Heat production during pulmonary artery sealing with energy vessel-sealing devices in a swine model.

OBJECTIVES: Energy vessel-sealing devices are being increasingly utilized to seal pulmonary artery (PA) branches during lobectomy. Heat from these devices can potentially injure surrounding tissues. We evaluated heat production from devices in a live animal model. METHODS: PA branches were sealed in pigs with 4 energy vessel-sealing devices: 2 ultrasonic (US), 1 advanced bipolar or 1 mixed US and bipolar (mixed) device. Thermocouples were implanted in tissue surrounding the PA branch being sealed to measure tissue temperature. A thermal camera measured the sealing site and the temperatures of the instruments. Pathological analysis was performed on PA stumps to identify thermal damage. RESULTS: A total of 37 PA branches were sealed in 4 pigs. Maximum tissue heat measured by the thermocouples for the 2 US, advanced bipolar and mixed devices was 42, 39, 42 and 46°C, respectively. The mean tissue temperatures at the site of the sealing measured with the thermal camera were 78, 75, 70 and 82°C (P = 0.834) and the mean instrument blade temperatures were 224, 195, 83 and 170°C (P = 0.000005) for the 2 US, advanced bipolar and mixed devices, respectively. The mean diameter of the region with tissue reaching 60°C or more measured with the thermal camera was between 4 and 6 mm for the 4 devices (P = 0.941). On pathological analysis, PA stumps had either thermal damage on the adventitia and external media (26/37) or transmural damage (11/37) at 1 mm from sealed site. CONCLUSIONS: A 3-mm safety margin between the instrument blades and vital structures is recommended. Instrument blades can reach high temperatures that may cause tissue damage.

Enhanced recovery after video-assisted thoracoscopic surgery lobectomy: a prospective, historically controlled, propensity-matched clinical study.

Background: Enhanced recovery pathways or fast-tracking following surgery can decrease the rate of postoperative complications and hospital length of stay. The objectives of this study were to implement an enhanced recovery after surgery (ERAS) pathway for patients undergoing a video-assisted thoracoscopic surgery (VATS) lobectomy, to assess the safety and efficiency of this protocol by measuring associated postoperative outcomes, and to compare the outcomes for patients in the ERAS group with the outcomes for patients in a propensity-matched control group. Methods: The study was a prospective clinical trial. Patients who were scheduled to undergo VATS lobectomy at the Centre hospitalier de l'Université de Montréal in Montréal, Quebec, Canada, were enrolled between November 2015 and October 2016. The ERAS pathway was used for all enrolled patients. The primary outcome was the number and severity of complications measured by the Comprehensive Complication Index. Secondary outcomes included length of stay, readmission and recovery. Recovery of patients was measured using EQ-5D-5L preoperatively and at 1 week, 1 month and 4 months after surgery. Prospectively enrolled patients were propensity matched to historical controls. Results: Ninety-eight patients (36 men and 62 women) in the ERAS group and 98 patients in the control group (29 men and 69 women) were included in the analysis. The mean age was 65.2 ± 9.3 years, the mean body mass index (BMI) was 26.9 ± 5.9 kg/m2 and the median Charlson Comorbidity Index score was 2 (interquartile range [IQR] 2-3) in the ERAS group. In the control group, the mean age was 66.2 ± 9.4 years, the mean BMI was 27.4 ± 5.6 kg/m2 and the median Charlson Comorbidity Index score was 3 (IQR 2-3). A total of 23 patients (23.4%) in the ERAS group and 28 (28.6%) in the control group experienced 1 or more postoperative complications. The mean Comprehensive Complication Index score was 7.4 ± 16.8 in the ERAS group compared with 8.0 ± 14.3 in the control group (p = 0.79). The median postoperative length of stay was 3 days in the ERAS group and 5 days in the control group (p < 0.001). Five patients in the ERAS group and 4 patients in the control group were readmitted. The protocol adherence rate was 64.3%. Conclusion: It is feasible to implement an enhanced recovery protocol after VATS lobectomy. Although the pathway is still early in its development in Canada, implementation of an ERAS pathway after VATS lobectomy was associated with decreased length of stay, with no observable increase in complication or readmission rates.

Contexte: Les protocoles de récupération optimisée, ou réhabilitation précoce, après une intervention chirurgicale permettent de réduire les taux de complications postopératoires et d'abréger le séjour hospitalier. Les objectifs de cette étude étaient d'appliquer les principes de récupération optimisée après une chirurgie (ou ERAS, enhanced recovery after surgery) à des patients soumis à une lobectomie par chirurgie thoracique vidéo-assistée (CTVA), d'évaluer l'innocuité et l'efficience d'un tel protocole en mesurant les paramètres postopératoires associés, et de comparer l'issue de l'intervention chez les patients du groupe ERAS à celle des patients d'un groupe témoin apparié par score de propension. Méthodes: Il s'agit d'un essai clinique prospectif. Des patients qui devaient subir une lobectomie par CTVA au Centre hospitalier de l'Université de Montréal, à Montréal, Québec, Canada, ont été recrutés entre novembre 2015 et octobre 2016. Les principes ERAS ont été appliqués à tous les patients inscrits. Le paramètre principal était le nombre et la gravité des complications mesurés à l'aide de l'Indice global de complications. Les paramètres secondaires incluaient la durée du séjour, les réadmissions et le rétablissement. Le rétablissement des patients a été mesuré à l'aide du questionnaire EQ-5D-5L avant, puis 1 semaine, 1 mois et 4 mois après la chirurgie. Les patients recrutés prospectivement ont été assortis à des témoins historiques par score de propension. Résultats: Au total, 98 patients (36 hommes et 62 femmes) du groupe ERAS et 98 patients du groupe témoin (29 hommes et 69 femmes) ont été inclus dans l'analyse. L'âge moyen était de 65,2 ± 9,3 ans, l'indice de masse corporelle (IMC) moyen était de 26,9 ± 5,9 kg/m2 et l'indice de comorbidité de Charlson médian était de 2 (éventail interquartile [ÉIQ] 2­3) dans le groupe ERAS. Dans le groupe témoin, l'âge moyen était de 66,2 ± 9,4 ans, l'IMC moyen était de 27,4 ± 5,6 kg/m2 et l'indice de comorbidité de Charlson médian était de 3 (ÉIQ 2­3). En tout, 23 patients (23,4 %) du groupe ERAS et 28 (28,6 %) du groupe témoin ont présenté au moins une complication postopératoire. L'Indice global de complications a été de 7,4 ± 16,8 dans le groupe ERAS, contre 8,0 ± 14,3 dans le groupe témoin (p = 0,79). La durée médiane du séjour postopératoire a été de 3 jours dans le groupe ERAS et de 5 jours dans le groupe témoin (p < 0,001). Cinq patients du groupe ERAS et 4 patients du groupe témoin ont été réadmis. Le taux d'adhésion au protocole a été de 64,3 %. Conclusion: Il est possible d'appliquer un protocole de récupération optimisée après la lobectomie par CTVA. Même si ce protocole en est encore à ses débuts au Canada, l'application de principes ERAS après la lobectomie par CTVA a été associée à un abrègement du séjour hospitalier, sans augmentation observable des taux de complications ou de réadmissions.

