Uniportal Video-Assisted Thoracoscopic Surgery Completion Lobectomy Long after Wedge Resection or Segmentectomy in the Same Lobe: A Bicenter Study.

BACKGROUND: Completion lobectomy (CL) following a prior resection in the same lobe may be complicated by severe pleural or hilar adhesions. The role of uniportal video-assisted thoracoscopic surgery (U-VATS) has never been evaluated in this setting. METHODS: Data were collected from two Italian centers. Between 2015 and 2022, 122 patients (60 men and 62 women, median age 67.7 ± 8.913) underwent U-VATS CL at least 4 weeks after previous lung surgery. RESULTS: Twenty-eight (22.9%) patients were affected by chronic obstructive pulmonary disease (COPD) and twenty-five (20.4%) were active smokers. Among the cohort, the initial surgery was performed using U-VATS in 103 (84.4%) patients, triportal-VATS in 8 (6.6%), and thoracotomy in 11 (9.0%). Anatomical segmentectomy was the initial surgery in 46 (37.7%) patients, while hilar lymphadenectomy was performed in 16 (13.1%) cases. CL was performed on 110 (90.2%) patients, segmentectomy on 10 (8.2%), and completion pneumonectomy on 2 (1.6%). Upon reoperation, moderate pleural adhesions were observed in 38 (31.1%) patients, with 2 (1.6%) exhibiting strong adhesions. Moderate hilar adhesions were found in 18 (14.8%) patients and strong adhesions in 11 (9.0%). The median operative time was 203.93 ± 74.4 min. In four (3.3%) patients, PA taping was performed. One patient experienced intraoperative bleeding that did not require conversion to thoracotomy. Conversion to thoracotomy was necessary in three (2.5%) patients. The median postoperative drainage stay and postoperative hospital stay were 5.67 ± 4.44 and 5.52 ± 2.66 days, respectively. Postoperative complications occurred in 34 (27.9%) patients. Thirty-day mortality was null. Histology was the only factor found to negatively influence intraoperative outcomes (p = 0.000). Factors identified as negatively impacting postoperative outcomes at univariate analyses were male sex (p = 0.003), age > 60 years (p = 0.003), COPD (p = 0.014), previous thoracotomy (p = 0.000), previous S2 segmentectomy (p = 0.001), previous S8 segmentectomy (p = 0.008), and interval between operations > 5 weeks (p= 0.005). In multivariate analysis, only COPD confirmed its role as an independent risk factor for postoperative complications (HR: 5.12, 95% CI (1.07-24.50), p = 0.04). CONCLUSIONS: U-VATS CL seems feasible and safe after wedge resection and anatomical segmentectomy.

Impact of enhanced pathway of care in uniportal video-assisted thoracoscopic surgery.

Enhanced Recovery After Surgery (E.R.A.S.) is a multimodal, evidence-based and patient-centered pathway designed to minimize surgical stress, enhancing recovery and improving perioperative outcomes. However, considering that the potential clinical implication of E.R.A.S. on patients undergoing video-assisted thoracic surgery (V.A.T.S.) has not properly defined, we proposed to implement our minimally invasive program with a specific clinical pathway able to enhance recovery after lung resection. Aim of this study was to assess the impact of this integrated program of Enhanced Pathway of Care (E.P.C.) in Uniportal V.A.T.S. patients undergoing lung resection, in terms of efficiency and safety. We conducted a retrospective, observational study enrolling patients undergoing uniportal V.A.T.S. resections from January 2015 to May 2020. Two groups were created: pre-E.P.C. and E.P.C. Propensity score matching analysis was performed to evaluate length of stay (LOS), postoperative cardiopulmonary complications (CPC) and readmission rate (READM). We analyzed 1167 patients (E.P.C. group: 182; pre-E.P.C. group: 985). E.P.C. group has a mean LOS shorter compared to pre-E.P.C. group (3.13 vs 4.19 days, p < 0.0001) without increasing on CPC (E.P.C. 12% vs pre-E.P.C. 11%, p = 0.74) and READM rate (E.P.C. 1.6% vs pre-E.P.C. 4.9%, p = 0.07). In particular, the LOS was shortened in the E.P.C. patients submitted to lobectomy, segmentectomy and wedge resection. Moreover, the three subgroups had similar CPC and READM rates for E.P.C. and control patients. In conclusion, this study demonstrated the benefits and safety of E.P.C. program showing a reduction of LOS for patients undergoing uniportal V.A.T.S. resection.

