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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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.

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.

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.

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.

Clinical courses and outcomes of five patients with primary lung cancer surgically treated while affected by Severe acute respiratory syndrome coronavirus 2.

OBJECTIVES: There is currently a lack of clinical data on the novel beta-coronavirus infection [caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)] and concomitant primary lung cancer. Our goal was to report our experiences with 5 patients treated for lung cancer while infected with SARS-CoV-2. METHODS: We retrospectively evaluated 5 adult patients infected with SARS-CoV-2 who were admitted to our thoracic surgery unit between 29 January 2020 and 4 March 2020 for surgical treatment of a primary lung cancer. Clinical data and outcomes are reported. RESULTS: All patients were men with a mean age of 74.0 years (range 67-80). Four of the 5 patients (80%) reported chronic comorbidities. Surgery comprised minimally invasive lobectomy (2 patients) and segmentectomy (1 patient), lobectomy with en bloc chest wall resection (1 patient) and pneumonectomy (1 patient). Mean chest drain duration was 12.4 days (range 8-22); mean hospital stay was 33.8 days (range 21-60). SARS-CoV-2-related symptoms were fever (3 patients), persistent cough (3 patients), diarrhoea (2 patients) and syncope (2 patients); 1 patient reported no symptoms. Morbidity related to surgery was 60%; 30-day mortality was 40%. Two patients (1 with a right pneumonectomy, 74 years old; 1 with a lobectomy with chest wall resection and reconstruction, 70 years old), developed SARS-CoV-2-related lung failure leading to death 60 and 32 days after surgery, respectively. CONCLUSIONS: Lung cancer surgery may represent a high-risk factor for developing a severe case of coronavirus disease 2019, particularly in patients with advanced stages of lung cancer. Additional strategies are needed to reduce the risk of morbidity and mortality from SARS-CoV-2 infection during treatment for lung cancer.

An Innovative Way to Achieve Safe Lung Deflation During One-Lung Ventilation in a Potential Coronavirus Disease 2019 Patient: A Case Report.

A novel coronavirus pandemic may be particularly hazardous to health care workers. Airway management is an aerosol-producing high-risk procedure. To minimize the production of airborne droplets, including pathogens such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), from the endotracheal tube during procedures requiring lung deflation, we devised a technique to mitigate the risk of infection transmission to health care personnel.