Novel Techniques in Video-assisted Thoracic Surgery (VATS) Lobectomy.

Twenty years ago, thoracic surgery witnessed the leap from thoracotomy to the first video-assisted thoracic surgery (VATS) lobectomy. Gradually VATS lobectomy has become widely accepted and practiced worldwide. As the idea of less-invasive, fewer, and smaller incisions is taken up by surgeons, thoracic surgery has witnessed the progress of the conventional three-port VATS lung resection to two-port VATS and finally the birth of uniportal VATS lobectomy. Incisions have also become much smaller over the years, such as those seen in total port access lobectomy or microlobectomy. A modified version of the uniportal VATS lobectomy through the subxiphoid incision has also recently been used. The movement toward less-invasive surgery has no doubt driven the innovation of sophisticated instruments and technology to cope with the demanding need of working through a restricted incision. Reported outcomes and results of these new developments are encouraging.

The use of octreotide in the treatment of chylothorax following cardiothoracic surgery.

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was 'Is octreotide (a long-acting somatostatin analogue) effective in patients with post-operative or traumatic chylothorax as a part of conservative management to reduce lymphorrhagia?' Altogether 180 papers were found using the reported search, of which 20 represented the best evidence to answer the clinical question. One case was reported twice and therefore was excluded, leaving us with 19 papers. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Although rare, iatrogenic and traumatic chylothorax have been well described in the literature. At present, there have been no randomized controlled clinical trials on the use of octreotide in chylothorax. Sixteen of 19 papers found octreotide to be effective in the treatment of chylothorax. Octreotide was found to have no complementary effect in three reports. Two of the papers were retrospective studies: one a randomized controlled trial in canines, and the remainder were case reports and case series. The two retrospective studies showed a success rate of 87-90% in the use of octreotide as an adjunct to conservative management for the treatment of chylothorax and hence preventing the need for further surgery. Experimental study in canines has shown significant drain reduction and earlier fistula closure, although transferability of this result to human is difficult to interpret. Twelve case reports found octreotide effective in reduction of the volume and arrest of chylothorax. Most reported benefit in 2-3 days of administration of octreotide. The general consensus is for conservative management with octreotide to be instituted for 1 week before consideration of surgery, although some authors have advocated for a large volume chylothorax, especially after oesophageal surgery with no response to conservative management with octreotide, to be operated on sooner. We concluded that octreotide is effective in the management of moderate to large volume chylothorax.