The everlasting issue of prolonged air leaks after lobectomy for non-small cell lung cancer: A data-driven prevention planning model in the era of minimally invasive approaches.

BACKGROUND AND OBJECTIVES: Prolonged air leaks (PAL) are the most frequent complication after lobectomy for non-small cell lung cancer, even in case of minimally invasive approaches. We developed a novel score to identify high-risk patients for PAL during minimally invasive lobectomy. METHODS: A dedicated database was created. We investigated preoperative candidate features and specific intraoperative variables. Univariate and subsequent logistic regression analysis with bootstrap resampling have been used. Model performance has been assessed by reckoning the area under the receiver operating characteristics curve and the Hosmer-Lemeshow goodness of fit. RESULTS: PAL (>5 days) occurred in 72 (15.69%) patients. Five variables emerged from the model. Each one was assigned a score to provide a cumulative scoring system: forced expiratory volume in 1 second below 86% (P = 0.004, 1.5 points), body mass index <24 ( P = 0.002, 1 point), active smoking ( P = 0.001, 1.5 points), incomplete fissures ( P = 0.004, 1.5 points), and adhesions ( P = 0.0001, 1 point). The new score provided a stratification into four risk classes. CONCLUSIONS: The risk score incorporates either general or more specific variables, providing a risk stratification that could be readily applied intra- and postoperatively. Henceforth, specific technical and management measures could be properly allocated to curb PAL.

[Comparative analysis of video-assisted thoracic surgery versus open resection for early-stage thymoma]. / Análisis comparativo del abordaje para el tratamiento del timoma estadio i-ii: VATS versus abordaje convencional.

BACKGROUND: Video-assisted thoracic surgery (VATS) has significantly developed over the last decade. However, a VATS approach for thymoma remains controversial. The aim of this study was to evaluate the feasibility of VATS thymectomy for the treatment of early-stage thymoma and to compare the outcomes with open resection. METHODS: A comparative study of 59 patients who underwent surgical resection for early stage thymoma (VATS: 44 and open resection: 15) between 1993 and 2011 was performed. Data of patient characteristics, morbidity, mortality, length of hospital stay, the relationship between miasthenia gravis-thymoma, recurrence, and survival were collected for statistical analysis. RESULTS: Thymomas were classified according to Masaoka staging system: 38 in stage I (VATS group: 29 and open group: 9) and 21 in stage II (VATS group: 15 and open group: 6). The mean tumor size in the open group was 7.6cm (13-4cm) and in the VATS group 6.9cm (12-2.5cm). The average length of stay was shorter in the VATS group than in the open group (P<.001). No significant differences were found in the estimated recurrence-free and overall 5-year survival rates (96% vs. 100%) between the 2 groups. CONCLUSIONS: VATS thymectomy for early-stage thymoma is technically feasible and is associated with a shorter hospital stay. The 5-year oncologic outcomes were similar in the open and VATS groups.

Results in mediastinal lymph node staging of surgical lung cancer: Data from the prospective cohort of the Spanish Video-Assisted Thoracic Surgery Group.

OBJECTIVES: The objective of this study was to assess the diagnostic performance of combined computerised tomography (CT) and positron emission tomography (PET) in mediastinal staging of surgical lung cancer based on data obtained from the prospective cohort of the Spanish Group for Video-Assisted Thoracic Surgery (GEVATS). METHODS: A total of 2782 patients underwent surgery for primary lung carcinoma. We analysed diagnostic success in mediastinal lymph node staging (cN2) using CT and PET. Bivariate and multivariate analyses were performed of the factors involved in this success. The risk of unexpected pN2 disease was analysed for cases in which an invasive testing is recommended: cN1, the tumour centrally located or the tumour diameter >3 cm. RESULTS: The overall success of CT together with PET was 82.9% with a positive predictive value of 0.21 and negative predictive value of 0.93. If the tumour was larger than 3 cm and for each unit increase in mediastinal SUVmax, the probability of success was lower with OR 0.59 (0.44-0.79) and 0.71 (0.66-0.75), respectively. In the video-assisted thoracic surgery (VATS) approach, the probability of success was higher with OR 2.04 (1.52-2.73). The risk of unexpected pN2 increased with the risk factors cN1, the tumour centrally located or the tumour diameter >3 cm: from 4.5% (0 factors) to 18.8% (3 factors) but did not differ significantly as a function of whether invasive testing was performed. CONCLUSIONS: CT and PET together have a high negative predictive value. The overall success of the staging is lower in the case of tumours >3 cm and high mediastinal SUVmax, and it is higher when VATS is performed. The risk of unexpected pN2 is higher if the disease is cN1, the tumour centrally located or the tumour diameter >3 cm but does not vary significantly as a function of whether patients have undergone invasive testing.

