Uniportal video-assisted thoracoscopic early learning curve for major lung resections in a high volume training center.

BACKGROUND: Uniportal video-assisted thoracoscopic surgery (VATS) for major lung resections is a novel upcoming approach, with increasing popularity worldwide. However, there is little literature regarding this technique's learning curve. We present our experience of the early learning curve of the uniportal VATS major lung resections in a high volume training centre, whilst analysing the advantages. METHODS: Sixty selected consecutive patients underwent uniportal VATS major lung resections, for early stage disease of NSCLC and benign disease during the learning curve of a single surgeon in a high volume training centre from July to October 2015. The perioperative variables and outcomes were collected prospectively and analysed retrospectively. RESULTS: The 60 patients undergoing a uniportal VATS approach included 47 lobectomies and 13 segmental resections, among which 56 cases of lung cancer and 4 of benign pulmonary disease were noted. Right upper lobectomy (RUL) was the most common procedure (42%). The mean operation time was 192.3±45.4 minutes, average blood loss was 167.9±94.4 mL. For patients with lung cancer, the total amount of lymph node stations sampled or dissected were 4.2±0.8. Chest drain duration was 2.9±0.9 days and length of hospital stay (LOS) was 4.38±1 days. Prolonged air leak (PAL) was the most common complication in 8.3% of the cases. PAL was the cause of prolonged hospital stay. One case was converted to thoracotomy for major bleeding. There were no deaths 30 days after surgery or readmissions. All cases had a R0 complete cancer resection on histology. CONCLUSIONS: The uniportal VATS lobectomy and segmentectomy early learning curve in a high volume training centre is a safe venture, allowing surgeons to reach an expert level faster and perform more complex resections with a shorter training time.

Uniportal video-assisted thoracoscopic segmentectomy.

Uniportal video-assisted thoracoscopic surgery (VATS) segmentectomy is a technically more complex procedure than uniportal VATS lobectomy, since a detailed comprehension of the segmental anatomy is required. Anatomic sublobar resection can achieve outcomes equivalent to lobectomy in selected patients with stage IA non-small cell lung carcinoma (NSCLC). In this paper we describe our clinical experiences and introduce the technical details of uniportal VATS segmentectomy, including expertise advice ("tips and tricks") in patient selection, positioning and incisions and technical highlights of the most common types of segmentectomies. Uniportal VATS segmentectomy is a demanding technique, safe and feasible in selected patients with good results in the literature that seems to be an acceptable alternative to conventional VATS or open thoracotomy when the surgeon completed the training period and learning curve.

Pierre-Marie-Bamberger syndrome and solitary fibrous tumor: a rare association.

A solitary fibrous tumor originates in the pleura with variable degrees of invasion. Hypertrophic osteoarthropathy, known as Pierre-Marie-Bamberger syndrome, is characterized by clubbing of the fingers due to bone surface and soft tissue calcification, historically known as a bronchogenic carcinoma paraneoplastic syndrome; however, a few cases have been associated with solitary fibrous tumors. We describe the case of a 38-year-old woman who presented with clubbing of the fingers. Studies revealed an intrathoracic fibrous tumor that was successfully treated with improvement in symptoms.

Initial experience in uniportal subxiphoid video-assisted thoracoscopic surgery for major lung resections.

OBJECTIVES: Uniportal subxiphoid video-assisted thoracoscopic (SVATS) surgery for major lung resections is a new approach, but clinical evidence is lacking. The aim of this study was to examine our experience with the use of the uniportal subxiphoid approach in video-assisted thoracoscopic (VATS) major lung resections and lymph node dissections. METHODS: From October 2014 to August 2015, 153 patients with early-stage non-small-cell lung carcinoma (NSCLC) and benign disease underwent uniportal subxiphoid VATS major lung resections. Patients were placed in a lateral position with 60-70° inclination, and a 4- to 5-cm midline median or transverse incision was made below the sternocostal triangle. A 10-mm 30° video camera and VATS instruments were used through the same single incision. Perioperative variables and outcomes were collected prospectively and analysed retrospectively. RESULTS: Of the 153 patients who underwent surgery with the uniportal subxiphoid VATS approach, 105 had lobectomies and 48 had segmental resections; 135 cases of lung cancer and 18 cases of benign pulmonary disease were noted. Right upper lobectomy was the most common procedure (51%), and left upper lobectomy was the most time-consuming procedure (190 ± 21 min). The mean operating time was 166.9 ± 12.6 min; the average volume of blood loss was 127.5 ± 27.6 ml. In patients with lung cancer, the mean total number of lymph node stations explored was 3.4 ± 0.8. The duration of chest drain use was 2.6 ± 0.2 days. The length of hospital stay was 4.3 ± 0.4 days. Perioperative arrhythmia was the most common complication (13% of cases). Prolonged air leak was the cause of prolonged hospital stay. Five cases were converted to conventional VATS due to technical difficulties, and eight cases were converted to thoracotomy due to major bleeding. Postoperative 30-day mortality was zero and there were no re-admissions. All cases had a R0 complete cancer resection on histology. CONCLUSIONS: Uniportal subxiphoid VATS lobectomy/segmentectomy is a feasible and safe procedure for early-stage lung cancer and benign disease.

Predictors of survival in lung torsion: A systematic review and pooled analysis.

