Pleuropulmonary Epithelioid Hemangioendothelioma.

We present the CT, thoracoscopic, and histological findings of a 55-year-old female with pleuropulmonary epithelioid hemangioendothelioma. The CT scan revealed pleuropulmonary lesions, and thoracoscopy allowed direct visualization and biopsy of the lesions. Histological analysis confirmed the diagnosis, emphasizing the utility of combining imaging, endoscopic, and pathological methods in diagnosing this rare tumor.

A Case of Pleuritis Associated With Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis Diagnosed Through Medical Thoracoscopy.

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) includes eosinophilic granulomatosis with polyangiitis, granulomatosis with polyangiitis, and microscopic polyangiitis. Pulmonary involvements such as interstitial pneumonia and alveolar hemorrhage are common in AAV, but pleuritis is rare. Here, we report a case of pleuritis associated with AAV. A 68-year-old woman was referred to our hospital because of bilateral wrist and knee pain, Raynaud's phenomenon, and a sclerotic change in her extreme fingers with elevation of proteinase 3 ANCA (PR3-ANCA) and myeloperoxidase-ANCA (MPO-ANCA). From a skin biopsy of her forearms and fingers, we diagnosed that the patient had limited systemic sclerosis. After her first visit at 15 months, she complained of pain in the side of her chest. Her chest X-ray and computed tomography showed left pleural effusion, and local anesthetic thoracoscopy was performed. Histological examination of the pleural revealed granuloma and vasculitis. Based on her symptoms and histological findings, we diagnosed this case as ANCA-associated vasculitis (AAV) and treated it with steroids and intravenous cyclophosphamide successfully. Pleuritis is a rare pulmonary lesion of AAV, and thoracoscopy under local anesthesia is useful for the histological examination of vasculitis.

Pulmonary Sequestration: A Monocentric Case Series Report.

Purpose: Pulmonary sequestration is a rare pulmonary malformation that often necessitates surgical intervention due to potential complications such as recurrent infections or hemoptysis. This case series presents the clinical trajectory of four patients diagnosed with pulmonary sequestration, from initial diagnosis through postoperative care, with a specific focus on the limited arterial supply in two of the cases. Materials and Methods: We conducted a retrospective descriptive analysis of four patients diagnosed with pulmonary sequestration who underwent surgical treatment at our institution between January 2013 and November 2022. The affected lung segments were excised via either thoracoscopy or thoracotomy. We evaluated perioperative and postoperative complications, hospital stay duration, histological findings, and the vascular supply of the affected areas. Results: Thoracoscopic surgery was initially preferred for all patients, though one required conversion to an open procedure due to technical challenges. Perioperative complications included increased pain and atelectasis. Two patients developed pleural empyema postoperatively, necessitating additional surgical intervention. The overall outcomes were favorable, with appropriate management addressing the complications effectively. Conclusions: Pulmonary sequestration, despite its rarity, often requires surgical treatment. Both thoracoscopic and open surgical methods are effective, though thoracoscopic surgery is generally preferred when feasible. The findings underscore the importance of meticulous preoperative planning and vigilant postoperative care to manage and mitigate potential complications.

Effect of Ultrasound-Guided External Oblique Intercostal Block on Postoperative Recovery After Subxiphoid Video-Assisted Thoracoscopic Thymectomy: A Randomized Controlled Trial.

