A simple size-tailored algorithm for the removal of chest drain following minimally invasive lobectomy: a prospective randomized study.

BACKGROUND: The pleural space can resorb 0.11-0.36 ml/kg of body weight/hour (h) per hemithorax. There are only a limited number of studies on thresholds for chest drain removal (CDR) and all are based on arbitrary amounts, for example, 300 ml/day. We studied an individualized size-based threshold for CDR-specifically 5 ml/kg, a simple, easily applicable measure. METHODS: This is a single-center prospective randomized trial enrolling 80 patients undergoing VATS lobectomy. There were two groups: an experimental (E) group, in which once the daily output went down to 5 ml/kg the chest drain was removed and a control (C) group, with chest drain removal as per our current practice of less than 250 ml/day. RESULTS: The groups did not differ in pre- and peri- and postoperative characteristics, except for chest drain duration (mean, SD 2.02 ± 0.97 vs. 3.25 ± 1.39 days, p < 0.001) and length of hospital stay (median, IQR 4.5; 3 vs. 6; 2.75 days, p = 0.008) in favor of E group. The re-intervention rate was the same in both groups (once in each group). CONCLUSION: The new threshold for chest drain removal following thoracoscopic lobectomy of 5 ml/kg/d leads to both shorter chest drainage and hospital stay without apparent increase in morbidity. (Clinical registration number: DRKS00014252).

[Initial Experience with Uniportal Video-Assisted Thoracoscopic Surgery for Anatomical Lung Resections: A Propensity Score Study and an Observational Assessment of the Learning Curve]. / Uniportale videoassistiert-thorakoskopische anatomische Lungenresektionen: erste Erfahrungen und ein Vergleich mit dem multiportalen Zugang.

INTRODUCTION: Uniportal video-assisted thoracoscopic surgery (UVATS) for anatomical lung resections has gained popularity of late. This study aimed to elucidate the impediments to implementing the uniportal access method into the daily routine of VATS lung resections. To this end, we reviewed our initial experience and evaluated our progress. METHODS: From January to May 2016, 24 consecutive UVATS anatomical lung resections (UVATS group) were performed by a single surgeon without any previous experience in UVATS surgery. These cases were matched in a one-to-one fashion with a cohort of 102 patients who had undergone "classical" VATS anatomical lung resections (VATS group) in the past 2’years performed by the same surgeon, using the nearest estimated propensity score. Based on an initial analysis, the UVATS group was further divided into two subgroups, UVATS1 and UVATS2, consisting of the first and last 12 cases. RESULTS: No UVATS patient required conversion to thoracotomy or needed an additional port. The VATS group had a shorter mean operation time if compared with the UVATS1 subgroup (MVATS = 152, MUVATS1 = 191; p = 0.019), but not if compared with the UVATS2 subgroup (MVATS = 152, MUVATS2 = 152; p = 1). There was no difference between the groups in the number of lymph node stations sampled (MVATS = 7, MUVATS1 = 7, MUVATS2 = 7; p = 0.92), the average number of dissected lymph nodes (MVATS = 19, MUVATS1 = 15, MUVATS2 = 18; p = 0.659), and the number and type of postoperative complications. As demonstrated on an audio-analogue pain scale (AAS), the UVATS groups needed significantly less pain medication until discharge (p < 0.001). CONCLUSION: The adoption of uniportal VATS for anatomical lung resections can be accomplished without any impact on operative or clinical success, if performed by a surgeon already experienced in "classical" VATS. In our experience, there was no need for additional courses, proctored cases or modification of surgical instruments, although all options mentioned above may facilitate adoption.

Prognostic factors for long-term survival following complete resection by lobectomy in stage I non-small cell lung cancer.