Sympathetic chain clipping for hyperhidrosis is not a reversible procedure.

BACKGROUND: Many techniques have been used to treat palmar hyperhidrosis. Compensatory sweating is a difficult adverse effect. Clipping has been proposed because of its supposed reversibility when clips are removed at a later date. The primary aims of this article are to investigate the neuronal lesion of the sympathetic chain caused by clipping and to study the possibility of regeneration after removal of the clips. METHODS: We performed an experimental study at the Minimally Invasive Surgery Centre Jesus Uson in Caceres (Spain). We used a swine model, performing clipping, unclipping, and extirpation of different segments of sympathetic chain with clips and after clip removal, following a chronogram of 10, 20, and 30 days. Pathologic studies of specimens and statistics were done at the University of Seville. RESULTS: Ten days after clipping, all sympathetic chains displayed evident Wallerian degeneration. Twenty days after clipping, Wallerian degeneration of myelinated fibers was more widespread and also more striking. Thirty days after clipping, a very marked macrophagic reaction was visible, with multiple signs of phagocytosis of myelin debris. By 30 days post operation and 20 days after clip removal, a few residual myelin and amyelinated fibers were visible. These findings suggest that axon regeneration is not possible. CONCLUSIONS: There are Wallerian degeneration and axon loss 10 days after clipping. The almost total absence of myelinated and amyelinated fibers following clip removal suggests that there was no nerve regeneration, and that therefore clipping cannot be considered a reversible technique.

Surgical Risk Following Anatomic Lung Resection in Thoracic Surgery: A Prediction Model Derived from a Spanish Multicenter Database. / Riesgo quirúrgico tras resección pulmonar anatómica en cirugía torácica. Modelo predictivo a partir de una base de datos nacional multicéntrica.

INTRODUCTION: The aim of this study was to develop a surgical risk prediction model in patients undergoing anatomic lung resections from the registry of the Spanish Video-Assisted Thoracic Surgery Group (GEVATS). METHODS: Data were collected from 3,533 patients undergoing anatomic lung resection for any diagnosis between December 20, 2016 and March 20, 2018. We defined a combined outcome variable: death or Clavien Dindo grade IV complication at 90 days after surgery. Univariate and multivariate analyses were performed by logistic regression. Internal validation of the model was performed using resampling techniques. RESULTS: The incidence of the outcome variable was 4.29% (95% CI 3.6-4.9). The variables remaining in the final logistic model were: age, sex, previous lung cancer resection, dyspnea (mMRC), right pneumonectomy, and ppo DLCO. The performance parameters of the model adjusted by resampling were: C-statistic 0.712 (95% CI 0.648-0.750), Brier score 0.042 and bootstrap shrinkage 0.854. CONCLUSIONS: The risk prediction model obtained from the GEVATS database is a simple, valid, and reliable model that is a useful tool for establishing the risk of a patient undergoing anatomic lung resection.

[Pericardial window by videothorascopy]. / Ventana pericárdica por videotoracoscopia.

