Intraoperative Nerve Monitoring during Minimally Invasive Esophagectomy and 3-Field Lymphadenectomy: Safety, Efficacy, and Feasibility.

Background: The objective of this study was to demonstrate the safety, efficacy, and feasibility of intraoperative monitoring of the recurrent laryngeal nerves during thoracoscopic and robotic 3-field esophagectomy. Methods: This retrospective analysis details our initial experience using intraoperative nerve monitoring (IONM) during minimally invasive 3-field esophagectomy. Data were obtained from a prospectively maintained database and electronic medical records. The study included all patients who underwent minimally invasive (video-assisted thoracic surgery/robotic) transthoracic esophagectomy with neck anastomosis. The patients were divided into those who underwent IONM during the study period and a historical cohort who underwent 3-field esophagectomy without IONM at the same institution. Appropriate statistical tests were used to compare the 2 groups. Results: Twenty-four patients underwent nerve monitoring during minimally invasive 3-field esophagectomy. Of these, 15 patients underwent thoraco-laparoscopic operation, while 9 received a robot-assisted procedure. In the immediate postoperative period, 8 of 24 patients (33.3%) experienced vocal cord paralysis. Relative to a historical cohort from the same institution, who were treated with surgery without nerve monitoring in the preceding 5 years, a 26% reduction was observed in the nerve paralysis rate (p=0.08). On follow-up, 6 of the 8 patients with vocal cord paralysis reported a return to normal vocal function. Additionally, patients who underwent IONM exhibited a higher nodal yield and a decreased frequency of tracheostomy and bronchoscopy. Conclusion: The use of IONM during minimally invasive 3-field esophagectomy is safe and feasible. This technique has the potential to decrease the incidence of recurrent nerve palsy and increase nodal yield.

Uniportal VATS left lower lobectomy: Fissure first technique.

This video tutorial describes a left lower lobectomy performed by the uniportal approach. A single 2-cm incision in the lateral chest wall is used as the utility port. The procedure begins with division of the inferior pulmonary ligament and isolation of the inferior pulmonary vein. This patient has densely adherent interlobar nodes, which are then dissected to demonstrate the interlobar pulmonary artery. Then we proceed to divide the anterior part of the fissure after identifying and safeguarding the lingular branches of the pulmonary artery. This step is followed by the division of the posterior part of the fissure after identification of the posterior branches of the pulmonary artery to the upper lobe. Then we identify the basilar trunk and divide it using endostaplers. Other branches of the interlobar artery are clearly identified, and the apicobasal artery is taken separately. This is followed by division of the inferior pulmonary vein and a systematic mediastinal nodal dissection.

Carinal Resection and Reconstruction for Tracheo-bronchial Neoplasms-Surgical Outcomes of 20 Consecutively Operated Cases.

Carinal resections for trachea-bronchial neoplasms are technically challenging and have high operative morbidity and mortality. This study examines the clinical experience of carinal resections for various tracheo-bronchial tumors in a dedicated thoracic surgery center. Medical records were retrospectively reviewed from March 2012 to December 2019 to identify all patients who underwent carinal resection. An analysis of demographic characteristics, perioperative variables including complications, was carried out. Perioperative outcome was the primary outcome measure. Twenty carinal resections were performed with a median follow-up of 2.4 years (range 0.5-4.1). Procedures included 8 isolated carinal resections (40%), 6 right carinal pneumonectomy (30%), 1 left carinal pneumonectomy (5%), and 5 carinal right upper sleeve lobectomy (25%). Age of the patients range from 18 to 62 years with 9/11 male-female ratio. Mean duration from symptom onset to diagnosis was 6.1 months. All post-operative complications occurred in 7 (35%) patients. Anastomotic complications occurred in 2 (10%) patients. Out of these, 1 patient was initially managed with stent placement, ultimately requiring pneumonectomy. Post-operative events were significantly higher in group of patients who underwent carinal resection with concomitant pulmonary resection (P = 0.01). No perioperative (90-day) mortality was found. Despite advances in perioperative management, carinal resection poses challenges for both patient and surgeon. Concomitant pulmonary resection was associated with increased risk of peri-operative complications. Appropriate patient selection, meticulous surgical technique, and stringent post-operative protocols are the key for success.