A Machine Learning Approach for Postoperative Outcome Prediction: Surgical Data Science Application in a Thoracic Surgery Setting.

BACKGROUND: The use of innovative methodologies, such as Surgical Data Science (SDS), based on artificial intelligence (AI) could prove to be useful for extracting knowledge from clinical data overcoming limitations inherent in medical registries analysis. The aim of the study is to verify if the application of an AI analysis to our database could develop a model able to predict cardiopulmonary complications in patients submitted to lung resection. METHODS: We retrospectively analyzed data of patients submitted to lobectomy, bilobectomy, segmentectomy and pneumonectomy (January 2006-December 2018). Fifty preoperative characteristics were used for predicting the occurrence of cardiopulmonary complications. The prediction model was developed by training and testing a machine learning (ML) algorithm (XGBOOST) able to deal with registries characterized by missing data. We calculated the receiver operating characteristic curve, true positive rate (TPR), positive predictive value (PPV) and accuracy of the model. RESULTS: We analyzed 1360 patients (lobectomy: 80.7%, segmentectomy: 11.9%, bilobectomy 3.7%, pneumonectomy: 3.7%) and 23.3% of them experienced cardiopulmonary complications. XGBOOST algorithm generated a model able to predict complications with an area under the curve of 0.75, a TPR of 0.76, a PPV of 0.68. The model's accuracy was 0.70. The algorithm included all the variables in the model regardless of their completeness. CONCLUSIONS: Using SDS principles in thoracic surgery for the first time, we developed an ML model able to predict cardiopulmonary complications after lung resection based on 50 patient characteristics. The prediction was also possible even in the case of those patients for whom we had incomplete data. This model could improve the process of counseling and the perioperative management of lung resection candidates.

Uniportal video-assisted thoracoscopic thymectomy: the glove-port with carbon dioxide insufflation.

BACKGROUND: Since 2004, uniportal video-assisted thoracic surgery (VATS) approach was progressively widespread and also applied in the treatment of thymoma, with promising results. We report the first series of patients who undergone uniportal VATS thymectomy using a homemade glove-port with carbon dioxide (CO2) insufflation. The aim of this article is to analyze the safety and feasibility to perform an extended thymectomy (ET). METHODS: A prospective, single-centre, short-term observational study including patients with mediastinal tumours undergoing scheduled uniportal VATS resection using a glove-port with CO2. Operations were performed through a single incision of 3.5 cm at the fifth intercostal space, right or left anterior axillary line. A 5 mm-30° camera and working instruments were employed through a glove-port with CO2. RESULTS: Thirty-eight patients (20 men; mean age 61.6 years) underwent ET between September 2016 and October 2019. Thirteen patients had a history of Myasthenia Gravis (MG) with thymoma and 8 had incidental findings of thymoma. Additionally, 8 mediastinal cysts and 9 thymic hyperplasia were included. Mean diameter of the tumor was 5.1 cm (range, 1.6-14 cm) and mean operation time was 143 minutes. Mean postoperative drainage duration and hospital stay were 2.3 and 4.3 days, respectively. Mean blood loss was 41 mL. There was no occurrence of surgical morbidity or mortality. During the follow-up period (1-36 months), no recurrence was noted. CONCLUSIONS: Our results suggest that uniportal VATS thymectomy through glove-port and CO2 is safe and feasible procedure, even with large thymomas. Furthermore, the glove-port system represents a valid, cheap and widely available alternative to the commercial devices usually adopted in thoracic surgery.

