVID-19 Treated with Uniportal Video-Assisted Thoracoscopic Surgery: A Case Report.

BACKGROUND The COVID-19 outbreak emerged in December 2019 in Wuhan, China. COVID-19 is caused by the SARS-CoV-2 coronavirus and mostly affects the respiratory system but can also affect other organs, including the cardiovascular system. Furthermore, the most common cardiac complications include severe left ventricular dysfunction, acute myocardial injury, and arrhythmias. Life-threatening cardiac tamponade and large pericardial effusion are exceedingly rare complications in patients recovered from COVID-19. Previously, this condition was treated with pericardiocentesis, colchicine, and corticosteroids. CASE REPORT We present the case of a 54-year-old man who recovered from a SARS-CoV-2 infection 7 days before presentation and describe a complicated pericardial effusion with life-threatening cardiac tamponade. To the best of our knowledge, this is the first case of pericardial effusion with cardiac tamponade that was successfully treated with single port or uniportal video-assisted thoracoscopic surgery with an excellent outcome. CONCLUSIONS Life-threatening cardiac tamponade with pericardial effusion is an exceedingly rare complication in patients recovered from COVID-19. Generally, patients diagnosed with pericardial effusion undergo a pericardiocentesis procedure. Although there are multiple treatment options for draining pericardial effusion, the recurrence rate with surgical pericardial window formation is the lowest. However, our patient underwent surgery using a uniportal video-assisted thoracoscopic surgery with an excellent outcome.

A holistic investigation of the global outcomes of spontaneous pneumothorax during 1980-2021, including the COVID-19 pandemic A bibliometric approach.

BACKGROUND: During coronavirus pandemic, despite the increase in the number of studies on spontaneous pneumothorax (SP), there is not enough bibliometric study in the literature. In this study, it was aimed to analyze scientific articles published on SP. METHODS: Studies published on SP between 1980 and 2021 were obtained from the Web of Science database and analyzed using statistical and bibliometric methods. Spearman correlation coefficient was used for correlation studies. The exponential smoothing estimator was used to forecast publication trend for coming years. Network visualization maps were used to analyze citations and identify trending topics. RESULTS: A total of 2422 publications were found. 1403 (57.9%) of these publications were articles. The articles on SP have increased with a non-linear trend in recent years. The top 5 contributors to the literature were USA (231, 16.4%), Japan (161, 11.4%), United Kingdom (98, 6.9%), France (81, 5.7%), and Taiwan (78, 5.5%). The top 3 most active institutions were National Taiwan University Hospital (22, 1.5%), Catholic University Korea (19, 1.3%), and National Taiwan University (19, 1.3%). The top 3 journals that published the most articles were Chest (51), Annals of Thoracic Surgery (46), and Journal of Thoracic Disease (45). The most studied subjects were primary SP, recurrence, thoracoscopy, pleurodesis, video-assisted thoracoscopic surgery, COVID-19, video-assisted thoracic surgery, chest tube(s), and secondary spontaneous pneumothorax. According to trend topics analysis, the keywords studied in recent years are COVID-19, chest tubes, pneumonia, subcutaneous emphysema, risk factors, dyspnea, primary SP, FLCN gene, tension pneumothorax, uniportal, postoperative recurrence, secondary spontaneous pneumothorax, chronic obstructive pulmonary disease, and uniportal. CONCLUSION: In this comprehensive bibliometric study, we summarized 1403 articles about SP, which has an increasing trend in the number of articles during the COVID-19 pandemic process. This article can be a useful resource for clinicians and scientists through presenting a summary of worldwide studies related to SP, including the ones during COVID-19 pandemic.

Pre-COVID-19 National Mortality Trends in Open and Video-Assisted Lobectomy for Non-Small Cell Lung Cancer.

