A Road Less Traveled: Endoscopic Retrograde Cholangiopancreatography in a Patient with Long-standing Achalasia and Sigmoid Esophagus.

Endoscopic retrograde cholangiopancreatography in a patient with achalasia and sigmoid esophagus poses a unique technical challenge, as one must safely guide the side viewing duodenoscope across a severely distorted distal esophagus and non-relaxing lower esophageal sphincter. In such patients, the use of an overtube is a simple solution that allows the safe passage of a duodenoscope and the removal of common bile duct stones.

Thoracoscopic left upper division (S1/2/3) resection: alternative posterior approach.

A minimally invasive pulmonary segmentectomy allows adequate oncological treatment in selected cases while preserving lung parenchyma and minimizing perioperative morbidity and length of hospital stay. Most lung segments may be resected as segmentectomies or as part of bisegmentectomies (as is the case for the lingula). In the author's experience, left upper division resection (S1, S2, S3 trisegmentectomy) may be challenging. Because the lingula and lingular structures need to be preserved, they may obstruct visualization and hamper the movement of the dissecting instruments. This has been the author's experience using an anterior approach. In contradistinction, a posterior approach allows direct access to the artery and arterial branches and greatly facilitates access to the segmental bronchus. Dissection of the bronchus proceeds from back to front, away from the artery. In addition, when we are isolating and encircling the bronchus, we have already freed the artery from the bronchus and it is safely out of the way. The advantages of a posterior approach are particularly apparent when pathological nodes between the bronchus and artery make the dissection tedious, as in the case presented. Regardless of the surgical approach, S1/S2/S3 trisegmentectomy remains a challenging procedure that requires great care in its execution.

Survival with optimal medical management in a cohort of severe necrotizing bacterial lung infections.

Background: Necrotizing pneumonia and lung gangrene represent a continuum of severe lung infection. Traditionally, severe cases have been referred for surgical debridement. However, this has been linked to high mortality. Some groups have published encouraging results using a conservative medical approach. Unfortunately, lack of a standardized definition of necrotizing pneumonia has precluded meaningful comparison between medical and surgical approach in severe cases. Our objective was to describe the outcome of a cohort of severe necrotizing pneumonia treated with optimal medical management. Methods: We conducted an observational retrospective study by reviewing charts and radiology records of patients hospitalized between 2006-2019 in a tertiary center. We included all patients with severe necrotizing infection, defined as a necrotizing cavity involving at least 50% of a lobe, or smaller multilobar cavities. We made no distinction between necrotizing pneumonia and gangrene as there are no standardized criteria. Results: A total of 50 consecutive patients were included. On imaging, 42% had multilobar cavities and mean diameter of the largest cavity in each case was 5.9 cm. 50% required mechanical ventilation (median duration 12 days) and 44% needed vasopressors. Four patients (8%) had decortication surgery, while none underwent lung resection. Four patients (8%) died. The extent of infiltrates and number of cavities were not associated with mortality but the extent of infiltrates was associated with risk of intubation (P=0.004). Conclusions: We presented one of the largest series of medically-treated severe necrotizing lung infections in the pre-coronavirus disease-2019 (COVID-19) era. The overwhelming majority of patients recovered with optimal medical management alone. Our results strongly support avoiding pulmonary resection in patients with severe necrotizing bacterial lung infections.

Thoracoscopic right-S10 segmentectomy: Alternative posterior approach.

Individual basal segmentectomies can be particularly challenging. The author has previously used an anterior approach when performing S10 segmentectomies. However, he finds that a posterior approach allows direct access to the vein and bronchus, which is further aided by dividing the posterior portion of the S6-S10 intersegmental plane. The trunk of the inferior pulmonary vein now becomes a convenient landmark because it hugs and delineates the segmental bronchus while it courses posteriorly. The author currently favors this approach for all S10 segmentectomies. Cross-sectional imaging and/or 3-dimensional reconstructions are essential in delineating anatomic relationships, in particular the relationship of the vein and its branches (which may vary) and the bronchus. They are also useful for locating the segmental artery, which typically lies just deep to the bronchus. Imaging is used both as a tool for preoperative planning and as a guide during operative dissection. Regardless of the approach, the S10 remains a difficult segmentectomy. Great care is required while dissecting and dividing delicate bronchovascular structures located deep within the operative field.

Necrotizing Esophagitis: A Big Squeeze?