Uniportal video-assisted thoracoscopic left superior segmentectomy.

Obtaining adequate margins when performing lung cancer resection is crucially important. Therefore, during thoracoscopic segmentectomy, where the direct palpation of the tumor is not always possible, it is mandatory to accurately identify the intersegmental plane in order to achieve a satisfactory oncological and surgical result. In this video tutorial, we demonstrate a uniportal video-assisted thoracoscopic (VATS) superior segmentectomy of the left lower lobe, adopting two different techniques for identifying the intersegmental plane: the inflation-deflation method and selective resected segmental inflation, and we present the pros and cons of each. With the inflation/deflation technique, which is the most common maneuver used, we inflated the whole lung after occlusion of the target segmental bronchus, inducing collapse of the superior segment and inflation of the remaining lobe. However, this inexpensive and easy method often makes identification of the intersegmental plane unreliable because of the collateral ventilation. Moreover, because of the expansion of inflated segments, it limits thoracic working space during the VATS procedure. In contrast, selective resected segmental inflation guarantees an optimal surgical space even during a VATS procedure. In this case, we directly inflated the segmental bronchus of the superior segment through a butterfly needle in order to selectively expand only the selected segment. The careful demarcation of the intersegmental plane is mandatory in order to obtain adequate margins and achieve a high success rate for thoracoscopic segmentectomy. Although a one-size-fits-all method is not feasible, we strongly recommend  making every effort for identifying it as best as possible; indeed, its inadequate demarcation may be the main cause of unsatisfactory surgical and oncological results in terms of locoregional recurrence and long-term survival.

Computed tomography-guided microcoil placement for localizing small pulmonary nodules before uniportal video-assisted thoracoscopic resection.

PURPOSE: The increasing number of computed tomography (CT) performed allows the more frequent identification of small, solid pulmonary nodules or ground-glass opacities. Video-assisted thoracic surgery (VATS) represents the standard in most lung resections. However, since VATS limit is the digital palpation of the lung parenchyma, many techniques of nodule localization were developed. The aim of this study was to determine the feasibility and safety of CT-guided microcoil insertion followed by uniportal VATS wedge resection (WR). MATERIALS AND METHODS: Retrospective study in a single institution, including patients undergone CT-guided microcoil insertion prior to uniportal VATS resection between May 2015 and December 2018. The lesion was identified using fluoroscopy. RESULTS: Forty-six consecutive patients were enrolled (22 male and 24 female). On CT: 5 cases of GGO, 2 cases of semisolid nodules, 39 cases of solid nodules. The median pathologic tumor size was 1.21 cm. Neither conversion to thoracotomy nor microcoil dislodgement was recorded. All patients underwent uniportal VATS WR (9/46 underwent completion lobectomy after frozen section). WR median time was 105 min (range 50-150 min). No patients required intraoperative re-resection for positive margins. After radiological procedure, 1 case of hematoma and 2 cases of pneumothorax were recorded. Four complications occurred in the postoperative period. The mean duration of chest drain and length of stay were 2.9 and 4.6 days, respectively. CONCLUSIONS: CT-guided microcoil insertion followed by uniportal VATS resection was a safe and feasible procedure having a minimal associated complications rate and offering surgeons the ease of localization of small intrapulmonary nodules.

DIPNECH: Association Between Histopathology and Clinical Presentation.