OBJECTIVE: Severe postoperative pain can occur after subxiphoid video-assisted thoracoscopic thymectomy (SVATT), affecting the quality of postoperative recovery. This study aimed to evaluate the effect of ultrasound-guided external oblique intercostal (EOI) block on recovery after SVATT. METHODS: A total of 60 patients undergoing SVATT were randomly divided into the EOI group (group E, n = 30) and the control group (group C, n = 30). Group E underwent ultrasound-guided bilateral EOI block at the 6th rib level and was injected 20 mL of 0.375% ropivacaine on each side. Group C was injected with 20 mL of 0.9% saline at the same site. After the operation, both groups received a patient-controlled intravenous analgesic (PCIA) pump. The 15-item Quality of Recovery (QoR-15) scores were recorded at 24 hours before surgery (T0), 24 hours after surgery (T3), and 48 hours after surgery (T4). The sufentanil usage in the first 24 hours postoperatively, the remifentanil dosage during surgery, the time of first pressing PCIA, and the cases of rescue analgesia were recorded. The visual analog scale (VAS) scores of patients at 6 (T1), 12 (T2), 24 (T3), and 48 hours (T4) after an operation during rest and coughing were recorded. The dermatomes of the sensory plane, block complications in group E, and the incidence of other postoperative adverse reactions in both groups were also recorded. RESULTS: Compared with group C, the QoR-15 scores of patients were significantly higher at T3 and T4 in the group E. The VAS scores were significantly lower at T1, T2, and T3 during rest and coughing in the group E. The sufentanil usage in the first 24 hours postoperatively, the remifentanil dosage during surgery, and the cases of rescue analgesia were significantly lower in group E, and the time of first pressing PCIA was significantly increased in group E (all P < .05). CONCLUSION: Ultrasound-guided EOI block can be safely used in patients undergoing SVATT, which can improve the quality of postoperative recovery and reduce postoperative pain.

Comparison of three-dimensional vs. two-dimensional assisted thoracoscopy for recurrent laryngeal nerve lymph nodes dissection in esophagectomy: a retrospective study.

BACKGROUND: This study aimed to explore the clinical value of 3D video-assisted thoracoscopic surgery in dissecting recurrent laryngeal nerve lymph nodes in patients undergoing minimally invasive esophagectomy. METHODS: A retrospective cohort study was conducted on 205 patients, including 120 males, who underwent esophagectomy from May 2018 to May 2020 in the Department of Thoracic Surgery at the Affiliated Huai'an No.1 People's Hospital of Nanjing Medical University. Perioperative parameters, including intraoperative blood loss, operation time, the number of dissected recurrent laryngeal nerve lymph nodes, the incidence and degree of postoperative recurrent laryngeal nerve injury, the volume of postoperative thoracic drainage, and postoperative complications, were compared between the 3D and 2D groups. RESULTS: There were no significant differences in the preoperative baseline data between these two groups (P > 0.05). The number of dissected recurrent laryngeal nerve lymph nodes in the 3D group was significantly higher than in the 2D group (P < 0.05). The operation times were significantly shorter in the 3D group than in the 2D group (P < 0.05). The volume of thoracic drainage in the first 2 days was significantly less in the 3D group than in the 2D group (P < 0.05). CONCLUSIONS: Compared to the 2D system, the application of 3D video-assisted thoracoscopic surgery in minimally invasive esophagectomy can increase the number of dissected recurrent laryngeal nerve lymph nodes and ensure safety. Additionally, it can reduce the duration of the operation, decrease early postoperative thoracic drainage volume, and promote patient recovery.

Surgical stabilization of rib fractures (SSRF): the WSES and CWIS position paper.

BACKGROUND: Rib fractures are one of the most common traumatic injuries and may result in significant morbidity and mortality. Despite growing evidence, technological advances and increasing acceptance, surgical stabilization of rib fractures (SSRF) remains not uniformly considered in trauma centers. Indications, contraindications, appropriate timing, surgical approaches and utilized implants are part of an ongoing debate. The present position paper, which is endorsed by the World Society of Emergency Surgery (WSES), and supported by the Chest Wall Injury Society, aims to provide a review of the literature investigating the use of SSRF in rib fracture management to develop graded position statements, providing an updated guide and reference for SSRF. METHODS: This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of experts then critically revised the manuscript and discussed it in detail, to develop a consensus on the position statements. RESULTS: A total of 287 studies (systematic reviews, randomized clinical trial, prospective and retrospective comparative studies, case series, original articles) have been selected from an initial pool of 9928 studies. Thirty-nine graded position statements were put forward to address eight crucial aspects of SSRF: surgical indications, contraindications, optimal timing of surgery, preoperative imaging evaluation, rib fracture sites for surgical fixation, management of concurrent thoracic injuries, surgical approach, stabilization methods and material selection. CONCLUSION: This consensus document addresses the key focus questions on surgical treatment of rib fractures. The expert recommendations clarify current evidences on SSRF indications, timing, operative planning, approaches and techniques, with the aim to guide clinicians in optimizing the management of rib fractures, to improve patient outcomes and direct future research.

