Portrayal of video-assisted mediastinoscopic lymphadenectomy's range subsequent to its simultaneous use with uniportal VAT-lobectomy for left-sided NSCLC: a case-based perspective.

BACKGROUND: Video-assisted mediastinoscopic lymphadenectomy (VAMLA) is the most precise approach combining staging and therapeutic interventions in non-small cell lung cancer (NSCLC). In the case of left-sided NSCLC, the likelihood of mediastinal lymph node metastases depends on the involvement of the left lung regional lymphatic network. As such, it appears obvious - at least for selected patients with mediastinal staging by either PET-CT or EBUS-TBNA ± EUS-FNA and with cN ≤ 2 - to merge VAMLA and left-sided video-assisted thoracoscopic (VAT) lobectomy for a single-stage therapeutical procedure. CASE PRESENTATION: We present the clinical course of an 83-year-old patient following simultaneous VAMLA and VAT-lobectomy for invasive mucinous adenocarcinoma of the left upper lobe with a provisional cT3cN0cM0 stage. The patient developed a clinically relevant postoperative pneumothorax due to a persistent parenchymal air leak. CT scan revealed a substantial pneumomediastinum and showed the capability of VAMLAs range for mediastinal lymph node dissection in a unique way. Following the prompt insertion of a second chest tube, the situation was stabilized with an unremarkable further in-hospital stay. The patient remains free of tumor recurrence or distant metastases at a one-year follow-up. CONCLUSION: Presenting this aperçu, we encourage reviving the debate on (1) precise mediastinal staging in general and (2) VAMLA's important role as a diagnostic and therapeutic tool.

Pyopericardium and extensive mediastinal abscess following EBUS-TBNA for mediastinal staging of NSCLC: a case report.

Background: Based on the algorithm on preoperative mediastinal staging in patients with non-small cell lung cancer (NSCLC), endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is indicated in case of computed tomography (CT)-enlarged or positron emission tomography (PET)-positive mediastinal lymph nodes. It represents both a safe minimal invasive procedure with complication rates of less than 1.5% and a valid tool with a high sensitivity defining mediastinal nodal disease. However, infectious complications like mediastinitis or pyopericardium are most feared. Case Description: A 54-year-old woman was admitted to our hospital for further investigation of a suspected NSCLC of the right upper lobe. EBUS-TBNA was performed to receive both diagnosis and samples of the mediastinal lymph nodes. Two weeks after EBUS-TBNA, the patient presented with symptoms of cardiogenic/septic shock: hypotension, tachycardia, chest pain and fever. Prompt diagnosis of concomitant infectious mediastinitis and extensive pyopericardium in consequence of EBUS-TBNA was obvious. Besides systemic antibiotics, bilateral thoracoscopic interventions finally made the breakthrough. The patient could be discharged roughly three weeks after emergent re-admittance. As being finally diagnosed with NSCLC (stage IIIA squamous cell carcinoma), the patient underwent-subsequent to induction chemotherapy-a definitive sequential chemoradiotherapy. Twelve-month follow-up confirmed stable disease. Conclusions: It is to be expected that with increasing application of EBUS-TBNA as mediastinal staging tool, the number of serious infection-related complications will rise accordingly. The efficacy of antibiotic prophylaxis after EBUS-TBNA has not yet been proved and is therefore not included in any guideline. Our case gives an impression on the severity of delayed infectious complications after EBUS-TBNA and outlines up-front surgery as primary objective to broadly debride all contagious abscess-/empyema sites. With increased use of EBUS-TBNA as mediastinal staging tool, clinicians should be aware of this rare but highly critical peri-interventional complication in order to closely monitor endangered patients.

Association of early-onset myasthenia gravis and primary Sjögren's syndrome: a case-based narrative review.