Endobronchial Carcinoids: Surgical Outcome in 100 Consecutive Patients and Factors Affecting Lung Preservation.

Bronchial carcinoids are slow-growing tumours of the neuroendocrine family. Most of them have a benign course with excellent outcome after complete resection. Due to their location in the primary bronchi, adequate resection with lung preservation requires considerable technical expertise. In this paper we present our surgical experience with endobronchial carcinoids and analyse the factors that predict possibility of lung preservation surgery. Retrospective analysis of a prospectively maintained database of patients operated for endobronchial carcinoids for the period March 2012 to September 2019 was carried out. Demographic factors and peri-operative variables were recorded and analysed. Factors that influence surgical outcome and possibility of lung preservation surgery were analysed. A total of 137 patients underwent surgery for resection of carcinoid tumours, out of which 100 had endobronchial carcinoids whereas 37 had peripheral carcinoids. The surgical procedure in 100 patients with endobronchial carcinoids included 14 left main bronchus sleeve resections, 13 pneumonectomies (7 right sided and 6 left sided), 10 right lower and middle bi-lobectomies, 10 lobectomies (4 left upper, 2 left lower and 4 right upper), and 53 sleeve lobectomies (18 left upper lobe sleeves, 8 left lower lobe sleeves, 20 right upper lobe sleeves, 5 right middle lobe sleeves and 2 right lower lobe sleeve lobectomies). There was no operative mortality. Median tumour size was 3.9 cm (range 5-130 mm). On univariate analysis, longer duration of symptoms was associated with poor surgical outcomes. On multivariate analysis, tumour in the main bronchus, duration of disease < 3 months (p = 0.006), left-sided disease (p = 0.03), and presence of healthy distal lung parenchyma (p < 0.001) were associated with successful lung preservation. Majority of endobronchial carcinoid tumours can be managed with lung-sparing procedures with minimal morbidity and mortality and excellent immediate and short-term outcomes. Early referral and experience of team performing these complex procedures are the key to success.

Minimal Access Surgery for Thymoma.

Thymoma is a rare epithelial tumor of the thymus gland. Despite rarity, it is the most common tumor of the anterior mediastinum. Surgical resection in the form of extended thymectomy is the gold standard operation. Conventionally and even in the current era of significant advances in the minimally invasive surgery, open transsternal extended thymectomy is considered the gold standard, particularly for advanced-stage tumors. There is however significant evidence now available for the use of minimally invasive approaches for early-stage thymomas. This article aims to discuss the various minimally invasive approaches currently being employed for thymomas.

Does an enhanced recovery after surgery protocol affect perioperative surgical outcomes in stage III tubercular empyema? A comparative analysis of 243 patients.

BACKGROUND: Enhanced recovery after surgery protocols in tuberculous empyema surgery have the potential for improved outcomes, but have not been studied widely. This study aimed to analyze the outcomes after implementation of an enhanced recovery after surgery protocol in patients undergoing surgery for tubercular empyema. METHODS: A retrospective analysis of patients who underwent surgery for tuberculous empyema in a dedicated thoracic surgery center from March 2012 to March 2019 was performed. The control group included patients operated on between March 2012 and March 2016. The enhanced recovery after surgery protocol was strictly introduced into our practice from April 2016. The study group included patients operated on between April 2016 and March 2019. All perioperative outcomes were measured, documented, analyzed, and compared between the two groups. There were 166 patients in the control group and 77 in the study group. RESULTS: Intraoperative blood loss (p = 0.0001), prolonged air leak (p = 0.04), chest tube duration (p = 0.005), and length of stay (p = 0.003) were significantly reduced in the study group. Overall rates of postoperative complications (p = 0.04) including wound infection (p = 0.01) were also significantly lower in the study group. CONCLUSIONS: Implementation of an enhanced recovery after surgery protocol in patients undergoing surgery for tuberculous empyema is feasible and effective. Application of such a protocol leads to less intraoperative blood loss, shorter hospital stay and duration of chest drainage, and fewer complications. Application of enhanced recovery after surgery protocols are strongly recommended in tubercular empyema surgery.