Medical Thoracoscopy Implementation after a European Respiratory Society Course Held from 2003 to 2016: A Survey.

BACKGROUND: Medical thoracoscopy (MT) is an important procedure in the management of patients with pleural diseases. OBJECTIVES: We designed a survey to explore whether the participants of our courses implement MT at their hospital after attending the course as no real-life data exist. METHODS: We distributed by e-mail a questionnaire to the participants of the courses. The questionnaire included general information about the participants, the precourse experience on MT, the postcourse implementation of the technique, and the reasons for failure. RESULTS: Responses were obtained from 104 of 324 (32.3%) identified emails. Responders were males (76%), seniors (59.7%), respiratory physicians (91.3%), working in a public/university hospital (78.8%), and mostly beginners (65.3%) from 41 countries. Following the course, 58.6% of responders either created or modified a MT program in their workplace. The reasons for not performing MT before the course were as follows: patients' referral to a thoracic surgeon, not enough training, lack of funding, department understaffed, and refusal by the hospital/department. Overall, these reasons were significantly decreased (p = 0.002) after the course. CONCLUSIONS: Real-life data of our survey suggest that more than half of the responders have implemented the technique or modified their practice according to the skills they got from the course.

Diagnostic yield of medical thoracoscopy in exudative pleural effusions in a region with high tuberculosis burden.

INTRODUCTION: Pleural effusion is frequently encountered in respiratory medicine. However, despite thorough assessment including closed pleural biopsy, the cause of around 20% of pleural effusions remains undetermined. Medical thoracoscopy (MT) is the investigation of choice in these circumstances especially if malignancy is suspected. The aim of this study is to evaluate the diagnostic yield of MT in exudative pleural effusions in a single center from East Malaysia. METHODS: Retrospective chart review of all adult patients who underwent MT for undiagnosed exudative pleural effusion in a 24-month duration. RESULTS: Our cohort comprised of 209 patients with a median age of 61 years old (IQR 48.5-69.5). There were 92 (44%) patients with malignant pleural effusion (MPE) and 117 (56%) benign effusions; which included 85 tuberculous pleural effusion (TBE) and 32 cases of non-tuberculous exudative pleural effusion. Conclusive pathological diagnosis was made in 79.4% of the cases. For diagnosis of MPE, MT had a sensitivity of 89.1% (95% CI 80.4-94.3), specificity of 100% (95% CI 96.0-100.0), and positive predictive value (PPV) of 100% (95% CI 94.4-100) and negative predictive value (NPV) of 92.1% (95% CI 85.6-95.9). For TBE, MT had a sensitivity of 90.5% (95% CI 81.8-95.6), specificity of 100% (95% CI 96.3- 100.0) PPV of 100% (95% CI 94.1-100) and NPV of 93.9% (95% CI 88.0-97.2). Overall complication rate was 3.3%. CONCLUSIONS: MT showed excellent sensitivity and specificity in the diagnosis of exudative pleural effusion in this region. It reduces empirical therapy by providing histological evidence of disease when initial non-invasive investigations were inconclusive.

Defining Benchmarks for Transthoracic Esophagectomy: A Multicenter Analysis of Total Minimally Invasive Esophagectomy in Low Risk Patients.

OBJECTIVE: To define "best possible" outcomes in total minimally invasive transthoracic esophagectomy (ttMIE). BACKGROUND: TtMIE, performed by experts in patients with low comorbidity, may serve as a benchmark procedure for esophagectomy. PATIENTS AND METHODS: From a cohort of 1057 ttMIE, performed over a 5-year period in 13 high-volume centers for esophageal surgery, we selected a study group of 334 patients (31.6%) that fulfilled criteria of low comorbidity (American Society of Anesthesiologists score ≤2, WHO/ECOG score ≤1, age ≤65 years, body mass index 19-29 kg/m). Endpoints included postoperative morbidity measured by the Clavien-Dindo classification and the comprehensive complication index. Benchmark values were defined as the 75th percentile of the median outcome parameters of the participating centers to represent best achievable results. RESULTS: Benchmark patients were predominantly male (82.9%) with a median age of 58 years (53-62). High intrathoracic (Ivor Lewis) and cervical esophagogastrostomy (McKeown) were performed in 188 (56.3%) and 146 (43.7%) patients, respectively. Median (IQR) ICU and hospital stay was 0 (0-2) and 12 (9-18) days, respectively. 56.0% of patients developed at least 1 complication, and 26.9% experienced major morbidity (≥grade III), mostly related to pulmonary complications (25.7%), anastomotic leakage (15.9%), and cardiac events (13.5%). Benchmark values at 30 days after hospital discharge were ≤55.7% and ≤30.8% for overall and major complications, ≤18.0% for readmission, ≤3.1% for positive resection margins, and ≥23 for lymph node yield. Benchmarks at 30 and 90 days were ≤1.0% and ≤4.6% for mortality, and ≤40.8 and ≤42.8 for the comprehensive complication index, respectively. CONCLUSION: This outcome analysis of patients with low comorbidity undergoing ttMIE may serve as a reference to evaluate surgical performance in major esophageal resection.