Coexistent myasthenia gravis (MG) and primary Sjögren's syndrome (pSS) is an absolute rarity. That is kind of a surprise as both entities seem to share the same corresponding immunologic mechanisms. We hereby report the case of a 41-year-old woman with coincident early-onset MG (EOMG) and pSS. Because EOMG was the leading clinical feature, she was primarily treated by innovative non-intubated uniportal subxiphoid video-assisted thoracoscopic surgery (VATS) thymectomy. As the association of EOMG and pSS is so unusual, we contextualize our findings with the relevant literature. Particular relevance is an anti-nuclear antibody screening throughout the clinical course of MG and-in reverse-a screening for MG variables when pSS patients complain either muscle fatigability or fatigable ptosis. As pSS patients do not develop any serious morbidity, supervising MG progress in patients with both diseases is of utmost importance. Apart from conscientious pSS diagnosis, prompt adjusting of EOMG progress is the essential aspect of targeted treatment. In this context, it is relevant that therapeutic decisions are made in a multidisciplinary approach. Due to its rarity, multicenter prospective studies of larger sample sizes are indispensably needed to obtain a better understanding of this unusual link.

Non-intubated Uniportal Subxiphoid Video-Assisted Thoracoscopic Surgery for Extended Thymectomy in Myasthenia Gravis Patients: A Case Series.

Minimally invasive strategies are increasingly popular in patients with myasthenia gravis (MG)-associated thymomas. Within the context of video-assisted thoracoscopic surgery (VATS) as a widely known minimally invasive option, the most recent achievement is uniportal subxiphoid VATS. In MG patients, it is mandatory (1) to minimize perioperative interference with administered anesthetics to avoid complications and (2) to achieve a complete surgical resection, as the prognosis essentially depends on radical tumor resection. In order to fulfill these criteria, we merged this surgical technique with its anesthesiologic counterpart: regional anesthesia with the maintenance of spontaneous ventilation via a laryngeal mask. Non-intubated uniportal subxiphoid VATS for extended thymectomy allowed radical thymectomy in all MG patients with both rapid symptom control and fast recovery.

Technique for ectopic intrathymic parathyroid adenoma: the uniportal subxiphoid approach.

Parathyroid adenomas (PAs) are the main cause for primary hyperparathyroidism with almost a quarter of them being ectopic, most likely located in the superior mediastinum within the thymus. Besides the challenge of their prompt and correct diagnosis, utmost care should be taken during surgical resection as leaving behind parathyroid tissue may result in metastasis and recurrence of hyperparathyroidism. With tumor excision via median sternotomy or thoracotomy being the conventional approaches for a long period, video-assisted thoracoscopic surgery (VATS) is of gaining popularity. As the lateral thoracic approach lacks in clarity on the contralateral mediastinum, the newest evolution in VATS-the supxiphoid approach-closes the gap to the insufficient intraoperative visibility and hence optimizes postoperative outcome. We hereby present the practicality of the uniportal subxiphoid resection of an ectopic mediastinal PA.

Video-assisted mediastinoscopic lymphadenectomy (VAMLA) for staging & treatment of non-small cell lung cancer (NSCLC).

Precise preoperative staging and restaging of mediastinal lymph nodes in patients with potentially resectable non-small cell lung cancer (NSCLC) is of supreme importance. Over the last years, algorithms on preoperative mediastinal staging incorporating imaging, endoscopic and surgical techniques have been widely published, offering more evidence concerning different mediastinal staging techniques. Current guidelines well define when and how to receive tissue confirmation in case of computed tomography (CT)-enlarged or positron emission tomography (PET)-positive mediastinal lymph nodes. Endosonography [(endoscopic bronchial ultrasonography/oesophageal ultrasonography (EBUS/EUS)] with fine needle aspiration still is the first choice (when accessible) since it is minimally invasive and has a high sensitivity to confirm mediastinal nodal disease. If negative, surgical staging with nodal dissection or biopsy is indicated. Video-assisted mediastinoscopic lymphadenectomy (VAMLA) and transcervical extended mediastinal lymphadenectomy (TEMLA) are preferred over conventional mediastinoscopy if a mediastinal R0-resection can be achieved. The mutual use of endoscopic and surgical staging effects highest accuracy. Straight surgical resection of tumors ≤3 cm (located within the external third of the lung) with systematic nodal dissection is justified as soon as there are no enlarged lymph nodes on CT-scan and once there is no nodal uptake on PET-CT. In case of central tumors and enlarged or FDG avid nodes regardless of cytological result, preoperative invasive mediastinal staging is indicated to rule out mediastinal nodal spread. However, accuracy needed in preoperative nodal staging has been under continuous debate ever since and with the advent of immunotherapy is right now intensely revived. During the last two decades VAMLA has been growing up from being a merely staging tool to an expert-recognized therapeutic tool in the context of minimal invasive lung cancer resection.

