Image-guided thoracoscopic lung resection using a dual-marker localization technique in a hybrid operating room.

BACKGROUND: We sought to describe the feasibility and safety of a dual-marker technique-based on a combination of near-infrared (NIR) marking and microcoil localization-before image-guided video-assisted thoracoscopic surgery (iVATS) of small and/or deep pulmonary lesions in a hybrid operating room (HOR). METHODS: We retrospectively reviewed the clinical records of consecutive patients who underwent iVATS resection in a HOR using the proposed dual-marker localization technique. Patients were initially imaged with cone-beam CT, and the needle trajectory was subsequently planned with the Syngo iGuide Needle Guidance software. Using a coaxial needle technique, a microcoil was initially deployed either in the immediate proximity or within the lesion of interest followed by injection of diluted indocyanine green (ICG; quantity: 0.3-0.5 mL; dye concentration: 0.125 mg/mL) at the pleural surface. A NIR thoracoscopic camera and a C-arm portable fluoroscopic system were used to guide the subsequent resection. RESULTS: A total of 11 patients were examined. The median lesion size was 6 mm, with a median distance from the pleural surface of 4 mm. Three nodules were solid, whereas the remaining eight were GGOs. All lesions were identifiable on intraoperative cone-beam CT images. The median time required for localization was 19 min. No conversion to thoracotomy or a multi-port approach was required, and there were no clinically significant adverse events after ICG injection or microcoil placement. CONCLUSIONS: Our study indicates that iVATS with a dual-marking approach (NIR marking and microcoil localization) is safe and useful to localize difficult-to-identify pulmonary nodules.

Esophageal stenting with minimally-invasive surgical intervention for delayed spontaneous esophageal perforation.

Background: Spontaneous esophageal perforation is a challenging surgical emergency with significant morbidity and mortality, and timely primary repair carries good outcomes. However, direct repair for a delayed spontaneous esophageal perforation is not always feasible and is associated with high mortality. Esophageal stenting can provide therapeutic benefits in the management of esophageal perforations. In this study, we review our experience with placing esophageal stents in combination with minimally-invasive surgical drainage to treat delayed spontaneous esophageal perforations. Methods: We retrospectively analyzed patients with delayed spontaneous esophageal perforations between September 2018 and March 2021. All patients were treated using a hybrid approach, including esophageal stenting across the gastroesophageal junction (GEJ) to reduce continued contamination, gastric decompression with extraluminal sutures to prevent stent migration, early enteral nutrition, and aggressive minimally-invasive thoracoscopic debridement and drainage of infected material. Results: There were 5 patients with delayed spontaneous esophageal perforation treated with this hybrid approach. The mean duration between symptoms and diagnosis was 5 days, and the interval between symptoms and esophageal stent insertion was 7 days. The median time to oral nutrition and to esophageal stent removal was 43 and 66 days. There was no stent migration or hospital mortality. Three patients (60%) had postoperative complications. All patients were successfully resumed on oral nutrition with esophageal preservation. Conclusions: A hybrid approach combining endoscopic esophageal stent placement with extraluminal sutures to prevent stent migration, thoracoscopic decortication with chest tube drainage, gastric decompression, and jejunostomy tube placement for early nutrition was feasible and effective in the treatment of delayed spontaneous esophageal perforations. This technique offers a less invasive treatment approach for a challenging clinical problem which has traditionally carried a high rate of morbidity and mortality.

Clinical Utility of Circulating Tumor Cells for Predicting Major Histopathological Response after Neoadjuvant Chemoradiotherapy in Patients with Esophageal Cancer.

BACKGROUND: A "surgery as needed" approach may be offered to patients with esophageal cancer (EC) who achieve major histopathological response (MaHR) after neoadjuvant chemoradiotherapy (nCRT). However, the utility of clinical response assessment (CRE) for predicting histopathological response to nCRT remains limited. Circulating tumor cells (CTCs) hold promise as biomarkers of response to nCRT. METHODS: We analyzed the clinical utility of post-nCRT CTCs, alone or in combination with CRE, in the prediction of MaHR. We defined MaHR as either the lack or a limited presence (≤10%) of vital residual tumor cells in the resected esophageal specimen in the absence of nodal involvement. RESULTS: Of the 48 study patients, 27 (56%) achieved MaHR. Patients with MaHR had a significantly lower CTCs count compared with those without (3.61 ± 4.53 versus 6.83 ± 5.22 per mL of blood, respectively; P = 0.027). Using a cutoff for positivity of 5 CTCs per mL of blood, the combination of CTCs and CRE allowed achieving a negative predictive value for MaHR of 93% (95% confidence interval [CI] = 70-99%) along with a false negative rate of 5% (95% CI = 1-33%). CONCLUSION: CTCs count assessed in combination with CRE can potentially help identify patients with EC who achieved MaHR after nCRT.

Musculoseptocutaneous Perforator of Anterolateral Thigh Flap: A Clinical Study.