Open thoracotomy versus VATS versus RATS for segmentectomy: a systematic review & Bayesian network meta-analysis.

BACKGROUND: Recent trials suggest that more conservative resections such as segmentectomy are non-inferior to more radical approaches. Most segmentectomy can be safely performed using video-assisted thoracoscopic surgery (VATS). The clinical benefits of robotic-assisted thoracoscopic surgery (RATS) remain unclear. We aimed to perform a systematic review evaluating the outcome of open thoracotomy, VATS, and RATS for segmentectomy. METHODS: A systematic database search was conducted of original articles exploring the outcome of open versus VATS versus RATS segmentectomy in PubMed, EMBASE and SCOPUS. The primary outcome was 30-day mortality. Secondary outcomes were hospital readmission, air leak, and post-operative pneumonia respectively. RESULTS: 11 studies were included with a total patient sample size of 7280. There were no differences between the three approaches in terms of 30-day mortality, hospital readmission, air leak, and post-operative pneumonia. CONCLUSION: There are no significant differences between the three approaches in the clinical outcomes measured. While our analysis demonstrates the potential benefits of RATS, it is important to note that the steep learning curve associated with this technique may impact its wider adoption and efficacy in the community. Further randomised control studies are required to compare the short and long terms results of VATS and RATS approaches.

Perioperative outcomes of thoracoscopic versus non-thoracoscopic minimally invasive repair of pectus excavatum: a systematic review and meta-analysis.

BACKGROUND: Pectus excavatum is the most common chest wall deformity, with the Nuss procedure being the preferred surgical approach for correction. However, the decision to use thoracoscopic assistance remains challenging. This study aimed to evaluate the perioperative outcomes of thoracoscopic-assisted versus non-thoracoscopic-assisted minimally invasive repair of pectus excavatum (TA-MIRPE vs. NTA-MIRPE). METHODS: A comprehensive search was conducted across PubMed, Medline, Embase, WOS, and CBM databases for studies published from 2010 to the present related to this topic. Meta-analysis was performed using RevMan 5.0 and STATA 15.0, with primary comparisons focusing on postoperative complications and the incidence of poor incision healing. RESULTS: Eighteen studies involving a total of 5933 patients were included in the analysis, with 1670 undergoing non-thoracoscopic surgery and 4263 receiving thoracoscopic surgery. The meta-analysis revealed that, compared to the NTA-MIRPE group, the TA-MIRPE group had longer operation times [SMD = 1.71, 95% CI (1.14, 2.28), P < 0.001] and extended postoperative hospital stays [SMD = 0.12, 95% CI (0.04, 0.20), P = 0.004]. However, the TA-MIRPE group showed a lower incidence of postoperative complications [OR = 0.48, 95% CI (0.35, 0.65), z = 4.63, P < 0.001] and higher patient satisfaction [OR = 1.88, 95% CI (1.32, 2.67), z = 3.51, P < 0.001]. CONCLUSION: While TA-MIRPE is associated with longer operation times and hospital stays, it offers greater patient satisfaction, reduces postoperative complications, and enhances surgical safety.

Thoracoscopic Repair of a Rare Case of Congenital Diaphragmatic Hernia with Eventration (Mixed Lesion).

Congenital diaphragmatic malformations include congenital diaphragmatic hernia (CDH) and eventration of the diaphragm. The clinical presentation is variable, and the prognosis depends on multiple factors. The coexistence of CDH and diaphragmatic eventration in the same patient is extremely unusual and has not been reported previously in the literature. We report this rare association in a 3-month-old male infant who was managed successfully by minimally invasive approach.

Role of thoracoscopy in diagnosis of tubercular pleural effusion in low ADA setting- A prospective, observational study.

