Early Postoperative Results after Thymectomy for Thymic Cancer: A Single-Institution Experience.

BACKGROUND: Surgery for thymic cancers is considered the key of curative treatment. Preoperative patients' characteristics and intraoperative features might influence postoperative outcome. We aim to verify short-term outcomes and possible risk factors for complications after thymectomy. METHODS: We retrospectively investigated patients undergoing surgery for thymoma or thymic carcinoma in the period between January 1, 2008, and December 31, 2021, in our department. Preoperative features, surgical technique (open, bilateral VATS, RATS), intraoperative characteristics and incidence of postoperative complications (PC) were analyzed. RESULTS: We included in the study 138 patients. Open surgery was performed in 76 patients (55.1%), in 36 VATS (26.1%) and in 26 RATS (36.1%). Resection of one or more adjacent organs due to neoplastic infiltration was required in 25 patients. PC appeared in 25 patients (52% Clavien-Dindo grade I, 12% grade IVa). Open surgery had a higher incidence of PC (p < 0.001), longer postoperative in-hospital stay (p = 0.045) and larger neoplasm (p = 0.006). PC were significant related to pulmonary resection (p = 0.006), phrenic nerve resection (p = 0.029), resection of more than one organ (p = 0.009) and open surgery (p = 0.001), but only extended surgery of more organs was confirmed as independent prognostic factor for PC (p = 0.0013). Patients with preoperative myasthenia symptoms have a trend toward stage IVa complications (p = 0.065). No differences were observed between outcomes of VATS and RATS. CONCLUSIONS: Extended resections are related to a higher incidence of PC, while VATS and RATS guarantee a lower incidence of PC and shorter postoperative stay even in patients that require extended resections. Symptomatic myasthenia patients might have a higher risk toward more severe complications.

Robotic resection of mediastinal left vagus neurofibroma.

A Correction has been published | View Neurogenic tumors represent 10 to 34% of all mediastinal tumors and among them, neurofibroma originating from the vagus nerve are rare entities. We present a case of a neurofibroma with cystic degeneration originating from the left branch of the vagus nerve in a 27-year-old man without von Recklinghausen disease. A complete robotic resection of the mediastinal mass has been performed, with amputation of the vagus nerve enclosed in the mass. The postoperative course was uneventful and the patient was discharged in two days.

National Multicenter Study on the Comparison of Robotic and Open Thymectomy for Thymic Neoplasms in Myasthenic Patients: Surgical, Neurological and Oncological Outcomes.

Thymectomy is the gold standard in the treatment of thymic neoplasm and plays a key role in the therapeutic path of myasthenia gravis. For years, sternotomy has been the traditional approach for removing anterior mediastinal lesions, although the robotic thymectomy is now widely performed. The literature is still lacking in papers comparing the two approaches and evaluating long-term oncological and neurological outcomes. This study aims to analyze the postoperative results of open and robotic thymectomy for thymic neoplasms in myasthenic patients. Surgical, oncological and neurological data of myasthenic patients affected by thymic neoplasms and surgically treated with extended thymectomy, both with the open and the robotic approach, in six Italian Thoracic Centers between 2011 and 2021 were evaluated. A total of 213 patients were enrolled in the study: 110 (51.6%) were treated with the open approach, and 103 (48.4%) were treated with robotic surgery. The open surgery, compared with the robotic, presented a shorter operating time (p < 0.001), a higher number of postoperative complications (p = 0.038) and longer postoperative hospitalization (p = 0.006). No other differences were observed in terms of surgical, oncological or neurological outcomes. The robotic approach can be considered safe and feasible, comparable to the open technique, in terms of surgical, oncological and neurological outcomes.

Robotic thymectomy in thymic tumours: a multicentre, nation-wide study.