INTRODUCTION: Pericardial effusion is a clinical condition requiring multidisciplinary management. There are several surgical techniques for its diagnosis and treatment. In the present study we report our experience in performing a pericardial window (PW) by videothorascopy. MATERIAL AND METHODS: We performed surgery on 56 patients (20 females and 36 males), with a mean age of 56±1.22 years, and diagnosed with moderate to severe chronic pericardial effusion. The side chosen for the approach depended on whether there was an associated pleural effusion or lung lesion, and if not the left side was chosen. RESULTS: The mean duration of the surgery was 37.6±16 minutes. The definitive diagnoses were malignant processes in 23% of cases, including bronchogenic carcinoma and breast cancer. The intra-operative mortality was 0%. CONCLUSIONS: Videothorascopic pericardial window is an effective and safe technique for the diagnosis and treatment of chronic pericardial effusion, and which enables it to be drained and perform a pleuro-pulmonary and/or mediastinal biopsy during the same surgical act.

Thymomectomy plus total thymectomy versus simple thymomectomy for early-stage thymoma without myasthenia gravis: a European Society of Thoracic Surgeons Thymic Working Group Study.

OBJECTIVES: Resection of thymic tumours including the removal of both the tumour and the thymus gland (thymothymectomy; TT) is the procedure of choice and is recommended in most relevant articles in the literature. Nevertheless, in recent years, some authors have suggested that resection of the tumour (simple thymomectomy; ST) may suffice from an oncological standpoint in patients with early-stage thymoma who do not have myasthenia gravis (MG) (non-MG). The goal of our study was to compare the short- and long-term outcomes of ST versus TT in non-MG early-stage thymomas using the European Society of Thoracic Surgeons thymic database. METHODS: A total of 498 non-MG patients with pathological stage I thymoma were included in the study. TT was performed in 466 (93.6%) of 498 patients who had surgery with curative intent; ST was done in 32 (6.4%). The completeness of resection, the rate of complications, the 30-day mortality, the overall recurrence and the freedom from recurrence were compared. We performed crude and propensity score-adjusted comparisons by surgical approach (ST vs TT). RESULTS: TT showed the same rate of postoperative complications, 30-day mortality and postoperative length of stay as ST. The 5-year overall survival rate was 89% in the TT group and 55% in the ST group. The 5-year freedom from recurrence was 96% in the TT group and 79% in the ST group. CONCLUSION: Patients with early-stage thymoma without MG who have a TT show significantly better freedom from recurrence than those who have an ST, without an increase in postoperative morbidity rate.

Spanish Video-Assisted Thoracic Surgery Group: Method, Auditing, and Initial Results From a National Prospective Cohort of Patients Receiving Anatomical Lung Resections.

INTRODUCTION: Our study sought to know the current implementation of video-assisted thoracoscopic surgery (VATS) for anatomical lung resections in Spain. We present our initial results and describe the auditing systems developed by the Spanish VATS Group (GEVATS). METHODS: We conducted a prospective multicentre cohort study that included patients receiving anatomical lung resections between 12/20/2016 and 03/20/2018. The main quality controls consisted of determining the recruitment rate of each centre and the accuracy of the perioperative data collected based on six key variables. The implications of a low recruitment rate were analysed for "90-day mortality" and "Grade IIIb-V complications". RESULTS: The series was composed of 3533 cases (1917 VATS; 54.3%) across 33 departments. The centres' median recruitment rate was 99% (25-75th:76-100%), with an overall recruitment rate of 83% and a data accuracy of 98%. We were unable to demonstrate a significant association between the recruitment rate and the risk of morbidity/mortality, but a trend was found in the unadjusted analysis for those centres with recruitment rates lower than 80% (centres with 95-100% rates as reference): grade IIIb-V OR=0.61 (p=0.081), 90-day mortality OR=0.46 (p=0.051). CONCLUSIONS: More than half of the anatomical lung resections in Spain are performed via VATS. According to our results, the centre's recruitment rate and its potential implications due to selection bias, should deserve further attention by the main voluntary multicentre studies of our speciality. The high representativeness as well as the reliability of the GEVATS data constitute a fundamental point of departure for this nationwide cohort.