BACKGROUND: Tubercular Pleural effusion (TBPE) is one of most common extrapulmonary tuberculosis. It can be difficult to diagnose due to low sensitivity of pleural fluid smear, culture and CBNAAT. Diagnosis of TBPE is then dependent on the level of pleural fluid Adenosine Deaminase (ADA). Thoracoscopic pleural biopsy gives definite diagnosis specially in Low Pleural fluid ADA setting. AIMS AND OBJECTIVE: This study was planned to find out the prevalence of tubercular etiology in patients of exudative pleural effusion with low ADA (ADA <40 IU/L). MATERIAL AND METHODS: A Prospective, observational study was carried out in a tertiary teaching institute in north India. Total 142 patients of pleural effusion with low ADA were enrolled. All patients underwent rigid thoracoscopy for confirmation of their diagnosis. RESULTS: Out of 142 patients, male were 78 (55%) and female were 64 (45%). Mean age of patients were 57.4 years. Tuberculosis was diagnosed as a cause of effusion in 22 (15.5%) out of 142 patients. Majority of TBPE patients had pleural thickening as thoracoscopic finding. Mean ADA level in TBPE was 27.36 ± 11.6 as compared to 18.55 ± 9.02 in non tubercular pleural effusion patients and this difference was significant statistically (P- 0.002). CONCLUSION: The diagnosis of patients having exudative, low ADA pleural effusion can be very easily confirmed by thoracoscopy guided pleural biopsy which has a very high diagnostic yield.

Evolution of Video Assisted Thoracoscopic Surgery for Thoracic Disc Herniation: Towards Biportal Thoracoscopic Approach.

OBJECTIVE: This work aims to describe the evolution of the video-assisted Thoracoscopic Surgery (VATS) approach from a multiportal access to a biportal access for thoracic herniated disc surgery. Thoracic disc herniation remains a challenging pathology for spine surgeons. VATS of the thoracic spine was described in the 90s and represented an important technical leap by including minimally invasive options for thoracic pathology. Nowadays, VATS in thoracic surgery tends to evolve towards an even less invasive technique, from a multiportal approach to a biportal one. METHODS: We describe the adoption of this approach for our spinal pathology in 3 patients. We use a two-port VATS. The largest (approximately 5 cm) with an Alexis retractor and a second port (1.5 cm) just for the camera. RESULTS: The 3 patients started walking in less than 24 hours and none suffered any complications related to the approach. All of them reported tolerable pain at the surgical site. Changing our previous VATS system from 3 to 5 ports was relatively easy regarding the surgical technique. CONCLUSIONS: This access allows the surgeon to manipulate the instrumentation confidently and the camera does not fog up as often. Extracting a piece of rib is unnecessary and theoretically, we only manipulate 1 or at most 2 intercostal nerves, so the patient's recovery is favorable.

A modern approach to multiple pulmonary resections in children with recurrent metastatic pulmonary disease.

Implications of repeated resections of pulmonary metastasis (PM) are not well documented in the modern era. Fifteen children underwent two (n = 8), three (n = 3), or four or more (n = 3) resections (total = 38 procedures), most commonly for osteosarcoma (71%). Operative approach included muscle-sparing thoracotomy (71%), non-muscle-sparing thoracotomy (18%), and video-assisted thoracoscopy (11%). Median resected nodules per procedure was four (range = 1-95). Prolonged air leaks were the most common postoperative complication (29%). Median hospital stay was 4 days, and no children were discharged with or have required oxygen. Event-free survival is 67% at median follow-up time of 54 months, with an overall survival rate of 64%. Repeat resection of PM appears to be well tolerated, without prolonged hospital stays or compromised pulmonary function.

Combined segmentectomy: S1 + S3, right upper lobe.

A particular challenge in minimally invasive pulmonary segmentectomy arises in the presence of a lesion close to a neighbouring segment. In this case, avoiding a lobectomy while ensuring complete resection with adequate margins may require the resection of two adjacent segments in the form of a bisegmentectomy. A combined segmentectomy of the S1 and S3 segments of the right upper lobe is readily performed through an anterior multiport thoracoscopic approachis systematic and straightforward, maximizing exposure while minimizing the extent of dissection.