Thoracoabdominal actinomycosis - Chameleon through kaleidoscope.

Actinomyces is a gram-positive anaerobic bacterium that generally inhabits the human commensal flora of the bronchial system, the gastrointestinal and urogenital tract. In the rare case of becoming invasive under certain circumstances, the resulting Actinomycosis affects most commonly cervicofacial, thoracic, abdominal and pelvic regions. Due to its rarity and presenting with nonspecific clinical symptoms, thoracic and/or abdominal Actinomycosis in particular are highly intriguing clinical conditions that can easily be mistaken for other diseases including malignancies. Astute considerations are therefore necessary whenever we are challenged diagnostically to allow early diagnosis and thus avoiding gratuitous invasive surgery. In order to highlight different issues of this ultimate chronic disease we report a particular case of thoracoabdominal Actinomycosis.

Training curriculum for European thoracic surgeons: a joint initiative of the European Society of Thoracic Surgeons and the European Respiratory Society.

Because of the differing definitions of the margins of thoracic surgery as a specialty and the variability in the training curricula among European countries, the European Society of Thoracic Surgeons formed a task force to elaborate a consensual proposal. The first step comprised creating a harmonized syllabus that was completed and published in 2018. This publication presents a proposal for a curriculum upon which the task force and the external expert reviewers have agreed. The curriculum was developed by the task force: each module and item describe the expected level of knowledge, skills and attitudes to be attained by the participants; learning opportunities, assessment tools and minimal clinical exposures have been defined as well. Competence in terms of non-technical skills has been defined for each module according to the CanMEDS (http://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e) glossary. The different modules were subsequently submitted to an internal and an external review process and re-edited accordingly before final validation. The authors hope that this document will serve as a roadmap for both thoracic surgical trainees and mentors. It should further guide continuous professional development. However, evolving scientific and technological advances are expected to modify the diagnosis and treatment of diseases and disorders in the future and hence will mandate periodical revisions of the document.

Glomus tumor of the trachea - Synopsis of histology & methodology of treatment.

Glomus tumors are neoplasms arising from modified smooth muscle cells surrounding arteriovenous anastomosis in the dermis and subcutaneous tissues, which are contributing to blood flow regulation and temperature control on the skin surface. Glomus cells are sparse or absent in visceral organs, making extracutaneous presentation of glomus tumors an extremely rare finding. We briefly report histological considerations on glomus tumors of the trachea and sum the multidisciplinary aspects of their staged endoscopic and surgical management using the example of a rare case presentation.

Does endoesophageal ultrasound-guided fine-needle aspiration replace mediastinoscopy in mediastinal staging of thoracic malignancies?