BACKGROUND: The aim of this study was to evaluate predictors for long-term overall survival (OS) in patients with stage I non-small cell lung cancer (NSCLC). METHODS: All patients undergoing complete resection by lobectomy for stage I NSCLC between October 2012 and December 2015 at a single center were included. Univariable and multivariable Cox regression analyses were performed to identify prognostic factors. RESULTS: A total of 92 patients were included. Univariable and multivariable Cox regression analyses revealed preoperative neutrophil to lymphocyte ratio (NLR, p = 0.005), preoperative diffusion capacity of the lungs for carbon monoxide (DLCO, p = 0.010) and forced expiratory volume in 1 second (FEV1, p = 0.041) as well as male gender (p = 0.026) as independent prognostic factors for OS. Combining the calculated cutoff values for FEV1 (<73.0%) and NLR (>3.49) into one parameter resulted in a highly significant difference in survival times when stratified by this variable. CONCLUSIONS: Recently, much emphasis has been put on the prognostic importance of blood biomarkers in NSCLC. In our study, NLR was an independent factor for OS, as were baseline characteristics such as DLCO, FEV1, and gender. Further studies on the association of biomarkers for systemic inflammation and lung function parameters with respect to patient survival are warranted.

New method in treatment of post-operative air leakage with fresh frozen plasma.

BACKGROUND: No consensus regarding the best post-operative treatment option for air leak has been established. In this study, we evaluate the use of intra-pleural fresh frozen plasma (FFP) as a promising treatment method. METHODS: Treatment for a sustained air leak (3 days) was warranted in approximately 12% of the lung surgeries at our institution. Fifty-two patients were treated with FFP by application of 250 mL daily. The patients were divided into two cohorts: cohort 1 consisted of 35 patients undergoing anatomical lung resections and cohort 2 consisted of 17 patients after miscellaneous types of lung surgery. Successfulness of the procedure as well as the potential influential factors was evaluated statistically and validated by a bootstrapping. Area under receiver operating characteristic curve was used to establish a cut-off value of the predictor. RESULTS: In the first cohort, air leakage was successfully treated in 28 (80%), while in seven (20%) it was still present after third treatment with FFP. The success rate in cohort 2 was 76.5%. The only covariate which appeared to remain significant in both cohorts was flow as displayed on the digital suction device prior to application of FFP. Flow ≤375 mL/min was indicative of successful aerostasis. CONCLUSION: Intra-pleural instillation of FFP seems to be a feasible method for the treatment of post-operative air leakage. Although the optimum strategy regarding its application as well as its limitations is yet to be established, an absence of complications or undesirable events makes this (off label) method a safe and promising alternative to existing options.

Cumulative Sum Analysis of the Learning Curve for Uniportal Video-Assisted Thoracoscopic Lobectomy and Lymphadenectomy.

Purpose: The study was performed to analyze the learning curve of performing uniportal video-assisted thoracoscopic surgery (uVATS) for lobectomy and lymphadenectomy, and to evaluate the possible disadvantages in outcomes during the course of learning. Materials and Methods: This is a prospective study of 52 consecutive patients undergoing uVATS lobectomy by a single surgeon from January 2016 to December 2017. Operation time (OPT) and the number of harvested lymph nodes (LNs) were evaluated by means of cumulative sum control chart by assessing efficiency (refinement in procedure to reach decreasing OPT and increasing number of harvested LNs) and mastery (absence of outliers). Failure rate, blood loss, and complications were retrospectively compared with the last 52 patients undergoing "classical" VATS lobectomy in the period before this study from January 2014 to December 2015. Results: Efficiency in OPT for uVATS was reached after 27 cases and mastery after 39 procedures (M1st = 172 ± 39 minutes; M2nd = 138 ± 34 minutes; p1-2 = 0.022; M3rd = 120 ± 25 minutes; p1-3 = 0.00; p2-3 = 0.65). Efficacy in the number of harvested LNs was reached after 26 cases and mastery after the 42nd procedure (MED1st = 17, IQR 12-19; M2nd = 21, IQR 16.25-29.75; p1-2 = 0.018; M3rd = 18, IQR 16-22; p1-3 = 0.004; p2-3 = 0.8). There were no significant differences in the failure rate (uVATS = 7.7%, VATS = 5.8%; P = .7), blood loss (MEDuVATS = 250 mL, IQR 200-387.5; MEDVATS = 225 mL, IQR 200-300; P = .77), and complications between the groups (uVATS = 13; 25%; VATS = 11; 21.2%; P = .41). Finally no significant differences could be found in OPT (uVATS = 151.36 ± 41.55; VATS = 156.69 ± 40.08; P = .52) or LNs (uVATS = 18, IQR 16-22; VATS = 19, IQR 14.25-20; P = .71) between the groups. Conclusions: Assuming a surgeon is skilled in "classic" VATS lung resections, achieving efficiency and mastery in uVATS is possible after sufficient experience even without dedicated education in this procedure, without measurable disadvantages throughout the course of learning. This study created a benchmark for already experienced VATS surgeons who are novices in uVATS, elucidating the number of operations required to reach both efficiency and mastery.