Pleural procedures and patient safety: a national BTS audit of practice.

The BTS pleural procedures audit collected data over a 2-month period in June and July 2011. In contrast with the 2010 audit, which focussed simply on chest drain insertions, data on all pleural aspirations and local anaesthetic thoracoscopy (LAT) was also collected. Ninety hospitals submitted data, covering a patient population of 33 million. Twenty-one per cent of centres ran a specialist pleural disease clinic, 71% had a nominated chest drain safety lead, and 20% had thoracic surgery on site. Additionally, one-third of centres had a physician-led LAT service.

Quantitative pediatric surgical skill assessment using a rapid-prototyped chest model.

INTRODUCTION: Though minimally invasive pediatric surgery has become more widespread, pediatric-specific surgical skills have not been quantitatively assessed. MATERIAL AND METHODS: As a first step toward the quantification of pediatric-specific surgical skills, a pediatric chest model comprising a three-dimensional rapid-prototyped pediatric ribcage with accurate anatomical dimensions, a suturing skin model with force-sensing capability, and forceps with motion-tracking sensors were developed. A skill assessment experiment was conducted by recruiting 16 inexperienced pediatric surgeons and 14 experienced pediatric surgeons to perform an endoscopic intracorporeal suturing and knot-tying task in both the pediatric chest model setup and the conventional box trainer setup. RESULTS: The instrument motion measurement was successful in only 20 surgeons due to sensor failure. The task completion time, total path length of instruments, and applied force were compared between the inexperienced and experienced surgeons as well as between the box trainer and chest model setups. The experienced surgeons demonstrated better performance in all parameters for both setups, and the pediatric chest model was more challenging due to the pediatric features replicated by the model. CONCLUSION: The pediatric chest model was valid for pediatric skill assessment, and further analysis of the collected data will be conducted to further investigate pediatric-specific skills.

Flex-rigid pleuroscopy under local anesthesia in patients with dry pleural dissemination on radiography.

OBJECTIVE: Medical thoracoscopy using a flex-rigid pleuroscope under local anesthesia is a recent diagnostic procedure for malignant pleural disease. Although most previous studies have reported its usefulness, especially in wet pleural dissemination, the feasibility of flex-rigid pleuroscopy in patients with dry pleural dissemination is not well established.We assessed the diagnostic performance of flex-rigid pleuroscopy under local anesthesia in patients suspected of dry pleural dissemination on radiography. METHODS: The pleuroscopic parameters of all patients (n = 56) who underwent flex-rigid pleuroscopy at the National Cancer Center Hospital from October 2011 to September 2013 were retrospectively reviewed. Those with computed tomography findings of asymmetric pleural thickening or pleural nodules without pleural effusion (dry group, n = 16) were compared with the remaining patients with pleural effusion (wet group). RESULTS: The dry group consisted of eight men and eight women, with a median age of 61 years (range, 48-79 years). The definitive diagnoses were adenocarcinoma (n = 10), mesothelioma (n = 2) and chronic inflammation (n = 3). The diagnostic accuracy was 93.8% (15/16). Only two minor complications were observed: mild chest pain (n = 1) and transient hypoxia (n = 1). No major complications such as pneumothorax were observed. The mean duration of post-operative chest tube drainage in the dry group was 2.31 ± 2.26 days. Complications, operation duration and diagnostic accuracy did not statistically differ between the two groups. CONCLUSIONS: Flex-rigid pleuroscopy under local anesthesia can be a well-tolerated diagnostic procedure for radiographic dry pleural dissemination with respect to diagnostic yield and complications.