Necrotizing esophagitis is rare and poorly understood. The etiologies reported in what little has been published (i.e., gastroesophageal reflux exacerbated by gastric outlet obstruction and low-flow ischemia) seem somewhat simplistic and lack any direct evidence. The following paper illustrates a recent clinical case while laying out arguments supporting esophageal spasm as a possible contributing factor.

Air leaks: Stapling affects porcine lungs biomechanics.

During thoracic operations, surgical staplers resect cancerous tumors and seal the spared lung. However, post-operative air leaks are undesirable clinical consequences: staple legs wound lung tissue. Subsequent to this trauma, air leaks from lung tissue into the pleural space. This affects the lung's physiology and patients' recovery. The objective is to biomechanically and visually characterize porcine lung tissue with and without staples in order to gain knowledge on air leakage following pulmonary resection. Therefore, a syringe pump filled with air inflates and deflates eleven porcine lungs cyclically without exceeding 10 cmH2O of pressure. Cameras capture stereo-images of the deformed lung surface at regular intervals while a microcontroller simultaneously records the alveolar pressure and the volume of air pumped. The raw images are then used to compute tri-dimensional displacements and strains with the Digital Image Correlation method (DIC). Air bubbles originated at staple holes of inner row from exposed porcine lung tissue due to torn pleural on costal surface. Compared during inflation, left upper or lower lobe resections have similar compliance (slope of the pressure vs volume curve), which are 9% lower than healthy lung compliance. However, lower lobes statistically burst at lower pressures than upper lobes (p-value<0.046) in ex vivo conditions confirming previous clinical in vivo studies. In parallel, the lung deformed mostly in the vicinity of staple holes and presented maximum shear strain near the observed leak location. To conclude, a novel technique DIC provided concrete evidence of the post-operative air leaks biomechanics. Further studies could investigate causal relationships between the mechanical parameters and the development of an air leak.

Learning curve for completely thoracoscopic anatomic sublobar resection.

BACKGROUND: Minimally invasive anatomic sublobar resection is increasingly being considered as an alternative to lobectomy in selected cases. However, this remains a technically challenging procedure and only 5 studies evaluating learning curves have been published to date. The aim of this study was to evaluate a single surgeon's learning curve for completely thoracoscopic anatomic sublobar resection. METHODS: A retrospective review was conducted of all thoracoscopic anatomic sublobar resections by one surgeon proficient in VATS lobectomy between January 2015 and January 2020. The primary outcome was operative time. Secondary outcomes were perioperative complications, duration of chest tube drainage and length of stay. RESULTS: There were 67 thoracoscopic anatomic sublobar resections performed in 66 patients. A Time-series plot and Cumulative Sum analysis of operative times showed a drop off after case 32, suggesting achievement of competency. After case 32, mean operative times were decreased (128.59±32.42 min. vs. 153.63±40.16 min, P=0.013) and there was a trend toward decreased blood loss (124.26±76.0 vs. 175.0±141.99 mL, P=0.073). A percentage 13.6% of patients had postoperative complications other than air leak and 88,9% of these were Clavien-Dindo class 1-2; postoperative complications were evenly distributed before and after case 32. Cumlulative Sum curves for the duration of chest tube drainage and length of stay did not show any significant change during the study period. CONCLUSIONS: This study suggests that for a surgeon proficient in VATS lobectomy, competency in completely thoracoscopic anatomic sublobar resection can be achieved after 32 cases and can be accomplished in a way that does not compromise perioperative outcomes.

Thoracoscopic apicoposterior segmentectomy, left upper lobe: Posterior approach.

Minimally invasive pulmonary segmentectomy allows adequate oncological treatment in selected cases while preserving lung parenchyma and minimizing perioperative morbidity and length of hospital stay. Most lung segments may be resected as segmentectomies or as part of bisegmentectomies (as is the case for the lingula). However, the resection of individual basal segments may be particularly challenging. Although several variations of minimally invasive pulmonary segmentectomy have been described, I favor a fully thoracoscopic multiport approach that allows direct access to the segmental structures, is straightforward, and is versatile enough to allow adaptation in case of unexpected intraoperative findings (such as conversion to lobectomy in the case of positive margins). Key aspects of apicoposterior segmentectomy include proper patient positioning, appropriate positioning of operating trocars, and a standardized technique using a direct posterior approach.

An overview and critique of the use of cumulative sum methods with surgical learning curve data.