Aspirin for patients undergoing major lung resections: hazardous or harmless?†.

OBJECTIVES: Acetylsalicylic acid (ASA, aspirin) is a medication widely used for primary and secondary prevention of cardiovascular diseases, which are the leading cause of morbidity and mortality worldwide. Whether aspirin should be continued or paused in the perioperative period remains controversial, especially in thoracic surgical settings. METHODS: A single-centred retrospective study comprised 486 patients. Of these, 329 patients did not use aspirin (group ASA-0) and 157 did (group ASA-1) during the perioperative period after anatomical lung resection at our hospital from January 2013 to December 2016. Major outcome measures were the amount of blood loss during the operation and during the first 5 days postoperatively (per Mercuriali's formula), as well as the amount and proportion of the blood transfusion (packed red cells) received. The need for reoperation due to a postoperative haemothorax and/or bleeding was recorded. The groups were also compared according to their rates of morbidity and mortality. Inferential statistical methods with bootstrap analysis using 1000 samples and the Mersenne Twister, a random number generator, were used. RESULTS: There were no significant differences between the 2 groups in intraoperative bleeding [ASA-0M = 418.69 ml, standard deviation (SD) ± 364.87; ASA-1M = 399.8 ml, SD ± 323.84; P = 0.58] or in total blood loss according to Mercuriali's formula (ASA-0M = 1111.62 ml, SD ± 816.69; ASA-1M = 1115.08 ml, SD ± 682.12; P = 0.95). A total of 104 patients received transfusions up to postoperative day 5: 71 patients in the ASA-0 group received 151 blood transfusions, whereas 33 patients in the ASA-1 group received 65 blood transfusions (P = 0.66). The indication for reoperation due to bleeding (ASA-1 = 3, ASA-0 = 4; P = 0.69) was similar between the groups. There was a trend towards higher rates of postoperative complications in the ASA-1 group (risk ratio (RR) = 1.28; P = 0.055); neither cardiovascular complications nor deaths were more frequent in either of the 2 groups (P = 0.73). CONCLUSIONS: Patients taking aspirin therapy and undergoing anatomical lung resection seem not to be at any disadvantage regarding bleeding. However, a trend towards a higher rate of postoperative complications indicates a basically increased risk for operations due to comorbidities in these patients.

Uniportal video-assisted thoracoscopic surgery for anatomical fissureless anterior segment resection (S3) of the right upper lobe followed by lymph node dissection.

Uniportal video-assisted thoracoscopic (UVATS) resections seem to offer real benefits over conventional surgery in terms of postoperative pain and better cosmetic results.  The procedure described in this tutorial, an anterior segment resection of the right upper lobe, is rarely performed, and fissureless resection of this segment by means of UVATS has, at time of writing, never been described in the literature.  Our patient was a 79-year-old female, admitted to our clinic for treatment of a solitary metachronous metastatic tumor of a colon carcinoma, located in the anterior segment of the right upper lobe. A fissureless anatomical anterior segment resection of the right upper lobe was conducted, followed by the radical lymph node dissection.  The postoperative course was event free and the patient was discharged on the 4th postoperative day. Fissureless VATS operations have an advantage compared to conventional operations in terms of reduced risk of prolonged air leak. Moreover, these operations take no longer to perform than conventional surgery and have no notable disadvantages, apart from the potential for using more staples.

Uniportal video-assisted thoracoscopic resection of anterior segment of the left upper lobe.