INTRODUCTION: In the current era of episode-based hospital reimbursements, it is important to determine the impact of hospital size on contemporary national trends in surgical technique and outcomes of lobectomy. METHODS: Patients aged >18 y undergoing open and video-assisted thoracoscopic surgery (VATS) lobectomy from 2008 to 2014 were identified using insurance claims data from the National Inpatient Sample. The impact of hospital size on surgical approach and outcomes for both open and VATS lobectomy were analyzed. RESULTS: Over the 7-y period, 202,668 lobectomies were performed nationally, including 71,638 VATS and 131,030 open. Although the overall number of lobectomies decreased (30,058 in 2008 versus 27,340 in 2014, P < 0.01), the proportion of VATS lobectomies increased (24.0% versus 46.9%), and open lobectomies decreased (76.0% versus 53.0%, all P < 0.01). When stratified by hospital size, small hospitals had a significant increase in the proportion of open lobectomies (6.4%-12.2%; P = 0.01) and trend toward increased number of VATS lobectomies (2.7%-12.2%). Annual mortality rates for VATS (range: 1.0%-1.9%) and open (range: 1.9%-2.4%) lobectomy did not significantly differ over time (all P > 0.05) but did decrease among small hospitals (4.1%-1.3% and 5.1%-1.1% for VATS and open, respectively; both P < 0.05). After adjusting for confounders, hospital bed size was not a predictor of in-hospital mortality. CONCLUSIONS: Utilization of VATS lobectomies has increased over time, more so among small hospitals. Mortality rates for open lobectomy remain consistently higher than VATS lobectomy (range 0.4%-1.4%) but did not significantly differ over time. This data can help benchmark hospital performance in the future.

Comparative early results of a robotics-assisted endoscope holder in single port thoracoscopic surgery in the era of COVID-19.

BACKGROUND: Innovations in surgical instruments have made single-port surgery more widely accepted and lead to a reduced demand for surgical assistants. As COVID-19 has ravaged the world, maintaining minimum medical staffing requirements and proper social distancing have become major topics of interest. We sought to evaluate the feasibility of applying the unisurgeon approach in single-port video-assisted thoracoscopic surgery aided by a robotic camera holder. METHODS: Operative time, blood loss, setup time, postoperative hospital stays, and the number of participating surgeons in single-port video-assisted thoracoscopic lung resections were gathered for investigation after the introduction of the ENDOFIXexo robotic endoscope holder system. In this cohort, we collected 213 patients who underwent single port video thoracoscope surgery, including 57 patients underwent robotic endoscope arm assisted surgery and case-matched 52 patients in the robotic arm-assisted group with patients in the human-assisted group through propensity score-matched analysis. RESULTS: In wedge resection, a single surgeon was able to completely operate on all lobes of target lesions. However, for anatomical resections, namely segmentectomy, the success rate was 95%, and for lobectomy, the success rate was only 64%. No significant differences between setup times, blood loss, or operative times between the two groups were observed. CONCLUSIONS: When an experienced uniport surgeon is assisted by a robotic endoscope holder, wedge resection is the most suitable procedure to be performed through unisurgeon single-port video-assisted thoracoscopic surgery without increasing setup time, operative time, or short-term complications. Verification of the technique's applicability for use in anatomic resections requires further investigation.

Starting the first robotic lobectomy program in the Eastern Europe during Coronavirus disease-2019 pandemic.

BACKGROUND: We report our experience in starting RATS (robotic-assisted thoracic surgery) lobectomy program during COVID-19 pandemic. METHODS: Data from 20 consecutive cases undergoing RATS lobectomy between August 2020 and April 2021 were prospectively accumulated into our database. RESULTS: The mean operational time was 235±69 minutes (median 210, range 175 to 370). Conversion-to-open rate was 5 %. One patient was converted to an open procedure during surgery due to surgical bleeding. One patient (5 %), with sever chronic obstructive pulmonary disease (COPD), had prolonged air leak with chest drainage 11 days and conservative treatment. Morbidity rate was 10 % (2 patients). Estimated costs of RATS lobectomy in our department were $9,590 (range $8,250-$12,730). 30-days mortality was 0%. CONCLUSIONS: Safe robotic surgery is based not only on improved robotic equipment, but also on good technical skills and medical knowledge. It requires training of the entire operating room team. The learning curve is steep, involving port placement, use of the correct robotic arms, availability of the proper instrumentation, and proper patient positioning (Tab. 2, Ref. 28).