Video-assisted thoracic surgery (VATS) lobectomy: 13 years' experience.

BACKGROUND: Major lung resection by video-assisted thoracic surgery (VATS) has been proven to be both safe and technically feasible, but is not routinely performed in most hospitals. The aim of this paper is to show our technique for VATS lobectomy and our experience and outcomes obtained. METHODS: We have performed a retrospective review included all patients undergoing major pulmonary resection by VATS at the General and Thoracic Surgery Unit, Virgen Macarena University Hospital, Seville (Spain) since 1992. The clinical records of all patients were drawn from the hospital archive and data for the following variables were recorded for analysis: age, sex, clinical diagnosis, clinical status, date of surgery, type of surgery, inoperability, conversion to conventional surgery and reasons, duration of surgery and intraoperative complications, postoperative and long-term complications, postoperative stay, diagnosis, definitive status, and mortality. We also describe our surgical technique for each lobectomy. RESULTS: A total of 237 major pulmonary resections were performed, on 203 males and 34 males, with a mean age of 61.43 years (non-small-cell bronchogenic carcinoma: 204, benign processes: 24, carcinoid tumors: 4, and lobectomy due to metastases: 5). The overall conversion rate was 14.01%. Mean duration of lobectomy was 153 min, with a median of 98 min, and mean postoperative stay was 4.2 days. The morbidity rate was 15.18%, mostly involving minor complications. Perioperative mortality was 3.7%. The actuarial 5-year survival rate was 77.7%. CONCLUSIONS: VATS lobectomy is a viable safe procedure that meets oncological criteria for lung cancer surgery. In our experience, VATS is currently to be considered ideally indicated for certain benign processes and for T1-T2 N0 M0 bronchogenic carcinomas.

Phytobezoar by aloe vera as long term complication after oesophagectomy resolved using cellulase.

Bezoars are uncommon diseases caused by the presence of indigestible mass of strange material in the gastrointestinal tract. Gold-standard treatment remains unclear and there are not clinical guidelines to follow. We present a very rare case of 53-year-old man suffering phytobezoar in a gastroplasty after oesophagectomy due to aloe vera ingestion as natural medicine. Finally it was solved with cellulase. Therefore, this is a scarcely complication after esophagectomy. Cellulase is a very good option to treat phytobezoar avoiding reintervention in this kind of patient.

Non-intubated thoracic surgery-A survey from the European Society of Thoracic Surgeons.

BACKGROUND: A survey amongst the European Society of Thoracic Surgeons (ESTS) members has been performed to investigate the currents trends, rates of adoption as well as potential for future expansion of non-intubated thoracic surgery (NITS) performed under spontaneous ventilation. METHODS: A 14-question-based questionnaire has been e-mailed to ESTS members. To facilitate the completion of the questionnaire, questions entailed either quantitative or multiple-choice answers. Investigated issues included previous experience with NITS and number of procedures performed, preferred types of anesthesia protocols (i.e., thoracic epidural anesthesia, intercostal or paravertebral blocks, laryngeal mask, use of additional sedation), type of procedures, ideal candidates for NITS, main advantages and technical disadvantages. Non-univocal answer to multiple-choice questions was permitted. RESULTS: Out of 105 responders, 62 reported an experience with NITS. The preferred types of anesthesia were intercostal blocks with (59%) or without (50%) sedation, followed by laryngeal mask with sedation (43%) and thoracic epidural anesthesia with sedation (20%). The most frequently performed procedures included thoracoscopic management of recurrent pleural effusion (98%), pleural decortication for empyema thoracis and lung biopsy for interstitial lung disease (26% each); pericardial window and mediastinal biopsy (20% each). More complex procedures such as lobectomy, lung volume reduction surgery and thymectomy have been performed by a minority of responders (2% each). Poor-risk patients due to co-morbidities (70%) and patients with poor pulmonary function (43%) were considered the ideal candidates. Main advantages included faster, recovery (67%), reduced morbidity (59%) and shorter hospital stay with decreased costs (43% each). Reported technical disadvantages included coughing (59%) and poor maneuverability due to diaphragmatic and lung movements (56%). Overall, 69% of responders indicated that NITS procedures will be likely to increase in the near future. CONCLUSIONS: Results of this survey, suggest that NITS is already quite widely adopted by ESTS members to perform simple thoracoscopic procedures. A future expanded adoption of this strategy is also hypothesized.

