Management of intra-operative major bleeding during single-port video-assisted thoracoscopic anatomic resection: two-center experience.

BACKGROUND: Our objective is to report on two centers' experience of intra-operative management of major vascular injury during single-port video-assisted thoracoscopic (SPVATS) anatomic resections, including bleeding control techniques, incidence, results, and risk factor analysis. METHODS: Consecutive patients (n = 442) who received SPVATS anatomic lung resections in two centers were enrolled. The different clinical parameters studied included age, previous thoracic surgery, obesity (BMI > 30), tumor location, neoadjuvant therapy, and pleural symphysis. In addition, peri-operative outcomes were compared between the groups, with or without vessel injury. RESULTS: There were no intra-operative deaths in our study. Overall major bleeding incidence was 4.5%, whereby 70% of major bleeding episodes could be managed with SPVATS techniques. In order to determine risk factors possibly related to intra-operative bleeding, we used case control matching to homogenize our study population. After case control matching, pleural symphysis was significantly related in the univariate (p = 0.005, Odds ratio 4.415, 95% CI 1.424-13.685) and multivariate analysis (p = 0.006, Odds ratio 4.926, 95% CI 1.577-15.384). Operative time (p < 0.001), blood loss (p < 0.001), and post-operative hospital stay (p = 0.012) were longer in patients with major vascular injury. There were no differences in 30-day mortality and 90-day morbidity. CONCLUSIONS: In summary, major intra-operative bleeding episodes during SPVATS anatomic lung resections are acceptable and most such bleeding episodes can be safely managed with SPVATS techniques.

The Burden of Comorbidity and Complexity in Sarcoidosis: Impact of Associated Chronic Diseases.

PURPOSE: To evaluate comorbidity, complexity and poor outcomes in patients with sarcoidosis and to compare those scores with a control group. METHODS: 218 consecutive patients were diagnosed with sarcoidosis according to the ATS/ERS/WASOG criteria; extrathoracic involvement was evaluated using the 2014 WASOG organ assessment instrument. Sarcoidosis patients were compared with an age- and gender-matched control group of primary care outpatients without sarcoidosis. Comorbidities were assessed retrospectively using the Charlson Comorbidity Index (CCI); complexity was evaluated according to the classification into Clinical Risk Groups (CRG) and severity levels. RESULTS: The cohort included 142 women and 76 men; the mean age was 47.1 years at diagnosis of sarcoidosis and 55.9 years at the last visit. Patients with a CCI > 1 had a higher frequency of calcium/vitamin D abnormalities (p < 0.001), kidney involvement (p = 0.005) and a higher mortality rate (p < 0.001) compared with patients with a CCI ≤ 1. Patients with a CRG ≥ 6 had a higher frequency of extrathoracic involvement (p = 0.039), calcium/vitamin D abnormalities (p = 0.019) and treatment with glucocorticoids (p = 0.032) compared with patients with a CRG < 6. 11% patients died after a mean follow-up of 102.3 months. Country of birth, kidney involvement and extrathoracic disease were significantly associated with death. Patients with sarcoidosis had a higher frequency of liver (p < 0.001), pulmonary (p = 0.002) and autoimmune disease (p = 0.011) and cancer (p = 0.007) compared with the control group. CONCLUSION: We found higher rates of comorbidity and complexity in patients with sarcoidosis compared with a control group. Liver, pulmonary, autoimmune and neoplastic diseases were the main comorbidities found in patients with sarcoidosis.

The Nikaidoh procedure for complex transposition of the great arteries: short-term follow-up.

BACKGROUND: The surgical treatment for complex forms of d-transposition of the great arteries associated with ventricular septal defect and left ventricular outflow tract obstruction remains controversial. In this study, we describe the classical surgical options - namely, the Rastelli procedure and the "réparation à l'étage ventriculaire" - and present our experience with the modified Nikaidoh procedure with early and short-term follow-up results. METHODS: Between 2007 and 2014, four patients with d-transposition of the great arteries associated with ventricular septal defect and left ventricular outflow tract obstruction underwent surgical repair at our institution by means of a modified Nikaidoh procedure. RESULTS: With a mean follow-up of 4.5 years, survival was 100%, and none of the patients required re-intervention or mechanical circulatory support. There was no recurrence of left ventricular outflow tract obstruction and no aortic valve regurgitation classified as more than mild. Left ventricular function was preserved. CONCLUSIONS: Aortic translocation with the modified Nikaidoh procedure is a safe and effective surgical treatment for certain complex forms of transposition of the great arteries, particularly those associated with ventricular septal defect and left ventricular outflow tract obstruction. It is associated with less need for re-intervention and better morbidity and mortality results in the short- and mid-term follow-up, when compared with the classical alternatives such as the Rastelli procedure.