OBJECTIVES: Robotic thymectomy has been suggested and considered technically feasible for thymic tumours. However, because of small-sample series and the lack of data on long-term results, controversies still exist on surgical and oncological results with this approach. We performed a large national multicentre study sought to evaluate the early and long-term outcomes after robot-assisted thoracoscopic thymectomy in thymic epithelial tumours. METHODS: All patients with thymic epithelial tumours operated through a robotic thoracoscopic approach between 2002 and 2022 from 15 Italian centres were enrolled. Demographic characteristics, clinical, intraoperative, postoperative, pathological and follow-up data were retrospectively collected and reviewed. RESULTS: There were 669 patients (307 men and 362 women), 312 (46.6%) of whom had associated myasthenia gravis. Complete thymectomy was performed in 657 (98%) cases and in 57 (8.5%) patients resection of other structures was necessary, with a R0 resection in all but 9 patients (98.6%). Twenty-three patients (3.4%) needed open conversion, but no perioperative mortality occurred. Fifty-one patients (7.7%) had postoperative complications. The median diameter of tumour resected was 4 cm (interquartile range 3-5.5 cm), and Masaoka stage was stage I in 39.8% of patients, stage II in 56.1%, stage III in 3.5% and stage IV in 0.6%. Thymoma was observed in 90.2% of patients while thymic carcinoma occurred in 2.8% of cases. At the end of the follow-up, only 2 patients died for tumour-related causes. Five- and ten-year recurrence rates were 7.4% and 8.3%, respectively. CONCLUSIONS: Through the largest collection of robotic thymectomy for thymic epithelial tumours we demonstrated that robot-enhanced thoracoscopic thymectomy is a technically sound and safe procedure with a low complication rate and optimal oncological outcomes.

Lung Transplant Recipients and COVID-19: Report of Two Cases.

Although the WHO has declared the end of the pandemic emergency, COVID-19 still poses a threat to immunocompromised patients. The COVID-19 pandemic has spread throughout the world over the last two years, causing a significant number of deaths. After three years, SARS-CoV-2 has lost its initial lethality but has shown a significantly worse prognosis for immunocompromised patients, especially those who have undergone lung transplantation, compared with the general population. This paper presents two compelling case studies that highlight the complex challenges of COVID-19 infection in lung transplant recipients. The first case involves a patient who received a bilateral lung transplant for pulmonary artery hypertension in 2009, followed by a kidney transplant in 2022. Surprisingly, despite an initially favorable clinical course after contracting COVID-19, the patient deteriorated rapidly and died within a few days due to extensive lung involvement. This case highlights the unpredictable nature of COVID-19 and its potentially devastating impact on lung transplant recipients. The second case involves a patient who underwent bilateral lung transplantation five years earlier for chronic obstructive pulmonary disease (COPD). This individual also contracted COVID-19 and had pre-existing complications, including chronic lung allograft rejection (CLAD) and diffuse bronchial stenosis. Following viral infection, the patient's clinical condition deteriorated rapidly, with worsening bronchial stenosis. This case highlights the ability of COVID-19 to exacerbate pre-existing pulmonary complications in transplant recipients. These cases highlight the urgent need for increased vigilance and tailored management strategies when dealing with COVID-19 in lung transplant recipients. The unpredictable and detrimental course of the disease observed in these patients highlights the importance of implementing stringent preventive measures, such as vaccination and strict adherence to infection control protocols, in this vulnerable population. Further research is essential to gain a full understanding of the unique dynamics of COVID-19 in lung transplant recipients and to develop targeted interventions to improve their outcomes.

Unsolved Issues in Thymic Epithelial Tumour Stage Classification: The Role of Tumour Dimension.

According to the different classifications now in use, thymic tumours are staged by the extent of local invasiveness, and tumour size is not included as a major determinant for the T category. The aim of this double-site retrospective study is to analyse the correlation between tumour dimension and overall survival (OS) in patients who underwent surgical treatment. From January 2000 to December 2020, patients with thymic epithelial tumours who underwent surgical resection were included in this study. Data from a total of 332 patients were analysed. Five- and ten-year overall survival (5-10 YOS) was 89.26% and 87.08%, respectively, while five- and ten-year disease-free survival (DFS) was 88.12% and 84.2%, respectively. Univariate analysis showed a significant correlation between male sex (p-value 0.02), older age (p-value < 0.01), absence of myasthenia gravis (p-value < 0.01), increase in pTNM (pathological Tumor Node Metastasis) (p-value 0.03) and increase in the number of infiltrated organs (p-value 0.02) with an increase in tumour dimension. Tumour dimension alone was not effective in the prediction of DFS and OS, both when considered as a continuous variable and when considered with a cut-off of 3 and 5 cm. However, with multivariate analysis, it was effective in predicting OS in the aforementioned conditions (p-value < 0.01). Moreover, multivariate analysis was also used in the thymoma and Masaoka I subgroups. In our experience, the role of tumour dimension as a descriptor of the T parameter of the TNM (Tumor Node Metastasis) staging system seemed to be useful in improving this system.