Cumulative sum (CUSUM) plots and methods have wide-ranging applications in healthcare. We review and discuss some issues related to the analysis of surgical learning curve (LC) data with a focus on three types of CUSUM statistical approaches. The underlying assumptions, benefits, and weaknesses of each approach are given. Our primary conclusion is that two types of CUSUM methods are useful in providing visual aids, but are subject to overinterpretation due to the lack of well-defined decision rules and performance metrics. The third type is based on plotting the CUSUM of the differences between observations and their average value. We show that this commonly applied retrospective method is frequently interpreted incorrectly and is thus unhelpful in the LC application. Curve-fitting methods are more suitable for meeting many of the goals associated with the study of surgical LCs.

Minimizing the Risk of Aerosol Contamination During Elective Lung Resection Surgery.

BACKGROUND: In the setting of the COVID-19 pandemic, the conduct of elective cancer surgery has become an issue because of the need to balance the requirement to treat patients with the possibility of transmission of the virus by asymptomatic carriers. A particular concern is the potential for viral transmission by way of aerosol which may be generated during perioperative care. There are currently no guidelines for the conduct of elective lung resection surgery in this context. METHODS: A working group composed of 1 thoracic surgeon, 2 anesthesiologists and 1 critical care specialist assessed the risk for aerosol during lung resection surgery and proposed steps for mitigation. After external review, a final draft was approved by the Committee for the Governance of Perioperative and Surgical Activities of the Hôpital Maisonneuve-Rosemont, in Montreal, Canada. RESULTS: The working group divided the risk for aerosol into 6 time-points: (1) intubation and extubation; (2) Lung isolation and patient positioning; (3) access to the chest; (4) conduct of the surgical procedure; (5) procedure termination and lung re-expansion; (6) chest drainage. Mitigating strategies were proposed for each time-point. CONCLUSIONS: The situation with COVID-19 is an opportunity to re-evaluate operating room protocols both for the purposes of this pandemic and similar situations in the future. In the context of lung resection surgery, specific time points during the procedure seem to pose specific risks for the genesis of aerosol and thus should be the focus of attention.

Thoracoscopic posterobasal segmentectomy, right lower lobe.

Minimally invasive pulmonary segmentectomy allows adequate oncologic treatment in selected cases while preserving lung parenchyma and minimizing perioperative morbidity and length of hospital stay. Most lung segments may be resected as segmentectomies or as part of bisegmentectomies (as is the case for the lingula). However, the resection of individual basal segments may be particularly challenging. Although several variations of minimally invasive pulmonary segmentectomy have been described, I favor a fully thoracoscopic multiport approach that allows direct access to the segmental structures, and is straightforward and versatile enough to allow for adaptation in case of unexpected intraoperative findings (such as conversion to lobectomy in the case of positive margins). Key aspects of posterobasal segmentectomy include proper patient positioning, appropriate positioning of operating trocars, standardized technique to expose and dissect the segmental vein, bronchus, and artery, and accurate division of the intersegmental plane.

Thoracoscopic anterobasal segmentectomy: Right lower lobe.

Minimally invasive pulmonary segmentectomy allows adequate oncologic treatment in selected cases while preserving lung parenchyma and minimizing perioperative morbidity and length of hospital stay.  Most lung segments can be resected as segmentectomies or as part of bisegmentectomies (as is the case for the lingula). However, the resection of individual basal segments can be particularly challenging. Although several variations of minimally invasive pulmonary segmentectomy have been described, I favor a fully thoracoscopic multiport approach that offers direct access to the segmental structures, and is straightforward and versatile enough to allow for adaptation in case of unexpected intraoperative findings (such as conversion to lobectomy in the case of positive margins). Key aspects of anterobasal segmentectomy include proper patient positioning, appropriate positioning of operating trocars, standardized technique to expose and dissect the segmental artery and bronchus, and accurate division of the intersegmental plane.

Thoracoscopic apical segmentectomy, right upper lobe.

Minimally invasive pulmonary segmentectomy allows adequate oncologic treatment in selected cases while preserving lung parenchyma and minimizing perioperative morbidity and length of hospital stay. Most lung segments may be resected as segmentectomies or as part of bisegmentectomies (as is the case for the lingula). Although several variations of minimally invasive pulmonary segmentectomy have been described, we favor a fully thoracoscopic multiport approach that allows direct access to the segmental structures, and is straightforward and versatile enough to allow for adaptation in case of unexpected intraoperative findings (such as conversion to lobectomy in the case of positive margins). Key aspects of right apical segmentectomy include proper patient positioning, appropriate positioning of operating trocars, standardized technique to expose and dissect the segmental artery and bronchus, and accurate division of the intersegmental plane.