Epidemiologic patterns of disease expression in sarcoidosis: age, gender and ethnicity-related differences.

OBJECTIVES: To evaluate the influence of age, gender and ethnicity in the clinical presentation of sarcoidosis in a cohort of Spanish patients. METHODS: We analysed 175 consecutive patients diagnosed with sarcoidosis between 1990 and 2014 in the Hospital Clinic of Barcelona, Spain. Sarcoidosis was diagnosed according to the 1999 WASOG criteria. Organ involvement was defined using the 2014 WASOG organ assessment instrument. RESULTS: There were 110 women and 65 men, with a mean age at diagnosis of 47.31 ± 15.46 years (range, 16-92); 23% of patients were born outside Spain. Women had a higher mean age (p=0.027), a higher frequency of cutaneous (OR=2.28) and musculoskeletal (OR=2.73) symptoms at diagnosis, and a lower frequency of cumulated WASOG involvements including renal involvement (OR=0.17), hypercalcaemia (OR=0.20) and raised ACE levels (OR=0.30). Patients aged ≥65 years had a lower frequency of cutaneous (OR=0.23) and musculoskeletal (OR=0.13) symptomatology at diagnosis and a higher frequency of cumulated WASOG involvements including renal involvement (OR=18.70) and calcium/vitamin D abnormalities (OR=5.31). According to ethnicity, non-Spanish-born patients had a lower mean age (40 vs. 49 years, p=0.001), a higher predominance of females (68% vs. 54%, p=0.036) and a higher frequency of radiographic stages I/II at diagnosis (97% vs. 78%, p=0.041) in comparison with Spanish-born patients. CONCLUSIONS: Using the new 2014 WASOG organ assessment instrument, we found that epidemiological features (age at diagnosis, gender and ethnicity) play a significant role in the presentation of sarcoidosis. Variations in these epidemiological features may aid early diagnostic suspicion, the search for histopathological confirmation and the prompt introduction of the appropriate therapy.

Uniportal fully robotic-assisted sleeve resections: surgical technique and initial experience of 30 cases.

Since the first uniportal video-assisted thoracoscopic surgery (uVATS) performed in 2010, the uniportal approach has evolved up to a point where even the most complex cases can be done. This is thanks to the experience acquired over the years, the specifically designed instruments and improvements in imaging. However, in these last few years, robotic-assisted thoracoscopic surgery (RATS) has also shown progress and distinct advantages compared to the uniportal VATS approach, thanks to advanced maneuverability of the robotic arms as well as the three-dimensional (3D) view. Excellent surgical outcomes have been reported and so too, the ergonomic benefits to the surgeon. The main limitation we find of the robotic systems is that they are designed for a multiport approach, requiring between three to five incisions to be able to perform surgeries. With the aim to offer the least invasive approach, using the robotic technology we decided to adapt the Da Vinci Xi® in September 2021 to develop the uniportal pure RATS approach (uRATS) performed by a single intercostal incision, without rib spreading and using the robotic staplers. We have now reached a point where we perform all type of procedures, including the more complex sleeve resections. Sleeve lobectomy is now widely accepted as a reliable and safe procedure to allow complete resection of centrally located tumors. Although it is a technically challenging surgical technique, it offers better outcomes when compared to pneumonectomy. The intrinsic characteristics of the robot such as the 3D view and improved maneuverability of instruments make the sleeve resections easier compared to thoracoscopic techniques. As in uVATS vs. multiport VATS, the uRATS approach, due to its geometrical characteristics, requires specific instrumentation, different movements and learning curve compared to multiport RATS. In this article we describe the surgical technique and our initial uniportal pure RATS experience with bronchial, vascular sleeves and carinal resections in 30 patients.

Uniportal fully robotic-assisted major pulmonary resections.