Short- and Long-Term Outcomes of Thoracoscopic and Open Repair For Esophageal Atresia and Tracheoesophageal Fistula.

BACKGROUND: The aim was to evaluate short- and long-term outcomes for thoracoscopic repair of EA/TEF and compare with open repair. METHODS: Patients who underwent EA/TEF repair during 2000-2020 were evaluated retrospectively. Patients with delayed repair were excluded. Demographic, operative, outcome data was collected. Outcomes were compared using Wilcoxon-rank sum tests for continuous, Chi-squared/Fisher's exact tests for categorical data. RESULTS: There were 104 patients with primary repair, 49 (47.1%) underwent thoracoscopic repair per surgeon's choice. Type C accounted for 101 (97.1%) of the cases. Gestational age and birth weight were higher in the thoracoscopy group (p = 0.001). The rate of ≥3 VACTERL anomalies was higher in the OR group (p = 0.016). Operative time, rate of anastomotic leak, time to first oral feeding were similar (p > 0.05). Thoracoscopy group had decreased length of ventilation (p = 0.026) and length of stay (p = 0.029). The incidence of anastomotic stricture was higher in the thoracoscopy group (p = 0.012). Recurrent TEF was one case in each group. Rates of tube feeding at discharge and in first year were similar (p > 0.05), rate in third year was decreased (p = 0.032) in the thoracoscopy group. Rates of anti-reflux medication in first and third years, and fundoplication rate were similar (p > 0.05). CONCLUSIONS: Many of the short- and long-term outcomes are comparable between thoracoscopic and open repair of EA/TEF. Length of ventilation, length of stay are decreased in the thoracoscopy group. Anastomotic stricture is higher, the need for long-term tube feeding is lower after thoracoscopic repair. Although these results could be affected by selection bias, they are still promising for advancing thoracoscopic repair of EA/TEF safely and efficiently. LEVEL OF EVIDENCE: Level III.

Descriptive analysis of therapeutic outcomes between thoracoscopic and transsternal thymectomy in myasthenia gravis patients from 2011 to 2021.

BACKGROUND: Myasthenia gravis is an autoimmune disease with high prevalence of thymus disorders, in which, thymectomy is considered one of the therapeutic approaches in improving the patients' clinical outcomes. Today, thoracoscopic thymectomy has received significant attention than the classic transsternal approach due to fewer complication. Therefore, this study was designed with the aim of investigating the therapeutic outcomes of thymectomy in patients with myasthenia gravis in the Afzalipour Hospital of Kerman between 2011 and 2021. METHODS: The current study is a descriptive analytical study on patients with myasthenia gravis who underwent surgical thymectomy within 2011-2021. Demographic and clinical characteristics of patients from the time of operation to three years of follow-up were extracted and recorded from clinical records or by phone calls. Data were analyzed using SPSS software. RESULTS: The data of 70 patients who underwent surgical thymectomy were analyzed. Thymectomy caused a significant reduction in the severity of the disease according to the Osserman classification (P = 0.001). It also significantly reduced the use of corticosteroids (P = 0.001) and IVIG (P = 0.015) compared to the time before the surgery. Sixty-two patients (88.57%) needed to take less medicine than before surgery. Left VATS was associated with less post-operative severity of the disease (P = 0.023). There were only two deaths during the follow-up period. CONCLUSION: Overall, the findings of the present study demonstrated that thoracoscopic thymectomy is a useful surgical approach that leads to faster recovery, reducing the severity of the disease, need for medication, and complications in patients with myasthenia gravis, In comparison with the transsternal approach.

Right Thoracoscopic Excision of an Esophageal Bronchogenic Cyst.

Bronchogenic cysts, first described in 1859, are rare congenital cystic malformations of the respiratory tract, with an incidence of one per 42,000-68,000 hospital admissions in one hospital series. They comprise 10-15% of mediastinal tumors and between 50% and 60% of mediastinal cystic lesions. Its clinical diagnosis is often challenging due to the absence of distinct imaging features. This case report focuses on the case of a 51-year-old female who initially received a misdiagnosis of esophageal leiomyoma. Subsequently, during exploration in the operating theater, right thoracoscopy revealed the presence of an esophageal bronchogenic cyst.

