Efficacy of a Surgical Cardiac Ablation Clamp using Nanosecond Pulsed Electric Fields: An Acute Porcine Model.

OBJECTIVE: This study examined the effectiveness of a recently developed non-thermal technology, nanosecond pulse field ablation (nsPFA), for surgical ablation of the atria in a beating heart porcine model. METHODS: Six pigs underwent sternotomy and ablation using an nsPFA parallel clamp. The ablation electrodes (53 mm long) were embedded in the jaws of the clamp. Nine lesions per pig were created in locations chosen to be representative of the Cox-Maze procedure. Four lesions were intended to electrically isolate parts of the atrium: the right atrial appendage, left atrial appendage, right pulmonary veins, and left pulmonary veins. For these lesions, exit block testing was performed both after ablation and before euthanasia; the time between the two tests was 3.3±0.5 hours (range 2 to 4 hours). Using purse string sutures, five more lesions were created up to the superior vena cava, down to the inferior vena cava, across the right atrial free wall, and at two distinct locations on the left atrial free wall. The clamp delivered a train of nanosecond duration pulses, with a total duration of 2.5 s, independent of tissue thickness. The heart tissue was stained with 1% triphenyltetrazolium chloride (TTC) after a dwelling period of two hours. Subsequently, each lesion was cross sectioned at 5 mm intervals to assess the ablation depth and transmurality. In some sections, transmurality could not be established on the basis of TTC staining alone; for these lesions, Gomori-trichrome stains were used, and the histological sections were evaluated for transmurality. RESULTS: The ablation time was 2.5 seconds per lesion, for a total of only 22.5 seconds ablation time to create 9 lesions. A total of 53 lesions were created, resulting in 388 separate histological sections. Transmurality was established in 386 sections (99.5%). Mean tissue thickness was 3.1±1.5 mm (range of 0.2 mm to 8.6 mm). Exit block was confirmed in 23 of the 24 lesions (96%) post-ablation and 23/24 (96%) pre-euthanasia. Over the course of the procedure, neither pulse-induced arrhythmias nor any other complications were noted. CONCLUSIONS: The novel nsPFA clamp device was effective in creating acute conduction block and transmural lesions in both the right and left atria in an acute porcine model. This non-thermal energy source has great potential to both shorten procedural time and enable effective ablation in the beating heart.

Non-intubated versus intubated video-assisted thoracoscopic lobectomy for lung cancer patients.

INTRODUCTION: Video-assisted thoracoscopic surgery (VATS) lobectomy has been shown to be a standard treatment for lung cancer patient due to less pain, post-operative complication and faster recovery. In recent years, Non-intubated video-assisted thoracoscopic surgery (NIVATS) is become an alternative approach for various types of thoracic surgery with a benefit on fewer complication from mechanical ventilation. Out study is aimed to study outcome compare between NIVATS lobectomy and to general anesthetic video assisted thoracoscopic surgery (GAVATS) lobectomy. METHODS: This is a retrospective cohort study conduct in Vajira hospital, Navamindradhiraj University, Bangkok, Thailand between January 2019 to September 2022.152 lung cancer patients underwent lobectomy. However, lung cancer patients whom needed to convert to GAVATS, open thoracotomy or emergency surgery were excluded from this study. In this study, we compare lung patients whom underwent NIVATS lobectomy and those whom underwent GAVATS lobectomy. These two groups are compared in term of pre-, intra- and post-operative outcomes. The inverse-probability weighting propensity score is used to identify the treatment effects of NIVATS. RESULTS: In total, there are 132 cases patients including in this analysis. There are 54 and 78 patients in the NIVATS and GAVATS respectively. Intra-operative outcome, induction and operative time are lower in the NIVATS lobectomy group (25 vs 30 min, p < 0.001 and 90 vs 120 min, p = 0.003). There is no difference regarding number of node resection, station of lymph node dissection, arrhythmia, postoperative complications, and pain visual analogue score (VAS) in both groups. Postoperative outcome, length of hospital stay is shorter in NIVATS lobectomy group (4 vs 5 days, p < 0.001). There is no patient which needed to convert from NIVATS to GAVATS. The treatment-effect analyzed by using inverse-probability weighting propensity score has shown benefits of NIVATS in terms of shorter hospital stays (coefficient -2.31, 95%CI -3.65 to -0.97, p = 0.001), and shorter chest tube duration (coefficient -1.59, 95%CI -2.93 to -0.26, p = 0.019). CONCLUSION: NIVATS lobectomy could be an alternative approach for lung cancer patients with benefits of lesser in hospital stays and duration of chest tube.

Case report: video-assisted thoracoscopic repair of right main bronchus transection after blunt chest injury.

Background: Traumatic tracheobronchial injury is a rare manifestation after blunt chest injury. The current standard treatment has wide spectrum from conservative treatment to open thoracotomy with repair airway regarding to severity of the disease. However, to the best of our knowledge, no one has reported airway repair in trauma using video-assisted thoracoscopic surgery (VATS) before. Hence, we describe the successful management and repair of a transected right main bronchus using VATS. Case Description: A 43-year-old male patient presented with chest tightness after a traumatic blunt chest injury; a chest computed tomography revealed multiple rib fractures and suspected right main bronchus injury with large pneumomediastinum and subcutaneous emphysema. Although the current standard treatment is to perform open thoracotomy with tracheal repair, we performed VATS repair of right main bronchus in purpose to reduce the stress from tissue trauma and minimally invasive fashion. Emergency surgery was scheduled for injury repair, and the transected right main stem bronchus and mediastinum hematoma were intraoperatively identified. The right main bronchus was repaired using polypropylene 4-0 interrupted sutures under uniportal VATS and covered with pericardial fat pad tissue. After the surgery, the patient had no air leak from chest tube drainage and recovered well. The patient was performed diagnostic bronchoscopy to confirm the patent airway at day 3 then discharged 7 days after surgery and was doing well at a 1-month follow-up. Conclusions: VATS repair is safe and feasible as an alternative approach to conventional thoracotomy approach in the treatment of traumatic tracheobronchial injury.

