Application of "suction-guided stapling" during uniportal thoracoscopic major lung resection.

Uniportal thoracoscopic major pulmonary resection is used worldwide as a minimally invasive surgery. Occasionally, it is difficult to insert a stapler smoothly during uniportal thoracoscopic major pulmonary resection because of limited angulation. To address this challenge, we used "suction-guided stapling" to divide the bronchus or pulmonary vein. Here, we provide details of this technique, including division of the pulmonary veins or bronchus in a video. In addition, we validate this technique by showing perioperative results of uniportal thoracoscopic major pulmonary resections in our department.

The learning curve of thoracoscopic surgery in a single surgeon and successful implementation of uniportal approach.

BACKGROUND: In some institutions, a recently introduced uniportal approach has replaced the multiportal approach for thoracoscopic major pulmonary resection. This study investigated the effect of this change on the surgical learning curve by examining the perioperative results of a single surgeon. METHODS: Between April 2012 and August 2020, 376 patients with primary lung cancer underwent thoracoscopic lobectomy with ND2a-1/2 lymphadenectomy in the authors' hospital. Surgery was performed by one of the authors in 189 of these patients, who were thus enrolled in this retrospective study. The surgeries were classified chronologically into five phases and the operative time, rate of intraoperative massive bleeding, and rate of postoperative prolonged air leak (PAL) were then compared. The learning curve (i.e., operative time) was assessed by Spearman's rank correlation test. The perioperative results achieved with the uniportal and multiportal approaches were also compared before and after the patients were matched for their characteristics based on the propensity score. RESULTS: The five phases differed significantly with respect to the operative time and rate of postoperative PAL (P<0.0001, P=0.0061). The correlation between operative time and number of consecutive cases was also significant (r=-0.579, P<0.0001). Superior results in terms of operative time (P<0.0001), duration of postoperative drainage (P<0.0001), and rate of postoperative PAL (P=0.0034) were obtained using a uniportal rather than multiportal approach. CONCLUSIONS: The transition from a multiportal to a uniportal approach did not cause a decline in the learning curve of thoracoscopic lobectomy with ND2a-1/2 lymphadenectomy.

[Erlotinib plus Bevacizumab Therapy for Postoperative Recurrence of Adenosquamous Cell Carcinoma Harboring EGFR Mutation-A Case Report].

A 59-year-old man clinically diagnosed with primary lung cancer underwent left lower lobectomy and lymph node dissection( ND2a-2). The postoperative pathological stage was ⅠB(pT2aN0M0), and the lesion was positive for epidermal growth factor receptor(EGFR)exon 21 L858R mutation. Thirty months after surgery, the patient developed pleural dissemination and effusion in the left pleural cavity. Carboplatin(AUC=6, day 1, every 3 weeks)and nab-paclitaxel(100 mg/m2, day 1 and day 8, every 3 weeks)were administered as first-line therapy. Progressive disease was evident 10 months after 4 courses of first-line therapy. Pembrolizumab(200 mg, day 1, every 3 weeks)was then administered as second-line therapy. After 7 months(9 courses of therapy), the lung cancer had metastasized to the left third intercostal muscle, and the pleural nodules regrew. The former lesion was treated with radiotherapy owing to the development of pain in the chest. Erlotinib (150 mg once daily)and bevacizumab(15 mg/kg, day 1, every 3 weeks)were initiated as third-line therapy, resulting in complete response at 14 months(67 months after surgery, 37 months after postoperative recurrence). The prognosis of patients with EGFR-positive pulmonary adenosquamous carcinoma and undergoing treatment with EGFR-tyrosine kinase inhibitors(TKI)is reportedly poor. Herein, we report a rare case of adenosquamous carcinoma with EGFR mutation presenting complete response following treatment with EGFR-TKI.

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

OBJECTIVE: In this study, we introduce a novel approach, thoracoscopic transareolar bullectomy, for treating young male patients with primary spontaneous pneumothorax (PSP). This approach might be less invasive and cosmetically superior to existing methods. We also prospectively compared transareolar and uniportal approaches. METHODS: Between April 2018 and July 2019, 40 patients were prospectively assigned to transareolar (n = 21) and uniportal (n = 19) groups. We compared patient characteristics and perioperative results. Approximately 1 week or 1 year after the operation, postoperative pain was evaluated using a numerical rating scale (NRS), and cosmetic satisfaction was graded on a four-point scale. RESULTS: We found no significant between-group differences in patient characteristics or perioperative results. NRS scores did not differ on postoperative day (POD) 7 (transareolar, 1.8 ± 0.9 vs. uniportal, 1.6 ± 0.9; p = 0.62) or in postoperative month (POM) 12 (transareolar, 1.3 ± 0.5 vs. uniportal, 1.1 ± 0.5; p = 0.18). In terms of cosmetic satisfaction, the transareolar group was more satisfied on POD 7 (transareolar, 3.5 ± 0.6 vs. uniportal, 2.9 ± 0.9; p = 0.02) and in POM 12 (transareolar, 3.8 ± 0.5 vs. uniportal, 3.3 ± 0.9; p = 0.0065). CONCLUSION: Although the perioperative results of the transareolar and uniportal approaches were similar, the former approach afforded a little better cosmetic satisfaction and might be useful option for young males with PSP.

[Postoperative Recurrence of ROS1‒Positive Pulmonary Adenocarcinoma after 19 Years].

A 73‒year‒old woman underwent right lower lobectomy for Stage ⅠA(pathological Stage T1N0M0)pulmonary adenocarcinoma. After 19 years, she complained of dyspnea on exertion. Computed tomography revealed metastatic lesions in the bilateral supraclavicular, mediastinal, and hilar lymph nodes. Thoracoscopic lymph node biopsy showed recurrence of the adenocarcinoma, and immunohistochemical staining confirmed that the metastases were ROS1‒positive. The patient responded well to crizotinib therapy. The prognosis of non‒small‒cell lung cancer is considered favorable when it does not recur within 5 years, postoperation. However, few studies have reported the recurrence of ROS1‒positive pulmonary adenocarcinoma after a long disease‒free interval. Long‒term postoperative follow‒up is essential for patients with ROS1‒positive pulmonary adenocarcinomas.

Dorsal (S2) segmentectomy of right upper lobe via a uniportal approach using near infrared imaging and indocyanine green administration.

Uniportal video-assisted thoracic surgery is becoming more common worldwide, but the limited angle of approach of inserted surgical instruments makes it challenging. Because of this, segmentectomy via a uniportal approach is more difficult technically than a multiportal approach. In addition, the inflation/deflation technique, which is a standard method for identifying the intersegmental plane, is often less useful because it can be difficult to get a good surgical view. To resolve this problem, a technique using near infrared imaging and indocyanine green  administration technique  can be very helpful in performing a uniportal segmentectomy. In this video tutorial, we demonstrate a uniportal thoracoscopic dorsal segmentectomy of the right upper lobe of a patient with primary lung cancer, using a near infrared imaging/indocyanine green technique. We explain the nuances of the procedure and how to perform it, and we discuss our successful results.