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is a rare disorder which can be an incidental finding in imaging tests performed during the investigation of another condition, or is the final diagnosis in patients evaluated for chronic obstructive complaints. To explore the possible association between specific histopathology features and the mode of clinical presentation, we retrieved the clinical, functional, radiological, and pathological data of all 13 patients diagnosed with DIPNECH at our Institution over a 14-year period (2000-2014). As compared to patients with incidental disease (6/13, 46 %), patients with symptomatic disease were younger [mean (SD): 57.7 vs. 68.7 years, p = 0.046], were more likely to have mosaic attenuation (100 vs. 0 %, p = 0.001) and small multiple nodules (100 vs. 17 %, p = 0.005) at CT, and showed a significantly higher number of foci of linear neuroendocrine proliferation [median (IQR): 28 (13-37) vs. 6 (5-13), p = 0.018] and of tumorlets [median (IQR): 10 (8-20) vs. 1 (1-1), p = 0.002] at histology. Incidental disease was found in association with pulmonary adenocarcinoma in five out of six patients (83.3 %). The results of our study provide preliminary evidence that symptomatic patients with DIPNECH represent a specific subset characterized by younger age and a higher burden of foci of neuroendocrine proliferation.

A Challenging Misleading Diagnosis in a Patient with Suspicion of Gastric Banding Slippage and Strangulation: Diagnosis and Laparoscopic Treatment.

A 51-year-old female (height 160 cm, weight 89 kg, BMI 34.8) presented at the emergency department complaining of sudden onset of sharp abdominal pain in the epigastrium, colicky in nature, dysphagia, nausea, and repeated retching with non-productive vomiting. She has had an adjustable gastric banding implanted laparoscopically 11 years earlier. Since then, she reported to have had only a moderate weight loss (initial BMI 44), although she was closely followed up and the reservoir properly filled by her obesity surgeon. A gastrografin was performed and showed no clear signs of slippage of the gastric band nor of gastric strangulation/ischemia. Nonetheless, the passage of the contrast through esophagogastric junction was slightly slow and restricted suggesting a moderate stenosis from the band. Two cubic centimeters of saline were aspirated from the reservoir to loosen the gastric band. However, on the following minutes, no significant relief of the sharp pain was observed. NSAIDS and morphine were repeatedly given without significant pain relief, and after a few hours, the pain was more intense and diffused to the upper abdomen. I.V. contract CT scan showed a large amount of free fluid, with severe small bowel distension and suspected volvulus and a transition point at the port site of the reservoir, suggesting a strangulated incisional hernia on this site and/or strangulating band adhesion. Urgent surgery was planned, and a laparoscopic approach was chosen. A large amount of free bloody fluid was found, and a long segment of small bowel was twisted around a strangulating band adhesion on the port site of the reservoir, incarcerated within an incisional hernia on the same port site. The strangulating band was cut, and the strangulated bowel was released. Gradual reversion of bowel ischemia was observed, and the gastric banding was removed according to the patient's preoperative request.

Severe descending mediastinitis after routine dental implant surgery: a case report.

PURPOSE: The aim of this article is to present a clinical case of severe descending mediastinitis following the insertion of three dental implants in the mandible. MATERIALS AND METHODS: A 64-year-old female was treated with an implant-supported rehabilitation for her mandibular missing teeth in positions 36, 45 and 46. RESULTS: Three days after the dental implant surgery, the patient complained of malaise, shiver and fever (38°C) with dysphagia and swelling of the mouth floor. The following day the patient was admitted to the hospital with a diagnosis of larynx oedema. Due to the worsening clinical conditions on day 5, she was transferred to the Thoracic Surgery Division with a diagnosis of left neck phlegmon and underwent cervicotomy. A CT scan at day 9 showed mediastinal extension of the phlegmon with initial pleural reaction. The patient then underwent cervicotomy again for drainage. On day 16, she underwent videothoracoscopy to drain a left pleural effusion. The patient was discharged on day 31. CONCLUSIONS: Despite the fact that descending mediastinitis has a very high mortality rate, in the present case proper treatment was able to resolve this serious complication. It is likely that the early diagnosis and prompt treatment prevented neck and mediastinal infection diffusion. Clinicians should always keep in mind that a potential fatal infection complication may arise after routine dental implant surgery in the mandible.