Robotic-assisted thoracoscopic surgery (RATS) has proven advantages over that of conventional thoracic surgery, primarily by offering a three-dimensional view and excellent maneuverability, and by providing great ergonomic comfort to the surgeon. The instrumentation specifically offers seven degrees of freedom, allowing for safe, yet complex dissections and radical lymphadenectomies. However, the robotic platform was initially designed with four robotic arms in mind, and therefore four to five incisions were needed for most thoracic approaches. The uniportal video-assisted thoracoscopic surgery (UVATS) approach, the philosophical predecessor to the uniportal robotic-assisted thoracoscopic surgery (URATS) approach, evolved very quickly with the help of the latest technologies during the last decade. Since the first cases of UVATS in 2010, we have improved upon the technique, such that we are now able to do increasingly more complex cases. This is due to the acquired experience, specifically designed instruments, better high-definition cameras and more angulated staplers. In our efforts to improve and adapt robotic surgery to the uniportal approach, we utilized the initial available platforms (Davinci Si and X) to test the feasibility of this approach, in terms of safety and possibilities. The latest platform, the Da Vinci Xi, due to the configuration of its arms, did indeed allow for us to reduce the number of incisions to two initially and finally to one. We hence decided to fully adapt the Da Vinci Xi® to allow for the URATS approach routinely, and performed the first fully robotic anatomic resections in the world in September 2021, in Coruña, Spain. We define pure or fully robotic URATS as robotic thoracic surgery performed by a single intercostal incision, without rib spreading, using the robotic camera, robotic dissecting instruments and robotic staplers.

Uniportal robotic versus thoracoscopic assisted surgery: a propensity score-matched analysis of the initial 100 cases.

Background: Minimally invasive surgery (MIS) is becoming the standard of care for anatomic lung resections. The advantages of the uniportal approach compared to the conventional multiple incision approach, multiportal video-assisted thoracic surgery (mVATS) and multiportal robotic-assisted thoracic surgery (mRATS), have been previously described. However, no research studies comparing early outcomes between uniportal video-assisted thoracic surgery (uVATS) and uniportal robotic-assisted thoracic surgery (uRATS) have been reported. Methods: Anatomic lung resections performed by uVATS and uRATS from August 2010 to October 2022 were enrolled. Early outcomes were compared after propensity score-matched (PSM) analysis by applying a multivariable logistic regression model including gender, age, smoking habit, forced expiratory volume in the first second (FEV1), cardiovascular risk factors (CVRF), pleural adhesions and tumor size. Results: A total of 200 patients who underwent anatomic lung resections by the same surgeon were recruited in this study, including the initial 100 uVATS patients and the initial 100 uRATS patients. After PSM analysis, each group included 68 patients. The comparison of the two groups showed no significant differences according to the TNM stage in patients with lung cancer, surgical time, intraoperative complications, conversion, number of nodal stations explored, opioid usage, prolonged air leak, length of intensive care unit (ICU) and hospitalization, reintervention and mortality. However, there were significant differences concerning the histology and type of resection (anatomic segmentectomies, the proportion of complex segmentectomies and the sleeve technique were significantly higher in the uRATS group), number of resected lymph nodes (significantly higher in the uRATS group), postoperative complications and duration of chest drain (significantly lower in the uRATS group). Conclusions: Judging from the short-term outcomes, our results confirm the safety, feasibility and efficacy of uRATS as a new minimally invasive technique that combines the benefits of the uniportal method and robotic systems.

Comparison of uniportal robotic-assisted thoracic surgery pulmonary anatomic resections with multiport robotic-assisted thoracic surgery: a multicenter study of the European experience.