Pivotal role of video-assisted thoracoscopic surgery in improving survival outcome of stage I non-small cell lung cancer in day surgery patients.

BACKGROUND: Lung cancer, the leading cause of cancer-related deaths worldwide, has high morbidity rates. Video-assisted thoracoscopic surgery (VATS) as day surgery makes surgical treatment ideally in time with the same quality of medical care. This study aimed to assess the safety of stage I NSCLC patients who underwent VATS at a day surgery center. METHODS: We retrospectively analyzed the clinical characteristics and tumor features of VATS patients at a single center, West China Hospital, from June 1, 2019, to December 31, 2020. Patients fulfilled all inclusion criteria, did not meet any exclusion criteria and underwent wedge resection, segmentectomy, or lobectomy with systematic lymph node dissection. RESULTS: The median patient age was 43 (range, 19-67) years. Of the 209 patients, most were women. A total of 108 (51.7%) patients underwent segmentectomy, 87 (41.6%) lobectomy, and 14 (6.7%) wedge resection with systematic lymph node dissection. According to the AJCC/UICC eighth edition of lung cancer stage grouping, stages IA, IA1, IA2, and IA3 were 195 (93.3%), 122 (58.4%), 50 (23.9%), and one (0.5%), respectively. A total of 36 (17.2%) patients were stage 0. Adenocarcinoma was predominantly the postoperative pathological diagnosis, as only 14 (6.7%) were benign. A total of 201 (96.17%) patients were discharged without a chest tube. The most common chief complaints were cough, incisional pain, and shortness of breath. No severe complications or life-threatening emergencies were observed. CONCLUSIONS: The day surgery mode of VATS for stage I NSCLC is safe and feasible, which makes surgical treatment ideally in time for stage I NSCLC patients with the same quality of medical care.

Powered articulation by the SigniaTM stapling system for stapling position adjustments: optimizing safe surgical margins in thoracoscopic sublobar resection.

Accumulation of experience and advances in techniques and instruments have enabled surgeons to perform video-assisted thoracic surgery (VATS) safely for sublobar resection, including segmentectomy and wedge resection. A key to successful VATS sublobar resection is to have adequate resection margins and the appropriate use of articulated surgical staplers is essential for this purpose. The SigniaTM stapling system (Covidien Japan, Tokyo) has been used extensively in the fields of thoracic surgery. Its features include high maneuverability with fully powered articulation, rotation, clamping, and firing, which the surgeon can control with one hand. We introduce the "sliding technique" using the SigniaTM system, which allows for adjustment of the resection lines of the pulmonary parenchyma to optimize safe surgical margins with minimal stapler movement, and without repetitively moving the stapler in and out of the pleural cavity, during VATS sublobar resection.

Novel technique for parietal pleural dissection using a laparoscopic hernia balloon.

We describe a novel technique for the creation of a pleural tent and pleurectomy via the use of a laparoscopic hernia balloon. In this method a Spacemaker™ Structural Balloon Trocar (Covidien, USA) is tunnelled under the pleura at the site of thoracotomy or video assisted thoracoscopic surgery port and incrementally inflated under vision. This method is less traumatic than traditional methods, is more likely to provide an intact pleural tent, and allows the surgeon to operate in a near bloodless operative field.

Development of cavitary lung disease as a long-term complication of coronavirus disease 2019 in a young previously healthy patient: a case report.