Surgical Management and Reconstruction of Diaphragm, Pericardium and Chest Wall in Mesothelioma Surgery: A Review.

Mesothelioma is an aggressive disease arising from parietal pleura. Surgery is a valuable option in the frame of a multimodality treatment. Several surgical approaches have been standardized with the aim of a macroscopic complete resection; these often require homolateral diaphragm and pericardial resection and reconstruction. Extrapleural pneumonectomy (EPP) and extended pleurectomy decortication (EPD) have been recognized as radical surgical procedures. Nevertheless, both operations are technically challenging and associated with a significant rate of peri-operative morbidity and non-negligible mortality. The diaphragmatic and pericardial reconstruction technique is mandatory to avoid respiratory impairment and to reduce post-operative complications like gastric and cardiac herniation. Moreover, in the case of localized chest wall recurrence, surgery might be considered a valuable therapeutical option for highly selected and fit patients. All the technical aspects of the resection and reconstruction of the diaphragm, pericardium, and chest wall are described as well as the possible use of new minimally invasive techniques. In addition, the choice of different prosthetic materials, considering the most recent innovations in the field, are discussed.

Boerhaave's syndrome: long free interval before successful primary repair. Case report.

AIM: Report case of a 66-year-old man come to our observation for a bilateral pleural effusion, ten days after clinical manifestations of chest pain, initially misdiagnosed with a myocardial infarction. MATERIAL OF STUDY: On the same day, the patient underwent an emergency chest CT scan with orally administered contrast medium that confirmed our suspicion of breakage of the esophageal wall. The patient underwent to a left thoracotomy: the visceral pleura and all the structures covered by the parietal pleura were affected by a widespread necrotic process. The subsequent cleansing of the pleural cavity revealed that the distal portion of the thoracic esophagus was lacerated for about 5 cm; the tear was repaired with continuous reabsorbable sutures; to protect the suture fundoplication of the gastric fundus was performed. RESULTS: Post-operative course was complicated on 15th day by a chylous spreading from the chest drains; to complete the postoperative checks, a chest CT scan was therefore performed, orally administering the contrast medium without any signs of extraluminal spreading; the chylous effusion resolved spontaneously with diet. After being discharged, the patient was followed on an outpatient basis for 36 months. CONCLUSION: Boerhaave's syndrome is a rare and serious clinical condition; when a patient is diagnosed after 24-48 hs, many surgeons follow conservative treatment; however primary repair can be safely accomplished regardless of the time interval between perforation and operation, like our singular experience demonstrated

Conversion due to vascular injury during video-assisted thoracic surgery lobectomy: A multicentre retrospective analysis from the Italian video-assisted thoracic surgery group registry.

OBJECTIVES: Vascular injuries are among the most severe causes of unplanned conversion during VATS lobectomies. The study aimed to analyse the incidence of vascular injuries and their risk factors during VATS lobectomy. METHODS: The Italian VATS lobectomy Registry was used to collect data from 66 Thoracic Surgery Units. From 2013 to October 2016 (out of more than 3,700 patients enrolled) only information from Units with an enrollment >100 VATS lobectomies were retrospectively analysed. Logistic regression analysis was performed on selected variables of the univariate analysis. RESULTS: Ten institutions contributed a total of 1,679 patients. Vascular injuries leading to conversion occurred in 44 (2.6%) patients. Years of experiences were inversely related to the risk of vascular injuries. Univariate analysis showed age, gender, surgical activity, Charlson Index Score and number of resected lymph nodes like significantly associated variables. Multivariate analysis revealed that number of resected lymph nodes, VATS experience ratio (number of VATS lobectomies/total lobectomies performed in the same year at same centre), and surgical activity of the centre were significantly associated with the risk of conversion. Unplanned thoracotomy was correlated with postoperative morbidity. CONCLUSION: Vascular injuries in VATS lobectomies represented a rare complication which could directly affect the postoperative outcomes. The predictive factors for conversion were multifactorial and depended on characteristics of centres and surgeons' seniority. Minimally invasive VATS lobectomy approaches did not influence the risk of vascular damages.