Application of indocyanine green in thoracic surgery: A review article.

Indocyanine green has been used in clinical practice for a long time because of its many advantages such as stable coloration, safety and cheapness. With the widespread development of thoracoscopic technology, thoracic surgeons have a higher demand for the identification of lesions and tissue structures under the thoracoscope, and the traditional white light imaging can no longer fully meet the needs of thoracic surgeons. In this situation, indocyanine green combined with NIR imaging technology has brought great help to thoracic surgeons. For example, indocyanine green plays an important role in the localization of small pulmonary nodules, the imaging of intersegmental lung planes, the imaging of thoracic ducts, and the assessment of blood supply to the tubular stomach. In this paper, we review the application of indocyanine green in thoracic surgery according to the related research and application at home and abroad.

Etiology of exudative pleural effusion among adults: differentiating between tuberculous and other causes, a multicenter prospective cohort study.

Objectives: Exudative pleural effusions have a broad etiology and usually necessitate further investigative workup, including invasive procedures. This study aimed to evaluate and compare the demographic, clinical, and biochemical characteristics of tuberculous, malignant, and chronic inflammatory pleural effusions. Methods: This is a 2-year prospective cohort study of patients referred for medical thoracoscopy with an exudative pleural effusion. Results: A total of 159 patients were enrolled in the study, with a mean age of 42.49 ± 13.8 years and the majority being males 121 (76.1%). As expected, patients with tuberculous effusions were significantly younger than those with non-tuberculous effusions (37.7 ± 10.9 vs 49.1 ± 14.9, P <0.001). Serum analysis showed significantly lower white blood cell count (7.5 × 109/L ± 2.7 vs 9.0 × 109/L ± 3.3, P = 0.004), higher total protein (76.2 g/dL ± 10.1 vs 70.2 g/dL ± 8.9, P <0.001), and higher median C-reactive protein (median 77.5, interquartile range 51-116 vs median 40.5, interquartile range 8-127, P <0.001) among tuberculous compared with non-tuberculosis effusions. Conclusions: Our study validates previous findings showing similar results in patients with tuberculous pleural effusions. A predictive model incorporating different demographic and clinical/laboratory characteristics may be useful in the early etiologic characterization of exudative pleural effusion.

Comparative analysis of the clinical effects of different thoracoscopic resection in the treatment of Stage I Non-Small Cell Lung Cancer.

Objective: To compare and analyze the clinical effects of thoracoscopic lobectomy and segmentectomy in stage I non-small cell lung cancer (NSCLC). Method: This was a retrospective study. Eighty patients with stage I NSCLC treated in Cangzhou People's Hospital from December 2019 to January 2022 were randomly divided into the segmentectomy group and lobectomy group, with 40 cases in each group. Further comparative analysis was carried out focusing on perioperative indexes, maximum ventilation volume (MVV), forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), VAS score of postoperative pain and complications. Result: There was no significant difference in the number of dissected lymph nodes and extubation time between the two groups (p>0.05). The operation time was longer, while intraoperative blood loss was less and the stay of stay in hospital was shorter in the segmentectomy group significantly than those in the lobectomy group (p<0.05). Furthermore, no significant difference was observed in MVV%, FVC% and FEV1% between the two groups before operation (p>0.05). Meanwhile, the segmentectomy group had evidently lower VAS scores at 1 d, 3 d and 5 d postoperatively than those in the lobectomy group (p<0.05). Besides, there was a much lower total incidence of complications in the segmentectomy group than that in the lobectomy group (p<0.05). Conclusion: Compared with lobectomy, thoracoscopic segmentectomy is more effective in the treatment of stage I NSCLC, with less bleeding and mild pain, which can alleviate pulmonary function injury and reduce postoperative complications that is conducive to the improved prognosis of patients.