Background: Robotic-assisted thoracic surgery (RATS) has seen increasing interest in the last few years, with most procedures primarily being performed in the conventional multiport manner. Our team has developed a new approach that has the potential to convert surgeons from uniportal video-assisted thoracic surgery (VATS) or open surgery to robotic-assisted surgery, uniportal-RATS (U-RATS). We aimed to evaluate the outcomes of one single incision, uniportal robotic-assisted thoracic surgery (U-RATS) against standard multiport RATS (M-RATS) with regards to safety, feasibility, surgical technique, immediate oncological result, postoperative recovery, and 30-day follow-up morbidity and mortality. Methods: We performed a large retrospective multi-institutional review of our prospectively curated database, including 101 consecutive U-RATS procedures performed from September 2021 to October 2022, in the European centers that our main surgeon operates in. We compared these cases to 101 consecutive M-RATS cases done by our colleagues in Barcelona between 2019 to 2022. Results: Both patient groups were similar with respect to demographics, smoking status and tumor size, but were significantly younger in the U-RATS group [M-RATS =69 (range, 39-81) years; U-RATS =63 years (range, 19-82) years; P<0.0001]. Most patients in both operative groups underwent resection of a primary non-small cell lung cancer (NSCLC) [M-RATS 96/101 (95%); U-RATS =60/101 (59%); P<0.0001]. The main type of anatomic resection was lobectomy for the multiport group, and segmentectomy for the U-RATS group. In the M-RATS group, only one anatomical segmentectomy was performed, while the U-RATS group had twenty-four (24%) segmentectomies (P=0.0006). All M-RATS and U-RATS surgical specimens had negative resection margins (R0) and contained an equivalent median number of lymph nodes available for pathologic analysis [M-RATS =11 (range, 5-54); U-RATS =15 (range, 0-41); P=0.87]. Conversion rate to thoracotomy was zero in the U-RATS group and low in M-RATS [M-RATS =2/101 (2%); U-RATS =0/101; P=0.19]. Median operative time was also statistically different [M-RATS =150 (range, 60-300) minutes; U-RATS =136 (range, 30-308) minutes; P=0.0001]. Median length of stay was significantly lower in U-RATS group at four days [M-RATS =5 (range, 2-31) days; U-RATS =4 (range, 1-18) days; P<0.0001]. Rate of complications and 30-day mortality was low in both groups. Conclusions: U-RATS is feasible and safe for anatomic lung resections and comparable to the multiport conventional approach regarding surgical outcomes. Given the similarity of the technique to uniportal VATS, it presents the potential to convert minimally invasive thoracic surgeons to a robotic-assisted approach.

Novice training: The time course for developing competence in single port video-assisted thoracoscopic lobectomy.

The competency in video-assisted thoracoscopic (VATS) lobectomy is expected to be achieved after surgeons practiced 30 to 50 cases according to previous reports. Does single port video-assisted thoracoscopic (SPVATS) lobectomy have a steeper learning curve and being harder to perform correctly, leading to long development times and high defect rates?From January, 2014 to February, 2017, 8 individual surgeons (3 were novices, 5 were pioneers in SPVATS surgery) submitted their cases chronologically to evaluate the learning curve of SPVATS lobectomy. Operating time (OT) was set as a surrogate marker for surgical competency. Postoperative outcomes and OT between the 2 groups were compared using propensity score matching (1:1 nearest neighbor). The learning curve for OT was evaluated using the cumulative sum (CUSUM) method.In the entire study cohort, a total of 356 cases were included (93 in junior consultant group [group A], 263 in senior consultant group [group B]). There were no significant differences between the 2 groups in operative time, conversion rate, postoperative complication rate, 30 and 90 days mortality rate. After propensity-score matching (86 pairs), operative time was longer in group A (214.33 ±â€Š62.18 vs 183.62 ±â€Š61.25 minutes, P = .001). Two-year overall survival rate was similar among 2 groups (P = .409). Competency was reached after junior surgeon completed 30th case of SPVATS lobectomy.SPVATS lobectomy is safe for the novice surgeon who wants to adopt this new surgical approach under well-developed training program. The learning curves for competence in SPVATS lobectomy are similar to VATS lobectomy in our series.

Impact of a systematic evaluation of connective tissue disease on diagnosis approach in patients with interstitial lung diseases.

To date, there is no clear agreement regarding which is the best method to detect a connective tissue disease (CTD) during the initial diagnosis of interstitial lung diseases (ILD). The aim of our study was to explore the impact of a systematic diagnostic strategy to detect CTD-associated ILD (CTD-ILD) in clinical practice, and to clarify the significance of interstitial pneumonia with autoimmune features (IPAF) diagnosis in ILD patients.Consecutive patients evaluated in an ILD Diagnostic Program were divided in 3 groups: IPAF, CTD-ILD, and other ILD forms. Clinical characteristics, exhaustive serologic testing, high resolution computed tomography (HRCT) images, lung biopsy specimens, and follow-up were prospectively collected and analyzed.Among 139 patients with ILD, CTD was present in 21 (15.1%), 24 (17.3%) fulfilled IPAF criteria, and 94 (67.6%) were classified as other ILD forms. Specific systemic autoimmune symptoms such as Raynaud phenomenon (19%), inflammatory arthropathy (66.7%), and skin manifestations (38.1%) were more frequent in CTD-ILD patients than in the other groups (all P < .001). Among autoantibodies, antinuclear antibody was the most frequently found in IPAF (42%), and CTD-ILD (40%) (P = .04). Nonspecific interstitial pneumonia, detected by HRCT scan, was the most frequently seen pattern in patients with IPAF (63.5%), or CTD-ILD (57.1%) (P < .001). In multivariate analysis, a suggestive radiological pattern by HRCT scan (odds ratio [OR] 15.1, 95% confidence interval [CI] 4.7-48.3, P < .001) was the strongest independent predictor of CTD-ILD or IPAF, followed by the presence of clinical features (OR 14.6, 95% CI 4.3-49.5, P < .001), and serological features (OR 12.4, 95% CI 3.5-44.0, P < .001).This systematic diagnostic strategy was useful in discriminating an underlying CTD in patients with ILD. The defined criteria for IPAF are fulfilled by a considerable proportion of patients referred for ILD.