Peripheral arterial embolism arising from pulmonary adenocarcinoma.

Bronchogenic carcinoma is a rare source of peripheral arterial embolism. We present the case of a 28-year-old female nonsmoker with an adenocarcinoma of the left main bronchus involving the pulmonary veins. While the patient was hospitalized awaiting operation, she presented embolization in her legs; embolectomy and fasciotomy were necessary to treat compartment syndrome. Echocardiography disclosed floating tumoral masses in the left atrium. Seven days later, an operation was performed with cardiopulmonary bypass to remove the tumor masses from the atrial lumen; pulmonary veins were sutured from within the atrium, and pneumonectomy was performed. Fulminant infection of the lower limbs developed that led to gangrene and multiple organ failure, and the patient died 8 days after the operation.

Experience and development of the video-assisted thoracic surgery lobectomy technique: comparative study with conventional surgery in stage I non-small cell lung cancer.

BACKGROUND: Surgical treatment of stage I non-small cell lung cancer (NSCLC) can be performed either by thoracotomy or by employing video-assisted thoracic surgery (VATS). The aim of this study was to compare long and short-term results of conventional surgery (CS) vs. VATS lobectomy in the treatment of stage I NSCLC. MATERIALS AND METHODS: We performed a retrospective, analytical study of patients undergoing surgery for stage I NSCLC during the period January 1993 to December 2005. The variables analyzed were overall survival, recurrence, distant metastasis, morbidity, mortality and hospital stay. During this period, 256 anatomic lung resections were performed: 141 by CS and 115 by VATS. RESULTS: There were statistically significant differences in: (i)mean hospital stay in patients with no complications (VATS group: 4.3 days vs. CS group: 8.7 days, P=.0001); (ii)mean hospital stay in patients with complications (VATS: 7.2 days vs. CS: 13.7 days, P=.0001), and (iii)morbidity (VATS: 15.6% vs. CS: 36.52%, P=.0001). No statistically significant differences were found in: (i)mortality (VATS: 2.17% vs. CS: 1.7%, P=.88); (ii)5-year overall survival (VATS: 68.1% vs. CS: 63.8%), and (iii) local recurrence and distant metastasis (P=.82). CONCLUSIONS: VATS lobectomy is a safe and effective approach, with a shorter hospital stay and lower morbidity than CS; no statistically significant differences were observed in survival in patients undergoing surgery for stage I NSCLC.

European guidelines on structure and qualification of general thoracic surgery.

OBJECTIVE: To update the recommendations for the structural characteristics of general thoracic surgery (GTS) in Europe in order to provide a document that can be used as a guide for harmonizing the general thoracic surgical practice in Europe. METHODS: A task force was created to set the structural, procedural and qualification characteristics of a European GTS unit. These criteria were endorsed by the Executive Committee of the European Society of Thoracic Surgeons and by the Thoracic Domain of the European Association for Cardio-Thoracic Surgery and were validated by the European Board of Thoracic Surgery at European Union of Medical Specialists. RESULTS: Criteria regarding definition and scope of GTS, structure and qualification of GTS unit, training and education and recommendations for subjects of particular interest (lung transplant, oesophageal surgery, minimally invasive thoracic surgery, quality surveillance) were developed. CONCLUSIONS: This document will hopefully represent the first step of a process of revision of the modern thoracic surgeons' curricula, which need to be qualitatively rethought in the setting of the qualification process. The structural criteria highlighted in the present document are meant to help and tackle the challenge of cultural and language barriers as well as of widely varying national training programmes.