Assistant-based standardization of prone position thoracoscopic esophagectomy.

Thoracoscopic esophagectomy in the prone position (TEPP) might enable solo-surgery in cases requiring resection of the esophagus and the surrounding lymph nodes due to the associated advantages of good exposure of the surgical field and ergonomic considerations for the surgeon. However, no one approach can be for all patients requiring extensive lymphadenectomy. We recently developed an assistant-based procedure to standardize exposure of the surgical field. Patients were divided into 1 of 2 groups:a pre-standardization group (n=37) and a post-standardization group (n=28). The thoracoscopic operative time was significantly shorter (p=0.0037) in the post-standardization group (n=28; 267 ± 31 min) than in the pre-standardization group (n=37;301 ± 53 min). Further, learning curve analysis using the moving average method showed stabilization of the thoracoscopic operative time after the standardization. No significant differences were found in the number of mediastinal lymph nodes dissected or intraoperative blood loss between the 2 groups. There were also no significant differences in the complication rate. Assistant-based surgery and standardization of the procedure resulted in a well-exposed and safe surgical field. TEPP decreased the operative time, even in patients requiring extensive lymphadenectomy.

[Optimization of surgical strategy in trauma of the chest: correlation of thoracoscopy and thoracotomy].

The authors analyzed an experience with treatment of 4372 patients. Videothoracoscopy allowed the number of usual drainages of the pleural cavity to be reduced in closed trauma from 16.3% to 2.3%, in wounds--from 3.9% to 0.4%. Persistent hemo- and airstasis were obtained by coagulation of the vessels of the thoracic wall and lung, suturing lung wounds. The coagulated hemothorax was removed, diaphragm wounds were sutured, the pericardium wounds were revised, the character of intrathoracic lesions was reliably determined in 98% of cases. Conversion into thoracotomy was fulfilled in 91 (5.5%) patients. Thoracotomy was fulfilled in 344 (8%) patients with indications to operative interventions and severe condition and unstable hemodynamics. The number of thoracotomies and lethality in patients with penetrating wounds of the chest became 1.5-2 times less, was not considerably changed in closed traumas.

Use of competency-based metrics to determine effectiveness of a postgraduate thoracoscopy course.

BACKGROUND: Despite the paradigm shift from process to competency-based education, no study has explored how competency-based metrics might be used to assess short-term effectiveness of thoracoscopy-related postgraduate medical education. OBJECTIVES: To assess the use of a single-group, pre-/post-test model comprised of multiple-choice questions (MCQ) and psychomotor skill measures to ascertain the effectiveness of a postgraduate thoracoscopy program. METHODS: A 37-item MCQ test of cognitive knowledge was administered to 17 chest physicians before and after a 2-day continued medical education-approved program. Pre- and post-course technical skills were assessed using rigid videothoracoscopy simulation stations. Competency-based metrics (mean relative gain, mean absolute gain, and class-average normalized gain ) were calculated. A >30% was used to determine curricular effectiveness. RESULTS: Mean cognitive knowledge score improved significantly from 20.9 to 28.7 (7.8 ± 1.3 points, p < 0.001), representing a relative gain of 37% and an absolute gain of 21%. Mean technical skill score improved significantly from 5.20 to 7.82 (2.62 ± 0.33 points, p < 0.001), representing a relative gain of 50% and an absolute gain of 33%. Non-parametric testing confirmed t test results (p < 0.001). Class-average normalized gains were 48 and 92%, respectively. CONCLUSION: Competency-based metrics, including class-average normalized gain, can be used to assess course effectiveness and to determine if a program meets predesignated objectives of knowledge acquisition and psychomotor technical skill.

Is the Laparotomy Here to Stay? A Review of the Disadvantages of Laparoscopy.

Minimally invasive procedures have seen increasing utilization in the pediatric patient population since the 1990s. Most thoracic and abdominal operations in pediatric surgery can be performed in a minimally invasive manner including those performed in neonates and infants. Thoracoscopic or laparoscopic operations can reduce hospital length of stay, minimize postoperative pain, and lead to more aesthetic results. However, it is important to be aware of the inherent risks, limitations, and adverse effects associated with these thoracoscopic and laparoscopic techniques, particularly in special populations. In this article, we will review the risks and limitations of laparoscopy in pediatric patients such as cost, operative time, reduced effectiveness, air embolism, hypercarbia, hypothermia, and access-related injuries.