OBJECTIVE: To determine the impact of endoesophageal ultrasound-guided fine-needle aspiration (EUS-FNA) on management of thoracic malignancies. METHODS: One hundred and twenty patients referred for invasive diagnostic and resection of thoracic malignancies were studied prospectively. Negative and inconclusive EUS-FNA findings were assessed by video-assisted mediastinoscopic lymphadenectomy (VAMLA) or open lymphadenectomy. RESULTS: One hundred and twenty patients, aged 64.1 years (range 38-85) underwent 120 EUS-FNA, 53 video-assisted mediastinoscopic and 48 open lymphadenectomies for diagnosis and treatment of 99 lung carcinoma, six lung metastases, five mesothelioma, three lymphoma, and eight other conditions. EUS-FNA showed T4 in 15/120 and adrenal or hepatic metastases in 9/120 cases. Prevalence of mediastinal lymph node metastases was 51.7%. EUS-FNA false-negative rate was 25.3%. EUS-FNA sensitivity was 91.7%, 78.1% and 43.8% for bulky disease, enlarged mediastinal nodes or normal nodes on CT scan, 50% and 96.6% for right- and left-sided tumours, and 80.6%, 78.9%, 23.8% and 25.0% for the lymph node stations 7, 5/6, 4R, and 4L. A 38.3% respectively 100% cut-down of mediastinoscopies leads in 7.5% respectively 20.8% to incorrect treatment decisions. CONCLUSIONS: EUS-FNA sensitivity depends on the localisation of the primary tumour, and extent and location of mediastinal disease. For left-sided tumours, EUS-FNA improves mediastinal staging by assessing stations 5 and 6 inaccessible to conventional mediastinoscopy. For extended mediastinal disease, mediastinoscopy can be avoided or spared for restaging after neoadjuvant therapy. Exclusion of mediastinal involvement requires mediastinoscopy or open lymphadenectomy. Beyond mediastinal nodal staging, EUS-FNA may detect T4 and M1 situations. Thus, EUS-FNA is a useful supplement to and not the replacement of mediastinoscopy.

A harmonized European training syllabus for thoracic surgery: report from the ESTS-ERS task force.

Training of European thoracic surgeons is subject to huge variations in terms of length of training, content of training and operative experience during training. Harmonization of training outcomes has been approached by creating the European Board of Thoracic Surgery, which has been accredited by the European Union of Medical Specialists (UEMS); however, a clear description of the content of training is lacking. Building on their recognized experience with curriculum building, task forces of the European Respiratory Society and the European Society of Thoracic Surgery agreed on a joint task force on training in thoracic surgery. The goal of this study is to report on the mission statement developed from the UEMS-driven survey, describe the Delphi method and the observed results and present the first large consensus-based syllabus. The working group is currently working on a description of the curriculum and assessment of learning outcomes.

Comparative intention-to-treat analysis of the video-assisted thoracoscopic surgery approach to pulmonary segmentectomy for lung carcinoma‡.

OBJECTIVES: To compare the video-assisted thoracoscopic surgery (VATS) with the open thoracotomy access to pulmonary segmentectomy by the clinical outcomes and long-term survival in lung carcinoma. METHODS: Non-randomized comparative intention-to-treat study of prospective institutional registry data and survival data of 100 consecutive patients undergoing segmentectomy. RESULTS: Within one decade (2002-12), 100 patients with proven or highly suspected lung carcinoma underwent 100 anatomical sub-lobar pulmonary resections (52 typical and 20 atypical segmentectomies, 28 split-lobe procedures). Fifty-six patients were operated by VATS and 44 by thoracotomy access. Comparison of demographic, medical, oncological and surgical baseline data did not provide evidence for differences between the VATS and thoracotomy groups. The surgery time for the VATS group was 225 ± 62 min and 195 ± 57 min for the thoracotomy group (P = 0.014). Postoperative hospitalization was 9 days for the VATS group and 12 days for the thoracotomy group (P = 0.034). Postoperative morbidity was 35.7% for the VATS group and 50% for the thoracotomy group (P = 0.161). Both groups had no 30-day mortality. Conversion to thoracotomy occurred in 30.4% of the VATS group. Conversion was more frequent in patients with male gender, critical and prohibitive lung function, tumours with diameters exceeding 3 cm and atypical segmentectomies. The fractions of the pathological Union international contre le cancer (UICC) stages I, II and III were 74.4, 11.6 and 14% in the VATS group, and 70, 20 and 10% in the thoracotomy group (P = 0.445), respectively. Five-year overall survival was 86% in the VATS group and 69.9% in the thoracotomy group (P = 0.047), and 5-year recurrence-free survival was 58.5 and 48.6% (P = 0.480), respectively. CONCLUSIONS: Compared with thoracotomy access, the VATS approach to segmentectomy was associated with less postoperative morbidity and a 25% decrease in median hospital stay, despite a conversion rate of 30% due to the inclusion of atypical segmentectomies, higher tumour stages and patients with critical function for single lung ventilation. Five-year survival estimates suggested a small but significant overall survival benefit and a 10% difference of recurrence-free survival in favour of VATS. Although not fully conclusive, long-term results indicate that the thoracoscopic access to segmentectomy is probably not inferior to the thoracotomy approach. Confirmation by a larger number of risk-adjusted outcome data is required.