Posterolateral thoracotomy without muscle division: a new approach to complex procedures.

Today, there is a strong increase in video-assisted thoracic surgery; however, there are still some diseases and interventions that need a wide pleural cavity exposure (i.e. sulcus tumours and extended resections). These complex procedures are usually performed via a standard posterolateral thoracotomy, which is a good approach but has significant disadvantage due to pain and difficulty coughing. We propose a new thoracotomy that avoids a dorsal muscle division but has the same intrathoracic exposure as a posterolateral thoracotomy.

Comparative study of talc poudrage versus pleural abrasion for the treatment of primary spontaneous pneumothorax.

Primary spontaneous pneumothorax is a pathology mainly affecting healthy young patients. Clinical guidelines do not specify the type of pleurodesis that should be conducted, due to the lack of comparative studies on the different techniques. The aim of this study was to compare talc poudrage and pleural abrasion in the treatment of spontaneous pneumothorax. A retrospective comparative study was performed, including 787 patients with primary spontaneous pneumothorax. The 787 patients were classified into two groups: Group A (pleural abrasion) n = 399 and Group B (talc pleurodesis) n = 388. The variables studied were recurrence, surgical time, morbidity and in-hospital length of stay. Statistical analysis was done by an unpaired t-test and Fisher's exact test (SSPS 18.0). Statistically significant differences were observed in the variables: surgical time (A: 46 ± 12.3; B: 37 ± 11.8 min; P < 0.001); length of stay (A: 4.7 ± 2.5; B: 4.3 ± 1.8 days; P = 0.01); apical air camera (A: 25; B: 4; P < 0.001); pleural effusion (A: 6; B: 0; P = 0.05). Talc poudrage shows shorter surgical times and length of stay, and lower re-intervention rates. Morbidity is lower in patients with talc poudrage. Statistically significant differences were not observed in recurrence, persistent air leaks, atelectasis and haemothorax.

Primary monophasic synovial sarcoma of the pleura: diagnosis and treatment.

Synovial sarcomas are uncommon soft tissue malignancies that usually affect the extremities in the vicinity of large joints. The recognition of this tumor in an unexpected site, such as the pleura, is often difficult and the monophasic variant of synovial sarcoma is often mistaken for some other spindle cell tumor. In this report, we describe a very rare case of primary monophasic synovial sarcoma of the pleura treated with radical surgery.

First rib resection using videothorascopy for the treatment of thoracic outlet syndrome.

OBJECTIVE: Thoracic outlet syndrome is a condition caused by compression of the subclavian artery, subclavian vein and/or the brachial plexus. Scalene muscle section and first rib removal is the most effective treatment. The objective of this article is to demonstrate first rib resection using videothoracoscopy. TECHNIQUE: We describe first rib removal by videothoracoscopy using three 12 mm entrance ports (although one is widened to 3 cm to introduce periosteotomy cutters and rib shears). We have performed this operation on three cases of thoracic outlet syndrome with very good results. CONCLUSIONS: Removal of the first rib by videothoracoscopy is a viable and very aesthetic technique with a low morbidity. It is a very good option for the majority of patients affected by this syndrome, particularly in obese patients or those with Pager-Schroetter syndrome.

Giant solitary fibrous tumor of the pleura.

Fibrous tumors of the pleura are rare, accounting for <5% of all pleural neoplasms. Although over 80% of pleural fibrous tumors have a benign course, local recurrence postsurgery and occasional malignant transformation have been reported; complete excision of the tumor together with postsurgery follow-up of all patients is therefore recommended. We report on a solitary fibrous tumor of the pleura measuring 30 cm and weighing 3560 g.