Anatomical segment resections are often technically more demanding than lobectomies. Anterior segment of the left upper lobe (S3) is usually removed within the standard resection of the upper three segments.    Our patient in this case was a 56-year-old with a known oropharyngeal carcinoma, otherwise amenable to curative treatment, who was admitted to our clinic with  a 1-cm nodule in the anterior segment of the left upper lobe.  Distant metastases were excluded, and a decision was made to proceed with a uniportal video-assisted thoracoscopic segmentectomy and lymphadenectomy. The procedure was successfully conducted without any adverse effects and the patient's postoperative course was uneventful.  The tumor was diagnosed as a primary solid 1-cm adenocarcinoma and the final stage was pT1aN0M0.

Surgery for lung tumors in the elderly: A retrospective cohort study on the influence of advanced age (over 80 years) on the development of complications by using a multivariate risk model.

BACKGROUND: The prevalence of lung cancer and other tumors is increasing among the elderly people. The purpose of this study was to examine the influence of advanced age (80 + years) on the immediate perioperative outcome as well as to define potential risk factors that may lead to increasing morbidity and mortality after lung resections. METHODS: A retrospective cohort analysis of the data from an electronic database of 208 elderly patients (165 patients ≥70 years, 45 patients ≥80 years) undergoing pulmonary anatomical resection for lung tumors during January 2013-December 2016 was conducted. The patients were initially observed and then divided into two groups: septuagenarians and octogenarians. The risk of developing postoperative complications in association with the numerous observed factors, which appeared significant in univariate tests, was assessed using univariate and multivariate logistic regression analyses to construct a risk model that assesses the highest chance of developing complications. Readmission rate and mortality within 90 days were recorded. RESULTS: There were 140 men and 68 women with the mean age of 76 ±â€¯4 years. A total of 15 pneumonectomies (7.2%), 11 bilobectomies (5.3%), 27 segmentectomies (13%), and 155 lobectomies (74.5%) were performed through 84 thoracotomies (40.4%) and 124 video-assisted thoracoscopic surgery (VATS) procedures (59.6%). Ninety-one patients (44%) exhibited at least one of 113 postoperative complications. There were four deaths (1.9%). Readmission rate was 12%, and 90-day mortality was 5.3%. There was no difference in postoperative morbidity among the groups according to their age (RR = 0.95; p = 78). According to multivariate logistic regression, adjusted Charlson Comorbidity Index≥11, FEV1≤0.72, DLCO≤0.57, male gender, and nonsegmentectomies appeared to be strong predictors for the development of complications. CONCLUSIONS: In this cohort, age more than 80 years was not found to be significant for the development of complications, when compared to the septuagenarians. Female gender, better lung function (FEV1>72%, DLCO>57%), less comorbidities (ACCI<11), and segmentectomy type of lung resection were associated with improved outcomes.

Posterior uniportal video-assisted thoracoscopic surgery for resection of the apical segment of the right lower lobe followed by completion lobectomy.

Uniportal thoracoscopic resections offer less pain and better cosmetic results. They are usually performed through an antero-lateral incision. Posterior uniportal approach has not been described yet. A 65-year-old female was admitted to our clinic for the treatment of an adenocarcinoma, located in the apical segment of the right lower lobe. Owing to the ideal location and size, anatomical segment resection and radical lymphadenectomy was planned. Fissureless video-assisted thoracoscopic resection of the apical segment of the right lower lobe, using a uniportal posterior approach was performed, followed by mediastinal lymphadenectomy. However, resection margins showed microscopic presence of lepidic tumour on frozen section analysis, so we needed to proceed with a completion lower lobectomy. Postoperative course was event-free and the patient was discharged on the 4th postoperative day. The 1.8-cm large tumour was diagnosed to be primary lepidic (80%) and acinar (20%) adenocarcinoma and the final TNM was pT2aN0M0.

Posterior uniportal video-assisted thoracoscopic surgery for anatomical lung resections.

