A Delphi Consensus report from the "Prolonged Air Leak: A Survey" study group on prevention and management of postoperative air leaks after minimally invasive anatomical resections.

OBJECTIVES: This study reports the results of an international expert consensus process evaluating the assessment of intraoperative air leaks (IAL) and treatment of postoperative prolonged air leaks (PAL) utilizing a Delphi process, with the aim of helping standardization and improving practice. METHODS: A panel of 45 questions was developed and submitted to an international working group of experts in minimally invasive lung cancer surgery. Modified Delphi methodology was used to review responses, including 3 rounds of voting. The consensus was defined a priori as >50% agreement among the experts. Clinical practice standards were graded as recommended or highly recommended if 50-74% or >75% of the experts reached an agreement, respectively. RESULTS: A total of 32 experts from 18 countries completed the questionnaires in all 3 rounds. Respondents agreed that PAL are defined as >5 days and that current risk models are rarely used. The consensus was reached in 33/45 issues (73.3%). IAL were classified as mild (<100 ml/min; 81%), moderate (100-400 ml/min; 71%) and severe (>400 ml/min; 74%). If mild IAL are detected, 68% do not treat; if moderate, consensus was not; if severe, 90% favoured treatment. CONCLUSIONS: This expert consensus working group reached an agreement on the majority of issues regarding the detection and management of IAL and PAL. In the absence of prospective, randomized evidence supporting most of these clinical decisions, this document may serve as a guideline to reduce practice variation.

Pleural Metastasis of Atypical Bronchial Carcinoid.

Pulmonary carcinoids are relatively rare tumors with low metastatic potential. Pleural carcinomatosis of a bronchial carcinoid has only been reported in 4 cases. Due to the rarity of this condition, there are no guidelines for its treatment or management. We report a case of atypical carcinoid with local recurrence and pleural metastases treated by video-assisted thoracoscopic surgery lobectomy and total pleurectomy with photodynamic therapy after non-radical wedge resection.

Uniportal video-assisted thoracic surgery lobectomy: a consensus report from the Uniportal VATS Interest Group (UVIG) of the European Society of Thoracic Surgeons (ESTS).

OBJECTIVES: Our goal was to report the results of the first consensus paper among international experts in uniportal video-assisted thoracoscopic surgery (UniVATS) lobectomy obtained through a Delphi process, the objective of which was to define and standardize the main procedural steps, optimize its indications and perioperative management and identify elements to assist in future training. METHODS: The 40 members of the working group were convened and organized on a voluntary basis by the Uniportal VATS Interest Group (UVIG) of the European Society of Thoracic Surgeons (ESTS). An e-consensus finding exercise using the Delphi method was applied to require 75% agreement for reaching consensus on each question. Repeated iterations of anonymous voting continued for 3 rounds. RESULTS: Overall, 31 international experts from 18 countries completed all 3 rounds of questionnaires. Although a technical quorum was not achieved, most of the responders agreed that the maximum size of a UniVATS incision should be ≤4 cm. Agreement was reached on many points outlining the currently accepted definition of a UniVATS lobectomy, its indications and contraindications, perioperative clinical management and recommendations for training and future research directions. CONCLUSIONS: The UVIG Consensus Report stated that UniVATS offers a valid alternative to standard VATS techniques. Only longer follow-up and randomized controlled studies will predict whether UniVATS represents a valid alternative approach to multiport VATS for major lung resections or whether it should be performed only in selected cases and by selected centres. The next step for the ESTS UVIG is the establishment of a UniVATS section inside the ESTS databases.

Risk factors and outcomes of prolonged air leak after pulmonary resections.

PURPOSE: Prolonged air leak (PAL) is a challenging complication in thoracic surgery. The aim of this study was to analyze the incidence, risk factors, and outcomes of PAL. METHODS: We retrospectively analyzed 319 patients treated in a single center submitted to lobectomy, bilobectomy, segmentectomy, and wedge resections from January 2012 until August 2015. PAL was defined as air leak lasting more than 7 days after surgery. RESULTS: The incidence of PAL was 14.7%. Bronchial obstruction (p < 0.05), low body mass index (BMI, p < 0.05), and hypoproteinemia (p < 0.001) were identified as independent preoperative risk factors of PAL. Intraoperative risk factors were lob- (p < 0.01) and bilobectomies (p < 0.05), pleural adhesions (p < 0.001), and length of stapler line (p < 0.001). Among the postoperative risk factors, we identified the use of active drainage (p < 0.01), the presence of subcutaneous emphysema (p < 0.001), massive air leak on the first postoperative day (POD 1, p < 0.001), and an incomplete re-expansion of the lung (p < 0.001). PAL was not associated with more complications in the postoperative period. One patient required reoperation due to a massive air leak. Twenty-six patients were discharged with a Heimlich valve with no complications and no need for re-admission. CONCLUSIONS: Bronchial obstruction, low BMI, hypoproteinemia, lob- and bilobectomies, pleural adhesions, length of stapler line, use of active drainage, the presence of subcutaneous emphysema, massive air leak on POD 1, and incomplete re-expansion of the lung were identified as independent risk factors of PAL. It had no influence on outcomes.

The role of indocyanine green fluorescence for intersegmental plane identification during video-assisted thoracoscopic surgery segmentectomies.