Phase 1 Trial Evaluating Safety of Pulmonary Artery Sealing With Ultrasonic Energy in VATS Lobectomy.

BACKGROUND: Energy-sealing devices may be useful to divide small pulmonary arteries (PAs) during video-assisted thoracoscopic surgery (VATS) lobectomy. We evaluated the safety of PA branch sealing with an ultrasonic energy vessel-sealing device during VATS lobectomy. METHODS: The study consisted of a phase 1 trial. Patients planned to undergo VATS lobectomy were prospectively enrolled. Target sample size was 20 patients. Branches of 7 mm or less were sealed and cut with an ultrasonic energy vessel-sealing device. The remainder of the lobectomy was performed in a standard fashion. Intraoperative, in-hospital, and 30-day postoperative bleeding were prospectively recorded. RESULTS: Thirty-three patients were prospectively enrolled. Thirteen patients were not amenable to PA sealing with the vessel-sealing device because all PA branch diameters exceeded 7 mm (n = 10), conversion to thoracotomy (n = 2), and lobectomy not performed (n = 1). A minimum of one PA branch was sealed with the device in 20 patients. Fifty-eight PA branches were divided in 20 patients: 31 with ultrasonic device, 24 with endostaplers, 2 with clips, and 1 with sutures. The mean vessel diameter sealed with the device was 4 mm. Two patients were converted to thoracotomy (1 with PA injury during dissection, 1 with PA tumor invasion). No intraoperative or postoperative bleeding was related to ultrasonic PA branch sealing. No postoperative deaths occurred. CONCLUSIONS: PA branch sealing for vessels 7 mm or less was safely achieved using an ultrasonic energy vessel-sealing device in VATS lobectomy. Large-scale, prospective, multi-institutional studies are necessary before widespread clinical application of energy for PA branch sealing in VATS lobectomy.

Pulmonary artery sealing with ultrasonic energy in open lobectomy: A phase I clinical trial.

OBJECTIVE: Pulmonary artery branch sealing in video-assisted thoracoscopic surgical lobectomy is usually achieved with vascular endostaplers. Iatrogenic pulmonary artery injury may be caused by endostaplers. We evaluated the safety of pulmonary artery sealing with an ultrasonic energy vessel-sealing device in a phase I clinical trial evaluating in vivo safety of the device during open lobectomy. METHODS: Patients scheduled to undergo elective open (thoracotomy) pulmonary lobectomy were prospectively enrolled. Target sample size was 10 patients. Pulmonary artery diameter was measured intraoperatively. All branches ≤7 mm were divided with an ultrasonic energy vessel-sealing device. The remainder of the lobectomy was performed in a standard fashion. Intraoperative and postoperative bleeding were strictly recorded. RESULTS: Eighteen patients were prospectively enrolled. Eight patients were not amenable to pulmonary artery sealing with the device. In the 10 patients included in the analysis, a total of 14 pulmonary arteries were sealed with the ultrasonic device. The mean vessel diameter was 5 mm (range, 2-7 mm). One patient underwent reoperation for bronchial artery bleeding (vessel not sealed with device). There was no intra- or postoperative bleeding related to ultrasonic pulmonary artery sealing. There was no postoperative mortality. CONCLUSIONS: Pulmonary artery sealing for vessels with diameter ≤7 mm was safely achieved with an ultrasonic energy vessel-sealing device in open lobectomy. The use of ultrasonic energy vessel-sealing devices in video-assisted thoracoscopic surgical lobectomy may have the advantage of making small, short, pulmonary artery branch sealing safer than with vascular endostaplers. Further studies are necessary before widespread application in lobectomy, including video-assisted thoracoscopic surgical lobectomy.

Evaluation of the Mediastinum: Differentiating Between Stations 4L, 5, and 6 Using EBUS and EUS.

Correct identification of mediastinal lymph node stations with endoscopic ultrasound (EUS) and endobronchial ultrasound (EBUS) requires knowledge of their ultrasonic anatomical positions and relations. The ultrasonic positions of the lymph node stations located in and around the aortopulmonary window (stations 4L, 5, and 6) can be more challenging to understand. The aim of this report is to describe the endosonographic anatomic positions of stations 4L, 5, and 6 and to demonstrate their locations using EUS and EBUS.