Predictive factors of postoperative complications in single-port video-assisted thoracoscopic anatomical resection: Two center experience.

The purpose of this study was to identify the risk factors for adverse events during single-port video-assisted thoracoscopic (SPVATS) anatomical resections.We retrospectively reviewed patients who had undergone SPVATS anatomic resections between January 2014 and February 2017 in Coruña University Hospital's Minimally Invasive Thoracic Surgery Unit (CHUAC, Spain) and Chang Gung Memorial Hospital (CGMH, Taiwan). Four hundred forty-two patients (male: 306, female: 136) were enrolled in this study. Logistic regression analysis was performed on variables for postoperative complications.Postoperative complications with a 30-day mortality occurred in 94 patients (21.3%) and with a 90-day mortality in 3 patients (0.7%) while the major complication rate was 3.9%. Prolonged air leak (PAL > 5 days) was the most common complication and came by postoperative arrhythmia. Logistic regression indicated that pleural symphysis (odds ratio (OR), 1.91; 95% confidence interval (CI), 1.14-3.18; P = .014), computed tomography (CT) pulmonary emphysema (OR, 2.63; 95% CI, 1.41-4.76; P = .002), well-developed pulmonary CT fissure line (OR, 0.49; 95% CI, 0.29-0.84; P = .009), and tumor size (≥3 cm) (OR, 2.15; 95% CI, 1.30-3.57; P = .003) were predictors of postoperative complications.Our preliminary results revealed that SPVATS anatomic resection achieves acceptable 30- and 90-day surgery related mortality (0.7%) and major complications rate (3.9%). Prolonged Air leak (PAL > 5 days) was the most common postoperative complication. Pleural symphysis, pulmonary emphysema, well-developed pulmonary CT fissure line and tumor size (≥3 cm) were predictors of adverse events during SPVATS anatomic resection.

Mid-term survival outcome of single-port video-assisted thoracoscopic anatomical lung resection: a two-centre experience.

OBJECTIVES: Single-port video-assisted thoracoscopic surgery (SPVATS) anatomical resection has been shown to be a feasible technique for lung cancer patients. Whether SPVATS has equivalent or better oncological outcomes for lung cancer patients remains controversial. The purpose of this study was to evaluate the perioperative and mid-term survival outcomes of SPVATS in 2 different medical centres. METHODS: We retrospectively reviewed patients who underwent SPVATS anatomical resections between January 2014 and February 2017 in Coruña University Hospital's Minimally Invasive Thoracic Surgery Unit (Spain) and Chang Gung Memorial Hospital (Taiwan). Survival outcomes were assessed by pathological stage according to the American Joint Committee on Cancer (AJCC) 7th and 8th classifications. RESULTS: In total, 307 patients were enrolled in this study. Mean drainage days and postoperative hospital stay were 3.90 ± 2.98 and 5.03 ± 3.34 days. The overall 30-day mortality, 90-day morbidity and mortality rate were 0.7%, 20.1% and 0.7%, respectively. The 2-year disease-free survival and 2-year overall survival of the cohort were 80.6% and 93.4% for 1A, 68.8% and 84.6% for 1B, 51.0% and 66.7% for 2A, 21.6% and 61.1% for 2B, 47.6% and 58.5% for 3A, respectively, following the AJCC 7th classification. By the AJCC 8th classification, these were 92.3% and 100% for 1A1, 73.7% and 91.4% for 1A2, 75.2% and 93.4% for 1A3, 62.1% and 85.9% for 1B, 55.6% and 72.7% for 2A, 47.1% and 64.2% for 2B and 42.1% and 60.3% for 3A. CONCLUSIONS: Our preliminary results revealed that SPVATS anatomical resection achieves acceptable 2-year survival outcomes for early-stage lung cancer and is consistent with AJCC 8th staging system 2-year survival data. For advanced stage non-small-cell lung cancer patients, further evaluation is warranted.