Uniportal video-assisted thoracic surgery lobectomy: a consensus report from the Uniportal VATS Interest Group (UVIG) of the European Society of Thoracic Surgeons (ESTS).

OBJECTIVES: Our goal was to report the results of the first consensus paper among international experts in uniportal video-assisted thoracoscopic surgery (UniVATS) lobectomy obtained through a Delphi process, the objective of which was to define and standardize the main procedural steps, optimize its indications and perioperative management and identify elements to assist in future training. METHODS: The 40 members of the working group were convened and organized on a voluntary basis by the Uniportal VATS Interest Group (UVIG) of the European Society of Thoracic Surgeons (ESTS). An e-consensus finding exercise using the Delphi method was applied to require 75% agreement for reaching consensus on each question. Repeated iterations of anonymous voting continued for 3 rounds. RESULTS: Overall, 31 international experts from 18 countries completed all 3 rounds of questionnaires. Although a technical quorum was not achieved, most of the responders agreed that the maximum size of a UniVATS incision should be ≤4 cm. Agreement was reached on many points outlining the currently accepted definition of a UniVATS lobectomy, its indications and contraindications, perioperative clinical management and recommendations for training and future research directions. CONCLUSIONS: The UVIG Consensus Report stated that UniVATS offers a valid alternative to standard VATS techniques. Only longer follow-up and randomized controlled studies will predict whether UniVATS represents a valid alternative approach to multiport VATS for major lung resections or whether it should be performed only in selected cases and by selected centres. The next step for the ESTS UVIG is the establishment of a UniVATS section inside the ESTS databases.

Robotic internal mammary lymphadenectomy: another possible minimally invasive approach to sampling lymph nodes in breast cancer patients.

Internal mammary lymphadenopathy may develop in breast cancer patients with silicone implants. Differential diagnosis includes malignant recurrence, infections, inflammations and granulomatous deposit. We report a case of internal mammary lymphadenopathy, in a patient with the previous history of breast cancer, requiring a tissue diagnosis. We performed a Robotic lymph nodes dissection of the left internal mammary. Final pathology diagnosis was positive for silicone granulomatous lymphadenitis secondary to silicone breast implants inserted after mastectomy for breast cancer.

Four arms robotic-assisted pulmonary resection-left upper lobectomy: how to do it.

Numerous published articles have shown the safety and efficacy of robotic anatomic pulmonary resection, including lobectomy for non-small cell lung cancer. Several techniques have been described to perform a lung lobectomy robotically. Since the beginning of our experience, we adopted a four-arm robotic approach with the da Vinci Si System. More recently we have used the newer Xi model, that offers a simplified and "quicker" set-up and docking time. This article emphases specifically on the technical aspects of how to complete the hilar dissection during four-arm robotic lobectomy.

Diaphragmatic and pericardial reconstruction after surgery for malignant pleural mesothelioma.

Extrapleural pneumonectomy (EPP) and pleurectomy-decortication (P/D) are both recognised surgical procedures for selected cases affected by malignant pleural mesothelioma (MPM). Surgical techniques have ameliorated over the last years, remaining the complete macroscopic resection of the disease the main surgical principle. EPP is defined as an en-bloc resection of the visceral pleura, parietal pleura, pericardium and diaphragm alongside the pneumonectomy. The thoracic domain of the International Association for Study of Lung Cancer (IASLC) recently clarified the, previously confused, surgical terminology. "Extended P/D" is considered as parietal and visceral pleurectomy, diaphragmatic and pericardial resection with the purpose to remove all macroscopic disease. The term "radical" was replaced by "extended" to underline that this procedure does not have oncologic radicality aims. Both operations above are technically challenging and associated with a significant rate of peri-operative morbidity and non-negligible mortality. The diaphragmatic and pericardial reconstruction technique is mandatory to avoid respiratory impairment and to reduce post-operative complications like gastric and cardiac herniation. The technical aspects of resection and reconstruction are described and the choice of different prosthetic materials, considering the most recent innovations in the field, are discussed.

Four arms robotic-assisted pulmonary resection-right lower/middle lobectomy: how to do it.