Split-lobe resections versus lobectomy for lung carcinoma of the left upper lobe: a pair-matched case-control study of clinical and oncological outcomes.

OBJECTIVES: To compare left upper split-lobe procedures, being upper trisegmentectomy and resection of the lingula, with left upper lobectomy for surgical treatment of lung carcinoma originating from the left upper lobe. METHODS: A pair-matched control study comparing the clinical and oncological outcomes of 22 consecutive patients after left upper split-lobe resections with those of 44 pair-matched controls that received left upper lobectomy for non-small-cell lung carcinomas. The control group was matched 1:2 for tumour diameter, histology, nodal status and patient age. In both groups, diagnosis and surgical treatment adhered to the principles of tissue-based preoperative mediastinal staging, intraoperative systematic nodal dissection, and gross surgical margins equal to the tumour diameter or at least 2 cm, a sufficient preoperative pulmonary function given. RESULTS: As intended by the study design, the split-lobe and lobectomy groups had similar median tumour diameters of 22.5 (range, 11-63) and 25 (range, 7-68) mm, respectively (P = 0.98), identical histologies (45.5% adenocarcinoma, 4.5% adenocarcinoma in situ, 45.5% squamous cell carcinoma and 4.5% neuroendocrine carcinoma) and identical pN stages (pN0 77.3%, pN1 9.1%, pN2 9.1% and ypN0 4.5%). In the split-lobe group, a lower preOP forced expiratory volume in one second (median 2.0 vs 2.3 l), a higher comorbidity (median Charlton score of 3 vs 2) and a preponderance of video-assisted thoracoscopy procedures (63.6 vs 27.3%) were prevalent (all P < 0.05). There were no significant outcome differences detected, neither with regard to the postoperative clinical course assessed by intra- and postoperative complications, operation time, tissue margins, duration of drainage and hospital stay and 30-day mortality, nor with regard to 5-year overall (0.89 vs 0.81, P = 0.90). CONCLUSIONS: Left upper lobectomy might be an overtreatment for selected cases of lung carcinoma whose resection by a split-lobe procedure produces adequate margins and a complete lymphadenectomy. Tumour diameters exceeding 2 cm, nodal involvement and previous neoadjuvant treatment do not necessarily exclude this option for selected patients under the condition of a meticulous nodal dissection. In this context, we would like to suggest a translational research of the split-lobe concept to other large pulmonary lobes.

Extended cervical mediastinoscopy revisited.

OBJECTIVES: To describe the diagnostic value of selective extended cervical mediastinoscopy (ECM) in combination with video-assisted mediastinoscopic lymphadenectomy (VAMLA) in mediastinal staging of potentially resectable left-sided lung carcinoma. METHODS: Institutional report on 110 ECM procedures indicated for enlarged lymph nodes within the aorto-pulmonary (AP) zone on computed tomography. Staging sensitivity, negative predictive value (NPV) and specificity of ECM, combined VAMLA and ECM, VAMLA alone and systematic dissection for lung resection via left-sided video-assisted thoracoscopic surgery (VATS) or thoracotomy were calculated from a subset of 92 patients with left-sided lung carcinoma. RESULTS: Selective ECM was performed in 12.6% of all video-mediastinoscopic procedures, and added, except for one vascular complication, there was no morbidity. ECM had an impact on mediastinal staging in 78.0% of the lung cancer cases. Sensitivity, NPV and specificity were 0.94, 0.96 and 1 for ECM to detect nodal involvement within the AP zone. Sensitivity, NPV and specificity to detect any mediastinal diseases were 0.94, 0.96 and 1 for the combination of ECM and VAMLA; 0.64, 0.80 and 1 for VAMLA alone and 0.76, 0.84 and 1 for systematic mediastinal dissection via left-sided VATS or thoracotomy approach. CONCLUSIONS: ECM complements VAMLA in comprehensive mediastinal dissection. Selective ECM is a valuable addendum to mediastinoscopic staging procedures for left-sided tumours, as it enhances sensitivity and NPV. Precaution and experience are required to circumvent the rare risk of potentially fatal vascular accidents.