BACKGROUND: The acceptance of uniportal video-assisted thoracoscopic surgery (uVATS) for anatomical lung resections has been growing in recent years. This study presents the first case-series in the literature with posterior uVATS (puVATS) technique for specific anatomical lung resections. METHODS: The first 20 consecutive patients who underwent an anatomical lung resection by a single surgeon, by means of puVATS technique were evaluated in terms of pre-, peri- and post-operative results. A single incision of 3.5-4.5 cm was made posteriorly in the 6th intercostal space at the so-called 'triangle of auscultation' to perform a resection of either a posterior segment of an upper lobe or a superior segment of a lower lobe for both lungs. RESULTS: There were 5 posterior segmentectomies and 3 apical segmentectomies of the right upper lobe and 6 apical segmentectomies of the left lower lobe. Moreover, there were 6 lobectomies, all except for one as an extension of initially planned "posterior" segmentectomy. There were no intraoperative complications. Median tumor size (IQR) was 1.65 cm (1.1-2.57 cm), while median incision size (IQR) was 3.5 cm (3.5-3.87 cm). Median operative time (IQR) was 160 minutes (142-178 minutes). Median number of removed lymph nodes (IQR) was 19 [15-20]. Four patients had postoperative complications: three had bronchitis and one developed heart failure, all of which resolved before patients were discharged. Median length of hospital stay (IQR) was 6 days (5-8 days). CONCLUSIONS: puVATS approach for posterior lung segment resections, even for lobectomy if needed, seems to be feasible and safe. Exposure of the bronchovascular structures of the 'posterior segments' is better, and local and mediastinal lymphadenectomy seem to be easier with access directly in front of the incision and the lung, rather than behind it.

Fissure-last video-assisted thoracoscopic lobectomy for 'non-upper' lobes.

BACKGROUND: Surgical approach into the fissural parenchyma may be an important and modifiable factor for the prevention of air leak after anatomical lung resections. Fissureless fissure-last technique has been described as useful technique to reduce air leak, yet in video-assisted thoracoscopic surgery (VATS) data are limited and mostly on the upper lobes. The purpose of this study is to evaluate the safety and feasibility of fissureless fissure-last VATS 'non-upper' lobectomies and the impact of it on the immediate outcome, especially relating to air leak. METHODS: This study is a monocentric single-surgeon retrospective analysis on prospectively collected data. During 24 months, 46 patients underwent VATS 'non-upper' lobectomy or lower bilobectomy, with conventional (VATS-c) technique in 20 and fissureless fissure-last (VATS-f) technique in 26 patients. Results were evaluated according to preoperative, perioperative and postoperative parameters. RESULTS: There were no differences between VATS-c and VATS-f groups in any characteristics or peri- and postoperative variables, except the number of staplers, where it was significantly higher in VATS-c group (MVATS-c = 5.7; MVATS-f = 7.7; P = 0.001). Operation time did not differ between the groups, but showed gender-related difference, being longer in males (MVATS-c = 188; MVATS-f = 157; P = 0.04). Prevalence of air leak was 20%; prolonged air leak (PAL) (>5 days) being 11% and PAL (>7 days) 0%. Patients with air leak were older by tendency (MVATS-c = 74.9; MVATS-f = 66.5; P = 0.08), had more complications (P = 0.025; relative risk = 2.65) and stayed longer at hospital (MVATS-c = 10.8; MVATS-f = 7.7; P = 0.02). Postoperative complications were present in 24% of patients. CONCLUSION: VATS-f lobectomy is safe and feasible not only for 'upper' but also for 'non-upper' lobes. When applied to properly selected patients, it may reduce air leak and PAL and thus may potentially reduce the rate of complications.

Fissureless fissure-last video-assisted thoracoscopic lobectomy for all lung lobes: a better alternative to decrease the incidence of prolonged air leak?