Auscultation of Velcro Crackles is Associated With Usual Interstitial Pneumonia.

Auscultation of Velcro crackles has been proposed as a key finding in physical lung examination in patients with interstitial lung diseases (ILDs), especially in idiopathic pulmonary fibrosis (IPF). However, no studies have been carried out to assess the association of Velcro crackles with other clinical variables.We evaluated a cohort of 132 patients, prospectively and consecutively included in our ILD diagnostic program at a tertiary referral center. All patients were auscultated during the physical examination. The patients were divided into 2 groups: "presence" or "nonpresence" of bilateral Velcro crackles.Of all patients assessed, 83 (63%) presented Velcro crackles in the respiratory auscultation. Patients with Velcro crackles usually had more frequently cough and dyspnea at the moment of diagnosis. Forced vital capacity (P = 0.002) and lung diffusion capacity for carbon monoxide (P = 0.04) was lower in these patients. The ILD-GAP index was higher in the group with Velcro crackles (P = 0.01). All patients with usual interstitial pneumonia (UIP) in high-resolution computed tomography and all patients with final IPF diagnosis presented Velcro crackles. In multivariate analysis, the presence of Velcro crackles was independently associated with an UIP pattern.In patients suspected of having ILD, the auscultation of Velcro crackles was associated with UIP, a possibility which must be taken into consideration in early ILD detection in primary care.

Anterior mediastinal tracheostomy as salvage operation.

BACKGROUND: This study aimed to assess early and long-term results after anterior mediastinal tracheostomy (AMT) as a salvage operation for recurrent neck malignancies. METHODS: Between October 2006 and February 2013, 12 patients (mean age, 57 years) underwent AMT. All patients had experienced stomal recurrence, with or without esophageal involvement, after laryngectomy. All patients had undergone previous radiotherapy (50.3 ± 6.2 [43-60] Gy) and previous surgical treatment: total laryngectomy (n = 11) and thyroidectomy (n = 2). RESULTS: The mean length of resected trachea was 3.7 ± 2.7 (2.5-6) cm. Resection was complete in 10 patients. All patients required relocation of the remaining trachea below the innominate artery and myocutaneous flap for coverage/stoma construction. AMT was associated with esophagectomy (n = 4) and supraaortic trunk resection (innominate artery, n = 2; carotid artery, n = 3). Seven patients required resection of the pharyngoesophageal region, and 4 patients underwent reconstruction, including primary closure of a pharyngeal remnant (n = 1) and gastric pull-up (n = 3). There was 1 operative death (8.3%) resulting from an infectious process leading to bypass fistulization. Major complications were partial tracheal necrosis (n = 3), pharyngeal fistula (n = 1), pneumonia (n = 4), and flap dehiscence (n = 2). Length of hospital stay was 30 ± 22.8 (13-86) days. Actuarial overall 5-year survival was 58.3%, and median estimated disease-free survival was 53 (31-75) months. CONCLUSIONS: Our experience with AMT as salvage therapy has shown acceptable long-term results if complete resection is achieved. This procedure is not risk free, and very careful patient selection is required because of a tortuous postoperative course, especially in combined pharyngeal-esophageal and vascular reconstruction.

Single-staged laryngotracheal reconstruction for idiopathic tracheal stenosis.