Cotton-derived oxidized cellulose in minimally invasive thoracic surgery: a clinicopathological study.

OBJECTIVE: The aim of this study was to identify resorption, clinical performance, and safety of cotton-derived oxidized cellulose gauze applied as a hemostat in minimally invasive oncologic thoracic surgery. METHODS: This is a pilot prospective noncomparative observational human in vivo study. A piece of cotton-derived oxidized cellulose gauze measuring 5 × 20 cm was inserted into the subcarinal space of patients with potentially resectable lung carcinoma at the time of video-assisted mediastinoscopic lymphadenectomy and reexamined several days later for macroscopic and histologic evaluation at the time of subsequent lung resection. The primary endpoint was the local situation at the implantation site described by cellulose remnants, fluid collections, and adhesions. The secondary endpoint was safety, described by the number of adverse events and surgical reinterventions. RESULTS: Twenty-five consecutive eligible patients with potentially resectable lung carcinoma were included. The desired hemostatic effect was achieved in all cases. No adverse events were observed. At re-exploration 10.5 (5-28) days later, the cellulose gauze was found to lose its solid structure from the fifth day on. Remnants were last detected 14 days after insertion. The implantation site exhibited no inflammatory changes and a remarkable small amount of fluid collections and adhesions. CONCLUSIONS: Mediastinal application of cotton-derived oxidized cellulose is safe and effective. A piece of gauze measuring 5 × 20 cm seems to be absorbed completely within 15 days, thus precluding any interference with oncologic restaging and follow-up. The absence of relevant adhesions facilitates further surgical procedures. Larger comparative confirmatory studies are required. For large-scale resorption studies, our clinical model should be translated into a porcine model.

Complete video-assisted thoracoscopic surgery anatomic segmentectomy for clinical stage I lung carcinoma - technique and feasibility.

This paper describes a prospective, observational, single-centre study of 20 consecutive patients with clinical stage I lung carcinoma undergoing anatomical sublobar resections using complete video-assisted thoracoscopic surgery (cVATS). Thirteen male and seven female patients with a median age of 68 (range 57-84) years and a median of four (range 0-9) relevant comorbid conditions presented with five right-sided and 15 left-sided tumours, with a median diameter of 2.3 (range 1.0-5.2) cm. Thirteen segmentectomies, three bisegmentectomies and four trisegmentectomies with lymphadenectomy of the N1 stations and the mediastinum were performed, with a median duration of 212 (range 91-397) min, a conversion rate to open surgery of 20% and conversion to lobectomy of 10%. In five patients, we noted 10 postoperative adverse events but no transfusions, no readmissions and zero mortality. Median drainage time was six days, with a median hospital stay of 8.5 days. According to the pTNM classification, 10, three, one, and six patients were staged as Ia, Ib, IIb and IIIa, respectively. The distance between the tumour and the parenchymal stapling line exceeded the tumour diameter in 56%, 0% and 0% of T1a, T1b and T2 tumours, respectively. To conclude, cVATS anatomical sublobar resections are technically feasible. We observed a favourable postoperative course in 20 multimorbid or aged patients. In patients fit for lobectomy, the tumour diameter should not exceed 2 cm.