OBJECTIVE: Lung torsion (LT) is a rare but life-threatening event. The objective of this study was to systematically review the natural history and clinical outcome of LT in published studies. METHODS: A review of publications on LT from January 1950 to December 2014 was performed using 3 databases (PubMed, EMBASE, and Web of Science). The primary efficacy outcome was LT-related mortality. Intervention was classified as direct resection (resection without detorsion), indirect resection (resection after detorsion), and reposition. Univariate comparisons of survival were performed using a logistic regression model. RESULTS: There were 109 patients from 91 studies identified in this analysis. LT was frequently reported after upper lobectomy (74.4%) and the middle lobe was the most vulnerable lesion (29.4%). The main clinical presentations were dyspnea (38.4%), fever (23.3%), and chest pain (17.4%). Radiologic findings suggestive of LT included worsening consolidation and abrupt truncation/tapering of the pulmonary artery. The overall mortality was 8.3%. Univariate analysis showed that the extent of torsion (whole LT vs lobar torsion) was significantly associated with survival (odds ratio, 5.867; P = .017). No significant difference was found between patients receiving direct resection and those receiving reposition; a trend was observed for worsening outcomes in patients treated with indirect resection (odds ratio, 5.300; P = .060). CONCLUSIONS: The systematic review reveals the prevalence, key diagnostic tests, and optimal treatment methods for lung torsion. Whole LT is associated with higher mortality rates than lobar torsion. If the tortuous part is viable, reposition and direct resection have similar survival rates; otherwise, direct resection should be performed.

Techniques and difficulties dealing with hilar and interlobar benign lymphadenopathy in uniportal VATS.

BACKGROUND: Surgical treatment of lung cancer has evolved to a minimally invasive approach and currently is recognized as an acceptable treatment for resectable non-small cell lung cancer (NSCLC). As the volume and complexity of cases has increased technical difficulties had arisen. Hilar and sublobar lymph nodes can represent a challenge for video-assisted thoracoscopic surgery (VATS) surgeons in order to complete a safe dissection of vascular and bronchial structures without complications or conversion. It is not unusual the patients with smoking history or benign infections in the past present with enlarged calcified nodes that are fused to the hilum, fissure and specially the bronchus which can lead to an accident during the procedure if the surgeon has no experience handling this issue. As the amount of surgeons carrying out VATS lobectomies grows it is very important for them to know what to do in this specific case so the completion of the procedure can be achieved safely. METHODS: The coordination between the surgeon and the assistant is very important in order to carry out the procedure without discomfort positions and good visualization, the use of energy devices in expert hands can help considerably during the dissection of lymph nodes in the hilum and fissure reducing the bleeding, which provides a clean operative field. It is a necessary maneuver during the dissection to find the correct adventitial plane between the lymph node and the structure before passing it. RESULTS: The videos in this article show the different maneuvers a VATS surgeon can implement when facing enlarged fussed lymph nodes in the hilum, fissure or mediastinum. Improving exposure, opening the fissure, using energy and carrying out the dissection through the correct plane are keys to complete the procedure successfully. CONCLUSIONS: With growing experience in uniportal VATS and advances in surgical technology, enlarged or fussed lymph nodes are no longer a contraindication to complete a VATS lobectomy, experience VATS surgeons have a repertory of options in order to perform a safe and effective dissection.

Subxiphoid mediastinal lymphadenectomy.

Video-assisted thoracoscopic surgery (VATS) has experience an exponential growth in lung anatomic resections. Since its beginnings in early 90s with the conventional multiport VATS to the more recent uniportal approach, a continuous search for a less invasive procedure has fueled the development of minimally invasive thoracic surgery. In this sense, subxiphoid uniportal VATS has surge as a uniportal option that avoids damage to the intercostal nerve created in a transthoracic approach. In order for this technique to become as an acceptable choice for lung cancer, oncologic principles must be respected, including a feasible and safe mediastinal lymphadenectomy. Although technically more difficult than other VATS approaches, a complete lymphadenectomy is possible in the hands of expert VATS surgeons through a subxiphoid approach.

Learning curve and subxiphoid lung resections most common technical issues.

BACKGROUND: Subxiphoid uniportal video-assisted thoracic surgery (SVATS) for major lung resections is a new approach. Clinical evidence is lacking. The aim of this article is to describe the learning curve of the 200 selected patients who underwent uniportal subxiphoid lobectomy or segmentectomy by subxiphoid midline incision, and with the lessons learned from this early experience in SVATS and from the experience with transthoracic uniportal VATS we sought to compile "tips and tricks" for managing the multiple intraoperative technical difficulties that can arise during the SVATS and help to set the recommendations for a SVATS program. METHODS: We describe the learning curve of the first 200 selected patients who underwent uniportal subxiphoid lobectomy or segmentectomy by subxiphoid midline incision From September 2014 with early-stage non-small cell lung carcinoma (NSCLC) and benign disease. We examine the rate of conversion and the operating time comparing group one (first 100 cases) with group two (subsequent 100 cases). RESULTS: Of the 200 consecutive selected cases (72 males, 128 females) with a mean age of 57.4±9 years, underwent either uniportal subxiphoid lobectomy or segmentectomy 136 were lobectomies and 64 were segmental resections The mean operating time was 170±45 mins; the average and after the case 86 the rate of the operating time appears to be similar. The conversion rate decrease from 13% in group one to 8% in group two. CONCLUSIONS: There is a gradual reduction in the operating time and rate conversion with increasing experience. Lessons from our initial experience in the learning curve period in SVATS helps to create this trouble shooting guide that offers "tips and tricks" to both avoid and manage numerous intra-operative technical difficulties that commonly arise during the SVATS initial experience.