In the last few years, robotic approach for anatomic lung resection has brought an innovative development in minimally invasive thoracic surgery. This study analyzes the technical aspects of performing the hilar dissection for a lobectomy via robotic approach. With a detailed step-by-step description and essential tips and videos, in this paper, we report the procedure to carry out a four-arm robotic middle and lower lobectomy.

Surgical approaches in patients with oligometastatic non-small cell lung cancer.

In recent years, retrospective analyses have suggested that an oligometastatic state could exist, but the best evidence to date that a temporary oligometastatic disease exists for lung cancer mainly derives from the survival data on retrospective patients underwent surgical resection of a single M1 site and all intrathoracic disease. The critical determinates of long-term survival include definitive treatment of the primary non-small cell lung cancer (NSCLC), a single organ site of synchronous or metachronous disease, a long disease-free interval between treatment of the primary NSCLC and development of metastases, and the absence of intrathoracic lymph node (N0) disease. The ongoing development of innovative approaches to local therapy and treatment directed to the oligometastatic sites should be defined in future studies.

Four arms robotic-assisted pulmonary resection-left lower lobectomy: how to do it.

Numerous published articles have shown the safety and efficacy of robotic lung resection, including lobectomy. The robotic approach offers similar survival rate to the open and video-assisted thoracoscopic surgery methods. Potential advantages provided by robotic technology, such as three-dimensional (3D) high-quality camera, wristed tools and ergonomic ease that seems to overcome certain video-assisted thoracic surgery (VATS) limits have been widely described. Several techniques have been developed by different surgeons to perform a robotic lobectomy. In this study, we present our technique for performing a four-arm robotic lobectomy for the treatment of early stage lung cancer. This is shown in clear, sequential steps. We also provide an instrument preference card, some operative tips and a high-quality video.

Surgical treatment of synchronous multiple neuroendocrine lung tumours (case series): is more always better?

Pulmonary neuroendocrine lung tumours are uncommon neoplasm; the presence of multiple and synchronous lesions is rare, and few case report are described in the literature. We present a case series of three patients without particular symptom and radiologic finding of multiple synchronous pulmonary nodules. All the patients underwent surgical treatment; histopathologic examination revealed typical carcinoid tumours in all three cases (one patient has a synchronous atypical carcinoid). No oncological progressions were observed at follow-up. A review of current literature is also presented with a suggested strategy management.

Uniportal video-assisted thoracic surgery for pneumothorax and blebs/bullae.

The last British Society of Thoracic Surgeons guidelines of 2010 for the management of primary spontaneous pneumothorax (PSP) stated that, after the first recurrence, the treatment of PSP should be a surgical operation, like a bullectomy accompanying with a procedure for inducing pleural adhesions. Therefore, the surgical approach is considered the best treatment to minimise the risk of recurrence in patients who experienced a PSP. There is substantial evidence in the literature demonstrating that the minimally invasive approach should be preferred to the thoracotomic procedure since it can reduce the postoperative pain and it is associated with a faster recovery of the physical and working activity. The video-assisted thoracic surgery (VATS) approach has been shown to offer greater advantages about patient pain and respiratory function when compared to thoracotomic incisions. A single port or single incision or uniportal approach was developed as an alternative to the standard multi-port VATS. Uniportal technique has shown to be safe and efficient not only for pulmonary resections and biopsies but also for lobectomy. When used for PSP, the bullectomy/blebectomy and pleural abrasion/pleurectomy is performed through the single incision through which the chest drain is then inserted. In this perspective, evidence showed that the minimally invasive approach should be preferred, confirming the advantages in comparison with traditional techniques.

Four arm robotic-assisted pulmonary resection-right upper lobectomy: how to do it.

Numerous published articles have shown the safety and efficacy of robotic lung resection, including lobectomy. Several techniques have been described by different authors to perform a robot assisted lung lobectomy. We adopted four arms robotic procedure. We usually perform three ports (10-15 mm) and an anterior 3 to 4 cm utility incision. This technique allows to safely proceed with an anterior to posterior approach to the hilum. In this study, we present in clear and sequential steps, the procedure to perform a right upper lobectomy for early stage lung cancer. We also supply a high-quality video, operative tips and a preference cards.