Uniportal thoracoscopic surgical management using a suture traction for primary pneumothorax.

BACKGROUND: We devised a new strategy using suture traction to facilitate the management of primary spontaneous pneumothorax during uniportal thoracoscopy. To test its validity, we compared the outcomes of our modified technique with those of conventional three-port thoracoscopy. METHODS: This retrospective study included all 43 consecutive patients with primary spontaneous pneumothorax undergoing thoracoscopy between January 2017 and December 2019. They were divided within two groups: uniportal thoracoscopy using suture traction (n = 21) and conventional 3-port thoracoscopy (n = 22). Postoperative pain, paresthesia, patient satisfaction, and surgical outcomes were compared to test the validity of our technique. RESULTS: There were no significant differences in operative time (47 ± 4.8 vs. 43 ± 7.9 min), number of staples used (2.5 ± 0.9 vs. 2.3 ± 0.6), postoperative drainage (235 ± 15 vs. 240 ± 19 mL), chest tube drainage time (3.2 ± 0.8 vs. 3.4 ± 1.8 days), and hospital stay (4.2 ± 1.2 vs. 4.3 ± 0.9 days). However, uniportal thoracoscopy was associated with less pain at 24 (p = 0.01), 48 (p = 0.02), and 72 h (p = 0.03) postoperatively, less paresthesia at 24 (p = 0.03), 48 (p = 0.02), and 72 h (p = 0.02) postoperatively, and greater patient satisfaction at 24 (p = 0.04), 48 (p = 0.02), and 72 h (p = 0.02) postoperatively. CONCLUSIONS: Our technique may facilitate the use of uniportal thoracoscopy for treatment of primary spontaneous pneumothorax, reducing neurological sequelae and improving patient satisfaction compared to the traditional three-port thoracoscopy.

Montgomery T-tube for management of tracheomalacia: Impact on voice-related quality of life.

INTRODUCTION: Tracheostomy is a common procedure for management of tracheomalacia. However, the limitation to speak related to tracheostomy cannula could affect the quality of life. OBJECTIVES: we reported a new minimally invasive procedure to replace tracheostomy cannula with Montgomery T-tube to improve the ability of speaking. METHODS: This is a single center study including all consecutive patients undergoing the replacement of standard tracheostomy cannula with T-tube for management of tracheomalacia. The end-points were to evaluate (a) the changes in Voice-related quality of Life (V-RQOL) before and after T-tube placement; and (b) the complications related to T-tube. RESULTS: Eleven patients were included in the study. T-tube was placed using flexible bronchoscopy and laryngeal mask airway. A suture was inserted through the proximal end of T-tube. Once the stent was introduced with a clamp into the trachea, a traction was applied on the suture to facilitate the alignment of the upper end of the stent. The comparison of V-RQOL values before and after T-tube insertion showed a significant improvement in social/emotional (39.2 ± 6.1 vs 66.8 ± 1.9; P = .0001); physical functioning (21 ± 5.7 vs 56.4 ± 5.3; P = 0.0001) and total V-RQOL scores (33.9 + 5.4 vs 61.3 + 6.1; P = 0.0001). No complications were seen during the insertion of the stent. In two patients, T-tube was obstructed by mucus that resolved with aspiration using flexible bronchoscopy (mean follow-up: 18 ± 10 months). CONCLUSIONS: Our technique is simple and safe, not needing specific skills and/or cumbersome devices. The replacement of tracheostomy cannula with T-tube seems to improve the quality of voice without adding major complications.

Is thymomectomy equivalent to complete thymectomy in non-myasthenic patients with early-stage thymoma?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed is whether thymomectomy can be equivalent to thymectomy for non-myasthenic early-stage thymoma in terms of recurrence and survival. Ten papers were chosen to answer the question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. All studies included in this analysis are retrospective; most of them are small and from single-institution experiences, and only 3 used propensity-matched analysis to minimize the patients' selection bias. The choice of performing thymectomy or thymomectomy was based on surgeons' preference rather than on a standardized surgical approach. Most papers found that thymectomy was equivalent to thymomectomy in terms of outcomes, but these results could be affected by the intergroup differences in terms of follow-up length, administration of induction or adjuvant therapy, histological subtypes distribution and tumour size. Conversely, the studies of the Japanese Association for Research on the Thymus and the Chinese Alliance for Research in Thymoma found a higher rate of local recurrence in the thymomectomy group than in the thymectomy group. The National Comprehensive Cancer Network, National Cancer Institute and International Thymic Malignancy Interest Group recommend complete thymectomy in non-myasthenic patients with early thymoma; therefore, the identified studies in this review are not strong enough to change this recommendation.

Complications related to endoscopic lung volume reduction for emphysema with endobronchial valves: results of a multicenter study.

BACKGROUND: Despite bronchoscopic lung volume reduction (BLVR) with valves is a minimally invasive treatment for emphysema, it can associate with some complications. We aimed at evaluating the rate and type of complications related to valve treatment and their impact on clinical outcomes. METHODS: It is a retrospective multicenter study including all consecutive patients with severe heterogeneous emphysema undergoing BLVR with endobronchial valve treatment and developed any complications related to this procedure. The type of complication, the time of onset, the treatment required and the out-come were evaluated. Response to treatment was assessed according to the minimal clinically important difference (MCID) as follows: an improvement of ≥15% in forced expiratory volume in one second (FEV1); of -8% in residual volume (RV); of ≥26 m in 6-minnute walking distance (6MWD); and of ≥4 points on the St. George's Respiratory Questionnaire (SGRQ). Target lobe volume reduction (TLVR) ≥350 mL was considered significant. RESULTS: One hundred and seven out of 423 (25.3%) treated patients had complications related to valve treatment including pneumothorax (17.3%); pneumonia (1.7%), chronic obstructive pulmonary disease (COPD) exacerbation (0.9%), respiratory failure (1.4%), valve migration (2.1%), and hemoptysis (1.9%). In all cases complications resolved with appropriate treatment including removal of valves in 21/107 cases (19.6%). Patients with TLVR ≥350 mL (n=64) vs. those <350 mL (n=43) had a statistically significant higher improvement in FEV1 (19.0%±3.9% vs. 3.0%±0.9%; P=0.0003); in RV (-10.0%±4.8% vs. -4.0%±2.9%; P=0.002); in 6MWD (33.0±19.0 vs. 12.0±6.3 metres; P=0.001); and in SGRQ (-15.0±2.9 vs. -8.0±3.5 points; P=0.01). Only patients with TLVR ≥350 mL met or exceeded the MCID cut-off criteria for FEV1 (19.0%±3.9%), RV (-10.0%±4.8%), 6MWT (33.0±19.0 metres), and SGQR (-15.0±2.9 points). Five patients (1.2%) died during follow-up for causes not related to valves treatment neither to any of the complications described. CONCLUSIONS: Valve treatment is a safe and reversible procedure. The presence of complications seems not to have a significant impact on clinical outcome in patients with lobar atelectasis. Due to poor clinical conditions and possible complications, BLVR should be performed in high volume centers with a multidisciplinary approach.