BACKGROUND: The anterolateral thigh flap is one of the most useful workhorse flaps for microsurgical reconstruction. However, it can pose a great challenge to surgeons because of its anatomical variability. As the technology advances, not only septocutaneous or musculocutaneous courses of anterolateral thigh perforators but also a hybrid musculoseptocutaneous perforator pattern have been identified on computerized imaging and on cadaveric study. However, there is a paucity of clinical study in the literature. The aim of this investigation was to identify the features of this pattern. METHODS: All patients undergoing anterolateral thigh flap harvest between September of 2017 and May of 2018 performed by a single surgeon are included. Every pulsatile perforator was dissected to document its location on the thigh, emerging location (septum/muscle), size, course, and origin. RESULTS: Thirty-seven patients with 115 perforators were identified. Ten percent of perforators were septocutaneous, 37 percent were musculoseptocutaneous, and 52 percent were musculocutaneous. Forty-seven percent of perforators emerged on the septum between the rectus femoris and the vastus lateralis. Eighty-one percent of patients had one or more perforators in the "hot zone." Medium and large perforators were more frequently located in the proximal and hot zones. All perforators originated from the vascular tree of the lateral circumflex femoral artery, with 10 percent originating from the transverse branch, 28 percent originating from the oblique branch, and 62 percent originating from the descending branch. CONCLUSIONS: A high proportion of musculoseptocutaneous perforators were identified. The clinical relevance of this is to be very cautious on the skin paddle design while harvesting the flap.

Trans-subxiphoid robotic surgery for anterior mediastinal disease: an initial case series.

BACKGROUND: Video-assisted thoracoscopic trans-subxiphoid surgery is an ideal technique for removing anterior mediastinal lesions. The diffusion of this method, however, has been limited by the complexity of surgical maneuvers to be performed in the narrow retrosternal space. Robotic surgery holds promise to overcome the technical limitations of the thoracoscopic trans-subxiphoid approach. Here, we describe a case series of patients who had undergone trans-subxiphoid robotic surgery-with a special focus on short-term outcomes. METHODS: Between January 2018 and January 2019, a total of 20 patients underwent trans-subxiphoid robotic surgery for maximal thymectomy or removal of anterior mediastinal masses. A 3-cm longitudinal incision was performed below the xiphoid process, through which carbon dioxide was insufflated and a camera port was inserted. Subsequently, the lower sections of the mediastinal pleura were detached bilaterally-followed by the creation of two bilateral 1-cm skin incisions on the anterior axillary line in the sixth intercostal space for the insertion of robotic arms. Upon completion of port positioning, the surgical robot was docked. RESULTS: All robotic surgery procedures were successfully completed. Neither conversion to open surgery nor the creation of additional ports was required. The median operating time and console time were 118 min [interquartile range (IQR): 84-147 min] and 92.5 min (IQR: 78.5-133.5 min), respectively. Drainage tube positioning was not required in 11 (55%) patients. There were no operative deaths, and the median length of postoperative hospital stay was 2.5 days (IQR: 2-3 days). One patient had postoperative chylothorax and received conservative treatment. CONCLUSIONS: The results of this case series provide initial support to the clinical feasibility, safety, and short-term positive outcomes of trans-subxiphoid robot-assisted surgery for anterior mediastinal disease.

Individualized Strategies for Intraoperative Localization of Non-palpable Pulmonary Nodules in a Hybrid Operating Room.

Background: Precise preoperative localization of small pulmonary nodules is a key prerequisite to their successful excision. With the advent of hybrid operating rooms (HORs), a patient-tailored approach encompassing simultaneous localization and removal of small pulmonary nodules has become feasible. In this study, we describe our individualized image-guided video assisted thoracoscopic surgery (iVATS) strategies implemented within a HOR environment. Specifically, localization was performed through different marking approaches (single- vs. double-marker) and access routes [percutaneous technique with Dyna-computed tomography (DynaCT) imaging vs. electromagnetic navigation bronchoscopy (ENB)]. Methods: Between April 2017 and November 2018, a total of 159 consecutive patients (harboring 174 pulmonary nodules) were treated with iVATS. The marking approach and access route were individually tailored according to lesion localization and its distance from the pleural surface. The efficacy and safety of our iVATS technique were determined through a retrospective review of clinical charts. Results: All of the localization procedures were performed in a HOR by a single team of thoracic surgeons. The mean tumor size on preoperative CT was 8.28 mm (95% confidence interval [CI]: 7.6-8.96 mm), whereas their mean distance from the pleural surface was 9.44 mm (95% CI: 8.11-10.77 mm). Of the 174 tumors, 150 were localized through a percutaneous DynaCT-guided approach (single-marker: 139, dual-marker: 11), whereas localization in the remaining 24 was accomplished via the ENB-guided approach (single-marker: 4; dual-marker: 20). The mean localization time was 17.78 min (95% CI:16.17-19.39 min). The overall localization success rate was 95.9%. We failed to localize a total of seven nodules either because of technical complications (pneumothorax, n = 3; microcoil dislodgement; n = 1) or machine failure (n = 3). No operative deaths were observed, and the mean length of postoperative stay was 3.65 days (95% CI: 3.19-4.11 days). Conclusions: The use of tailored marking approaches and access routes allowed us to individualize the iVATS procedure for small pulmonary nodules, ultimately promoting a more patient-centered workflow.