OBJECTIVES: Prolonged air leak (PAL) after major lung resections is a common postoperative complication that leads to extended length of hospital stay (LOS) and increased hospital costs. Dissection of the lung tissue through the fissure may increase the incidence of PAL especially in the patients with incomplete fissures. The objective of this study was to evaluate the impact of the fissureless fissure-last technique in VATS lobectomy on immediate outcome, especially relating to air leak and LOS. METHODS: This is an observational analysis on prospectively collected data of a single thoracic surgery unit. A total of 54 consecutive patients underwent VATS lobectomy and mediastinal lymphadenectomy-in 24 patients conventional VATS lobectomy (Group 1), in 30 patients fissureless VATS lobectomy (Group 2) was performed. The two groups were compared according to preoperative, operative and postoperative parameters. RESULTS: No differences were found when comparing patient characteristics, operation time (M1 = 185 min; M2 = 176 min; P = 0.52) and number of staplers used (M1 = 6.2; M2 = 7.7; P = 0.088). The presence of air leak (P = 0.004; RR = 3.5), PAL (P = 0.003; RR = 10), in days with chest tube (M1 = 7.2; M2 = 4.2; P = 0.028) and LOS (M1 = 12.7; M2 = 8.9; P = 0.020) was significantly more frequent in patients that underwent conventional VATS lobectomy. Focusing on the air leak, significance was present in male gender (P = 0.034; RR = 2.41), higher ASA (M1 = 3.04; M2 = 2.67; P = 0.012), postoperative complications other than air leak (P = 0.001; RR = 5.78) and age between groups with and without air leak (M1 = 63.9; M2 = 74.1; P < 0.001). CONCLUSIONS: Fissureless fissure-last VATS lobectomy is a feasible and equivalent to conventional VATS lobectomy in terms of operation time, stapler use and complications. Fissureless fissure-last VATS lobectomy, however, appears to be a superior technique to conventional VATS lobectomy in terms of preventing PAL and reducing the LOS.

Postoperative chest tube management: snapshot of German diversity.

OBJECTIVES: The management of chest tubes is one of the most critical aspects in patient care in thoracic surgery, and no consensus exists regarding the ideal chest tube management strategy. METHODS: Chest tube management protocols and their effects on chest tube therapy were compared at four German specialist thoracic surgery units. Altogether, 79 patients were stratified for underlying disease and type of surgery. A digital chest drainage system was applied to objectify the presence of air leakages. RESULTS: In our analysis, the average length of drainage therapy was 4.9 ± 2.8 days. Different chest tube management protocols resulted in a significant degree of scatter between units (P = 0.0348). Higher arbitrary postoperative suction levels (4 kPa) resulted in earlier chest tube removal than lower suction levels (2 kPa) (4.2 ± 2.4 vs 5.4 ± 3.0 days, P = 0.06). Patient discharge following chest tube removal was delayed on average by 3.2 ± 2.9 days. This delay was not correlated with the previous duration of chest tube therapy (Spearman's ρ=-0.15, P = 0.25) in contrast to the total length of hospital stay (ρ = 0.59, P < 0.001).

Combined videothoracoscopic and videomediastinoscopic approach improves radicality of minimally invasive mediastinal lymphadenectomy for early stage lung carcinoma.

OBJECTIVES: To assess the feasibility and radicality of a combined thoracoscopic and mediastinoscopic approach to mediastinal lymphadenectomy compared to thoracoscopy only for minimally invasive management of early stage lung carcinoma. METHODS: Prospective observational study of patients undergoing anatomical thoracoscopic lung resection for lung carcinoma in our department in 2007. Mediastinal lymphadenectomy was performed either thoracoscopically (VATS group) or by a combination of video-assisted mediastinoscopic lymphadenectomy (VAMLA) and thoracoscopy (VAMLA+VATS group). Inclusion criteria for the study were: stage Ia on CT scan, no central tumor at bronchoscopy, and no contraindications against lobectomy or segmentectomy. RESULTS: Eighteen VAMLA+VATS and fourteen VATS patients were studied. For histology, pTNM stage, type of resection, semiquantitative assessment of the fissure and vascular dissection plane, conversions, blood loss, operation time, adverse events and drainage time, no differences between the two groups were observed. In the VATS group, there was a slight preponderance of women, and right-sided tumors. In the VAMLA+VATS group, both the number of dissected mediastinal lymph node stations (mean, 6.4 stations vs 3.6 stations) and the weight of the mediastinal specimen (median, 11.2 groups vs 5.5 groups), were significantly higher than in the VATS group (p<0.05). CONCLUSIONS: A combined approach by VATS and VAMLA improves radicality of minimally invasive mediastinal lymphadenectomy without increase in operation time, morbidity, and drainage time.