BACKGROUND: According to recent studies, thoracoscopic segmentectomy is an acceptable alternative to lobectomy for treating different lung diseases. This approach appears to have equivalent rates of postoperative morbidity with potentially similar long-term results even in selected lung cancer patients. At the same time, surgical success is highly dependent on intraoperative interpretation of segmental anatomy. We aimed to analyze our lung segmentectomy experience and identify the role of indocyanine green (ICG)-fluorescence for intersegmental plane detection. METHODS: A total of 86 consecutive patients who underwent 90 thoracoscopic segmentectomies with near-infrared-indocyanine green (NIR-ICG) method between September 2015 and December 2017 were investigated. According to the preoperative 3D lung hilar model, vascular and bronchial branches of the target segment were divided. ICG was thereafter injected into the central or peripheral vein. The boundary lines between the areas with and without fluorescence was marked on the visceral pleura by electrocautery. RESULTS: The fluorescence was detected immediately after bolus ICG injection in the central vein in all patients but had a time delay of 10-25 seconds in cases of peripheral vein administration. The median duration of intensive ICG staining was 90 seconds, regardless of the injection method. Well-defined fluorescence borders were observed in 86 of 90 (95.6%) segmentectomies due to technical reasons in three cases and severe emphysema in one. Chronic obstructive pulmonary disease (COPD) in other patients did not impair the boundary line identification, but reduced the duration of intensive ICG staining. No ICG-related complications were observed. CONCLUSIONS: The ICG-fluorescence technology is safe and effective for verification of anatomic segment borders for video-assisted thoracoscopic surgery (VATS). The perfusion-based ICG fluorescence technique has advantages for thoracoscopic surgeries compared to other methods. Doubling the dose of ICG allows clear detection of the intersegmental plane, even in certain suboptimal conditions.

The results of video-assisted thoracoscopic thymectomies in Saint Petersburg, Russia: 20-year of experience.

BACKGROUND: During the period from 1996 to 2016, we have performed 281 thymectomies in patients with various diseases of the thymus. In 179 patients, thymic pathology was associated with autoimmune myasthenia gravis (MG), and, in 108 patients, thymoma was diagnosed. METHODS: The majority of surgeries [254] were performed using video thoracoscopy, 79 of them with an additional cervical approach. The long-term results of video thoracoscopic thymectomies in myasthenic patients were followed up for 1 to 15.5 years. RESULTS: In 26% of the patients, a complete and stable remission was achieved, in 47%-clinical manifestation improved. Local recurrence of thymoma developed in one patient (0.9%). CONCLUSIONS: Comparison of postoperative complications and long-term results demonstrated that extended video-assisted thoracoscopic thymectomy (VATS-TE) is a radical, efficient, safe, technically feasible and a well-tolerated surgery. It improves the course of MG as a part of multimodality treatment more efficiently than a conservative therapy alone. The course of MG after VATS-TE shows that the cumulative incidence of remissions/improvements reaches its maximum by the 3rd year after the surgery. VATS-TE is radical and safe for removal of noninvasive thymomas up to 8 cm in size. Additional neck incision (VATS-TE + cervical approach) does not provide further advantages, but rather may be a cause of specific postoperative complications.

Thymic MIS: state of the art across the world (Russian Federation).

First VATS thymectomy was performed 25 years ago (Landreneau et al., 1992). After that, minimally invasive approaches for surgical procedures have rapidly increased in the world. The aim of this paper was study of current problems and the status of surgery for thymus diseases in Russia. This is first global survey of all thoracic centers, which had experience in thymic surgery.

Technical difficulties and extending the indications for VATS lobectomy.

BACKGROUND: Data on advantages of video-assisted thoracoscopic surgery (VATS) lobectomies has been accumulated during the last 10 years then number of thoracoscopic anatomic pulmonary resections rapidly increased. But still there is no agreement about limitations of the method. The most popular "technical contraindications" for VATS anatomic pulmonary resections are: dense pleural adhesions, incompleteness of interlobar fissure, previous chemo- or/and radiotherapy, perivascular or/and peribronchial fibrosis, tumor larger than 5 cm, chest wall involvement, centrally located tumor, severe comorbidity, advanced age, severe COPD and emphysema. Extending of indications for the VATS anatomic pulmonary resection and its influence on the immediate outcomes was investigated. METHODS: Ninety two consecutive cases of VATS anatomic pulmonary resection performed by the single surgeon from January 2012 till December 2013 at the Federal University Hospital #122 in Saint Petersburg, Russia were retrospectively analyzed. Forty three males and 49 females at the age from 21 to 87 years old (mean age 59±7.2). The most of the cases were comprised by lung cancer of I-III stage together with bronchiectasis and tuberculomas. Conversion rate was 3.2% mostly due to perivascular calcification and/or fibrosis. There were no cases of 30-days mortality and readmission. All those patients retrospectively divided into two groups: with standard and extended indications for the VATS lobectomy. Inclusion in "extended" group was made if patients had one or more technical challenges among following: size of the lesion 5 cm and more; strong pleural adhesions and/or "bad fissure"; adjacent structures involvement; hilar or mediastinal lymph nodes enlargement or involvement; centrally located tumors; previous chemo- or chemoradiotherapy or previous thoracic surgery. RESULTS: According to these criteria, 45 standard (S) and 47 extended (E) patients were pair-matched with no statistically significant differences between the groups in common patients' characteristics. Postoperative comparison of "standard" and "expanded" groups revealed some differences in average operation time (152 vs. 189 min), in number of resected mediastinal lymph nodes (10.2 vs. 13.1), and in the mean time before removal of the chest tube (3.9 vs. 5.2 days). But the blood loss, morbidity and the length of hospital stay were almost the same in the two groups. CONCLUSIONS: Extension of indications to VATS lobectomy does not compromise the short-term results. Incompleteness of interlobar fissures, pleural adhesions, preoperative chemotherapy, big size of lesion, and some cases of centrally located tumors are not supposed to be the contraindications for VATS lobectomy. Peribronchial and perivascular lymph node calcification may complicate and even preclude lobectomy by VATS.