BACKGROUND: Cavities are frequent manifestations of a wide variety of pathological processes involving the lung. There has been a growing body of evidence of coronavirus disease 2019 leading to a cavitary pulmonary disease. CASE PRESENTATION: A healthy 29-year-old Filipino male presented to the hospital a couple of months after convalescence from coronavirus disease 2019 with severe pleuritic chest pain, fever, chills, and shortness of breath, and was found to have a cavitary lung lesion on chest computed tomography. While conservative management alone failed to improve the patient's condition, he ultimately underwent left lung video-assisted thoracoscopic surgery decortication. Even though the surgical pathology revealed only necrosis with dense acute inflammation and granulation tissue with no microorganisms, he gradually improved with medical therapy adjunct with surgical therapy. CONCLUSION: Documented cases of cavitary lung disease secondary to coronavirus disease 2019 have been mostly reported in the acute or subacute phase of the infection. However, clinicians should recognize this entity as a late complication of coronavirus disease 2019, even in previously healthy individuals.

Lobectomy with pathological examination in lung cancer patients who recovered from COVID-19.

We present two cases of lobectomy in lung cancer patients who recovered from COVID-19 before surgical treatment. In both cases, video-assisted thoracoscopic surgery was initiated and hilar fibrosis was detected; as a result, conversion was performed in one case. There were no postoperative complications and mortality. Also, we demonstrate the results of pathological examination in patients who have recovered from COVID-19.

Simultaneous versus staged resections for bilateral pulmonary metastases.

BACKGROUND: For patients with bilateral pulmonary metastases, staged resections have historically been the preferred surgical intervention. During the spring of 2020, the COVID-19 pandemic made patient travel to the hospital challenging and necessitated reduction in operative volume so that resources could be conserved. We report our experience with synchronous bilateral metastasectomies for the treatment of disease in both lungs. METHODS: Patients with bilateral pulmonary metastases who underwent simultaneous bilateral resections were compared with a cohort of patients who underwent staged resections. We used nearest-neighbor propensity score (1:1) matching to adjust for confounders. Perioperative outcomes were compared between groups using paired statistical analysis techniques. RESULTS: Between 1998 and 2020, 36 patients underwent bilateral simultaneous metastasectomies. We matched 31 pairs of patients. The length of stay was significantly shorter in patients undergoing simultaneous resection (median 3 vs. 8 days, p < .001) and operative time was shorter (156 vs. 235.5 min, p < .001) when compared to the sum of both procedures in the staged group. The groups did not significantly differ with regard to postoperative complications. CONCLUSION: In a carefully selected patient population, simultaneous bilateral metastasectomy is a safe option. A single procedure confers benefits for both the patient as well as the hospital resource system.

Anesthetic Considerations in a Patient With LVAD and COVID-19 Undergoing Video-Assisted Thoracic Surgery.

Increased survival with left ventricular assist devices (LVAD) has led to a large number of patients with LVADs presenting for noncardiac surgeries (NCS). With studies showing that a trained noncardiac anesthesiologist can safely manage these patients when they present for NCS, it is vital that all anesthesiologists understand the LVAD physiology and its implications in various surgeries. This is even more relevant during the current pandemic in which these complex cardiopulmonary interactions may be even more challenging in patients with coronavirus disease 2019 (COVID-19). The authors describe a case of a patient with COVID-19 with an LVAD who needed thoracoscopic decortication for recurrent complex pleural effusion and briefly discuss unique challenges presented and their management.

Pulmonary Lobectomy After COVID-19.

Concomitant coronavirus disease 19 (COVID-19) is a major risk factor for complications in any type of surgical procedure, especially in thoracic surgery, were the primary organ involved, the lung, is manipulated to perform parenchymal resection. However, it is not clear whether previous infection from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may lead to increased morbidity and mortality for subsequent procedures once radiologic resolution is achieved. We report a young patient with lung cancer who successfully underwent a right upper lobectomy for primary adenocarcinoma by video-assisted thoracoscopic surgery with no complication in the early postoperative phase.