BACKGROUND: This study retrospectively evaluated the results of surgically treated idiopathic tracheal stenosis. METHODS: Of the 220 patients surgically treated for idiopathic subglottic and tracheal stenosis in the participating hospitals, we reviewed the surgical records of all patients with idiopathic tracheal stenosis. This subgroup required resection of all of the involved mucosa but frequently had undergone more conservative treatments that damaged the tracheal mucosa and cartilage and complicated the definitive surgical treatment. RESULTS: During the study period, 60 women (93.8%) and 4 men (6.2%), who were a mean age of 50 years (range, 19 to 77 years), were surgically treated for idiopathic tracheal stenosis, with no operative deaths. Of these 64 patients, 38 (59.3%) had undergone previous treatments in other centers: dilation, 26 (40.6%); laser only, 19 (31%); laser plus tracheal prosthesis, 5 (7.8%); tracheostomy, 7 (11.6%); T tube, 2 (3%); and laryngotracheal operations, 5 (7.8%). All patients were treated with a single-staged tracheal or laryngotracheal operation, of which 59 (98%) successful. Four of the most complex stenoses, with vocal cords and cricoid plate involvement, underwent reoperation for restenosis or larynx inconsistency. One patient was considered biologically unfit for reoperation and required a permanent T tube for restenosis. Half of the operations were temporary tracheostomies with T tube for larynx modelling. The most frequent postoperative complications were dysphonic voice in 10 patients (although in 7 instances this began months or years before the operation), granulation tissue in 10, aspiration in 3, and wound infections in 2. CONCLUSIONS: Idiopathic stenosis occurred predominantly (90% of cases) in women. Single-staged laryngotracheal correction was successful in 97%. Technique selection, with or without temporary laryngeal stenting, must be individualized with respect to the vocal cords' mobility, function, and distance from the stenosis.

Extended sleeve lobectomy: one more step toward avoiding pneumonectomy in centrally located lung cancer.

BACKGROUND: The purpose of this study was to evaluate surgical outcomes of extended sleeve lobectomy (ESL) in centrally located non-small-cell lung cancer (NSCLC), sparing lung tissue and aggressively avoiding pneumonectomy. METHODS: Patients who underwent ESL between January 2006 and January 2013 were included prospectively. An atypical bronchial anastomosis was used for sleeve lobectomy involving additional lobes or segments. RESULTS: We included 27 patients, aged 62.7 ± 8.2 years (range, 49-83 years), with a forced expiratory volume in 1 second (FEV1) of 2.27 ± 0.6 (range, 1.6-2.7). According to the Okada classification, 16 cases were type A (right upper lobe + middle lobe ± segment 6), 7 cases were type B (left upper lobe + segment 6), and 2 cases were type C (left lower lobe + segments 4-5); we additionally classified 2 patients with right lower lobe tumors involving the right main bronchus as type D (right lower lobe + middle lobe). Anastomosis was performed between the right superior and right main bronchial stumps. Eleven patients underwent combined pulmonary angioplasties. Complete resection was achieved in all cases. There were no operative deaths. Mean segment reimplantation was 4.5 ± 0.84 (range, 3-6), resulting in a mean FEV1 improvement of 0.620 ± 0.16 (right-sided ESL) and 0.393 ± 0.21 (left-sided ESL). The complication rate was 25% (no immediate anastomosis-related complications; 1 case of delayed bronchial stenosis). No local recurrence was reported. At 6 months, mean FEV1 was 1.5 ± 0.4 (right-sided ESL) and 1.4 ± 0.3 (left-sided ESL). Mean follow-up time was 28 ± 19 months (range, 7-72 months). Overall 5-year survival was 62%. CONCLUSIONS: In patients with centrally located NSCLC, lung-sparing ESL, whose safety and reliability rival that of pneumonectomy, should be considered. Functional effectiveness is higher with right-sided than with left-sided ESL.

Uniportal video-assisted thoracoscopic lobectomy: two years of experience.

BACKGROUND: A video-assisted thoracoscopic approach to lobectomy varies among surgeons. Typically, 3 to 4 incisions are made. Our approach has evolved from a 3-port to a 2-port approach to a single 4- to 5-cm incision with no rib spreading. We report results with single-incision video-assisted thoracic major pulmonary resections during our first 2 years of experience. METHODS: In June 2010, we began performing video-assisted thoracoscopic lobectomies through a uniportal approach (no rib spreading). By July 12, 2012, 102 patients had undergone this single-incision approach. RESULTS: Of 102 attempted major resections, 97 were successfully completed with a single incision (operations in 3 patients were converted to open surgery and 2 patients needed 1 additional incision). Five uniportal pneumonectomies were not included in the study. We have analyzed early outcomes of successful uniportal lobectomies (92 patients studied). Right upper lobectomy was the most frequent resection (28 cases). Mean surgical time was 154.1 ± 46 minutes (range, 60-310 minutes), mean number of lymph nodes was 14.5 ± 7 (range, 5-38 nodes), and mean number of explored nodal stations was 4.6 ± 1.2 (range, 3-8 stations). The mean tumor size was 2.8 ± 1.5 cm (0-6.5 cm). The median duration of time a chest tube was in place was 2 days and the median length of hospital stay was 3 days. There were complications in 14 patients; no postoperative 30-day mortality was reported. CONCLUSIONS: Single-incision video-assisted thoracoscopic anatomic resection is a feasible and safe procedure with good perioperative results, especially when performed by surgeons experienced with the double-port technique and anterior thoracotomy.