Coverage of the Left Subclavian Artery in Blunt Thoracic Aortic Injury Repair Is Rarely Indicated.

BACKGROUND: Thoracic endovascular repair has become the standard treatment for blunt thoracic aortic injury (BTAI). Occlusion of the left subclavian artery (LSA) is generally required for an adequate landing zone (ALZ). We propose that coverage of the LSA is not necessary for BTAI even with a short landing zone (SLZ). METHODS: Retrospective review of BTAI patients, who were treated from January 2008 to December 2020, was analyzed. BTAI was categorized into 2 cohorts, SLZ <20 mm and ALZ >20 mm. Demographic data, trauma scores, grade of BTAI, procedure-related data, and clinical outcomes were analyzed. t-Test and chi-squared tests were used for statistical analysis. RESULTS: Thoracic endovascular repair was performed in 59 BTAI patients (mean age of 38.9 ± 14 years, mean Injury Severity Score of 40.4 ± 9.3). Two cohorts were identified: 49 patients had an SLZ, and 10 patients had an ALZ (14 ± 3.1 mm vs. 25 ± 4.1 mm, P = 0.03). The procedures were performed successfully with 59 patients (86.4%) deploying in zone 3. In-hospital mortality (SLZ group: 4.1% vs. ALZ group: 0, P = 0.318), endoleak (SLZ group: 4.1% vs. ALZ group: 20%, P = 0.45), stroke (SLZ group: 0 vs. ALZ group: 0, P = 1), spinal cord ischemia (SLZ group: 2% vs. ALZ group: 0, P = 1), left arm ischemia (SLZ group: 0 vs. ALZ group: 0, P =1), and reintervention rate (SLZ group: 0 vs. ALZ group: 0, P = 1) were not statistically different between cohorts. CONCLUSIONS: BTAI repair with an SLZ can be treated successfully without covering the LSA, analyzing technical success and in-hospital complications. Mid- and long-term data are necessary to confirm the durability of this technique.

Concomitant umbilical endometriosis with catamenial pneumothorax: a case report.

Catamenial pneumothorax is an extremely rare conditions that affects women and is one of a group of diseases called extra-pelvic endometriosis. Moreover, when concomitant of extra-pelvic endometriosis occurs in the same patient is rarer to be found. A 35-year-old female presented with a 3-month history of bleeding from the umbilicus during her menstrual cycles. Right pneumothorax was incidentally detected on her abdominal X-ray already taken in primary care, and chest and abdominal computed tomography showed a 2.5-cm enhancing mass below umbilicus. As a result, the patient was diagnosed as concomitant Catamenial pneumothorax with umbilical endometriosis. Thus, she underwent video-assisted thoracoscopic surgery (VATS), diaphragmatic resection and repair using a polypropylene mesh and umbilical mass excision. Pathological analysis of the collected specimens revealed both umbilical and diaphragmatic endometriosis. Hence, she was treated with a gonadotropin-releasing hormone agonist to prevent disease recurrence. During a 6-month follow-up, she displayed no sign of umbilical bleeding or pneumothorax. This case report demonstrates the concurrent manifestation of catamenial pneumothorax and umbilical endometriosis as part of extra-pelvic endometriosis and does support the retrograde menstruation theory as the etiology of extra-pelvic endometriosis.

Effectiveness of fibrin sealant after pulmonary resection: a propensity score matching analysis.

Introduction: Alveolar air leak is a common and troublesome complication after pulmonary resection because it can lead to longer hospital stay and chest tube drainage time. Aim: As fibrin sealants are useful in the management of alveolar air leaks, we evaluated their benefit in patients undergoing pulmonary resection. Material and methods: This retrospective study included patients who underwent pulmonary resection in our hospital between 2016 and 2021. We grouped patients on the basis of whether fibrin sealant was used during surgery and compared outcomes between those with (fibrin sealant group) and without (control group) sealant use after propensity score matching (1 : 1). Results: During the study period, 375 patients underwent pulmonary resection; of these, fibrin sealant was applied at the staple line in 107 patients (fibrin sealant group), whereas sealant was not used in 268 patients (control group). After propensity score matching (1 : 1), there were 95 patients in both groups. There were no differences between the two groups in duration of chest tube drainage (3 days vs. 3 days; p = 0.753) or length of hospital stay (5 days vs. 4 days; p = 0.499). However, the sealant group showed higher cost of hospitalization (USD 4,360 vs. 3,614; p < 0.001). Multivariate analysis for identifying risk factors of persistent air leak revealed that male sex and chronic obstructive pulmonary disease were associated. Conclusions: Our results indicate that application of fibrin sealant was not effective in reducing length of hospital stay, duration of chest drains or air leakage.