Pulmonary sleeve resection in locally advanced lung cancer using cryopreserved allograft for pulmonary artery replacement.

BACKGROUND: During lobectomy, resection of pulmonary artery, followed by reconstruction or replacement with or without concomitant sleeve bronchial resection, is feasible in selected cases. We report morbidity, mortality, and technical issues in pulmonary artery replacement using a cryopreserved arterial allograft after sleeve resection for centrally located non-small cell lung carcinoma (NSCLC). METHODS: We reviewed clinical and pathologic data of patients who underwent arterial sleeve lobectomy with pulmonary artery replacement in our institution from 2007 to 2012. RESULTS: Of 178 centrally located NSCLCs, sleeve resections were performed in 92 (51%), pneumonectomies in 33 (18%), and lobectomies in 53 (31%). Of the 32 (34.7%) pulmonary) reconstructions (excluding tangential suture), 20 (21.7%) were end-to-end anastomosis, 2 (2.1%) were pericardial patch reconstructions, and 10 (11%) were PA replacements. Clinical T staging was cT2a in 4 patients, cT2b in 3, cT3 in 2, and cT4 in 1. Four patients received concurrent induction chemoradiotherapy. Three patients underwent a double-sleeve right lobectomy. Cryopreserved allografts used were descending thoracic aorta (n = 3) and pulmonary arteries (n = 7). Complete resection (R0) was achieved in all patients. Final N staging was pN0 (n = 4), pN1 (n = 5), and pN2 (n = 1). There was no operative mortality. Four patients had major morbidity, including 1 early conduit thrombosis treated by pneumonectomy completion. Graft patency, assessed by contrast-enhanced computed tomography scan, was 90%. Mean follow-up was 25 ± 14 (range, 8-47) months (30% for >36 months). Overall 5-year survival was 66.7%, and the estimated median disease-free survival was 42 months. CONCLUSIONS: In central NSCLCs, conservative surgery using a cryopreserved arterial allograft to replace the pulmonary artery after extended segmental resection could avoid pneumonectomy in selected patients.

Video-assisted thoracoscopic lobectomy in the treatment of intralobar pulmonary sequestration.

Pulmonary sequestration is a congenital malformation characterised by cystic, non-functioning embryonic lung tissue with vascularisation of an abnormal systemic artery. They are classified as intralobar (75%) and extralobar (25%) and are more common in the left lung and lower lobes (60-90%). We report two cases of intralobar pulmonary sequestration located in the lower lobe of the left lung which were subjected to video-assisted thoracoscopic surgery (VATS). Both patients had recurrent infections for which, after performing imaging tests, they were diagnosed with intralobar pulmonary sequestration in the left lower lobe, with an afferent arterial branch to the malformation from the aorta. A lower lobectomy was performed by video-assisted surgery, dividing the aberrant aortic artery with an endostapler. A single thoracic chest tube was placed and removed on postoperative day 2 and the patients were discharged on the same day. In both cases, the pathology examination revealed intralobar pulmonary sequestration. Pulmonary sequestrations are uncommon malformations that can be operated on using minimally invasive techniques, thereby permitting early discharge and a low rate of complications.

Uni-incisional video-assisted thoracoscopic left lower lobectomy in a patient with an incomplete fissure.

Video-assisted thoracoscopic surgery (VATS) was introduced nearly two decades ago. Since then, there has been a rapid development in minimal invasive techniques for lung cancer treatment. The common approach is the one performed through three incisions, including a utility incision of ∼3 to 5 cm. However, lobectomy can be performed by using only two incisions (one camera port and working incision). A few clinics perform this approach. We began the two-incision technique in our institution in February 2009. After performing 95 cases with this technique, we observed that for lower lobes the second incision could be eliminated, and we performed the surgery by using only the 4-cm utility incision. This article describes a case report of a 57-year-old woman operated by this uni-incisional approach for a lower lobe video-assisted thoracoscopic surgery lobectomy.