Culture of safety and error traps in pediatric thoracoscopy.

Growing adoption of thoracoscopy by pediatric surgeons has resulted in increasingly complex operations being performed. Although common complications of these procedures have decreased with experience, surgeons are still at risk to fall into error traps where routine practice in uncommon situations results in unanticipated complications. A background culture of safety that rewards multidisciplinary communication, teamwork, openness and standardization of care can assist surgeons to recognize, address and report error traps when they arise. This article serves to encourage a culture of safety and raise awareness of error traps in pediatric thoracoscopy to minimize potential harm and improve quality of care.

Error traps and culture of safety in esophageal atresia repair.

Esophageal atresia (EA) repair has always been a source of immense professional gratification for the pediatric surgeon. In many ways, this anomaly defines the entire profession. Due to its rarity, there is an increased risk of inadvertent events occurring during correction. This article describes some of the error traps that may occur in attempting esophageal reconstruction and how they may be avoided.

Is there any role for thoracoscopy in the diagnosis of benign pleural effusions.

Thoracoscopy in the endoscopy suite, has a high diagnostic yield of undiagnosed pleural effusions with minimal and mild complications. Whereas relatively minimal invasive techniques, such as thoracentesis, image-guided pleural biopsy or blind pleural biopsy, can yield sufficient cell or tissue material to establish the diagnosis of the underlying condition, more definite invasive diagnostic and therapeutic procedure, such as thoracoscopy, may be required for accurate sampling and diagnosis, and further provide real-time treatment options in same procedure. If thoracoscopy is considered the gold standard for the diagnosis is a fact in case. The current review aims to provide informations on thoracoscopy indications in benign pleural diseases according to up to date publications.

Video-assisted thoracoscopic surgery compared with thoracotomy: early and late follow-up of radiographical and functional outcome.

BACKGROUND CONTEXT: Video-assisted thoracoscopic surgery (VATS) is a new technique that allows for access to anterior spinal pathology using a minimally invasive approach. Proponents of this procedure argue that anterior thoracic spine surgery can be performed with the same accuracy and completeness as is possible by the conventional open approach but through much smaller skin and muscle incisions. Advantages of VATS include decreased blood loss, shorter hospital stay, and improved cosmesis. PURPOSE: To detect if VATS is equally as effective as open thoracotomy, both combined with instrumented posterior spinal fusion, with respect to fusion rate, percent curve correction, and functional outcome. STUDY DESIGN: Retrospective case control. PATIENT SAMPLE: Seventeen patients underwent VATS/instrumented posterior spinal fusion for thoracic curvatures exceeding 50 degrees . A control cohort of patients that were age matched, sex matched, and curve magnitude matched underwent open thoracotomy/instrumented posterior spinal fusion. OUTCOME MEASURES: Percentage of curve correction, fusion rate, intraoperative and postoperative clinical parameters, and functional outcome scores. METHODS: Preoperative and postoperative radiographs were analyzed to calculate the percentage of major curve correction in the coronal and sagittal planes as well as the rate of fusion. In addition, operative reports and medical records were analyzed for the following outcomes: estimated operative blood loss, length of surgery, chest tube output, length of hospitalization, and complications. Average follow-up time was 26 months in the VATS group and 27 months in the thoracotomy group. Finally, functional outcome was assessed using the Scoliosis Research Society (SRS-22) and Oswestry Disability Index (ODI) scoring system. RESULTS: The VATS group (mean age, 30) averaged 5.4 anterior levels and 11 posterior levels fused. The thoracotomy group (mean age, 32) averaged 5.8 anterior levels and 12 posterior levels fused. Estimated blood loss was nearly identical for the posterior procedures in both groups, whereas the anterior blood loss was significantly higher in the thoracotomy group as compared with the VATS group (541 cc vs. 288 cc). Operative time did not differ significantly between the two cohorts. Percent curve correction immediately postoperative (52% correction VATS; 51% correction thoracotomy) as well as at the 2-year follow-up (50% VATS and 54% thoracotomy) was nearly identical. There was no difference in postoperative ODI (p=.6) or SRS scores (p=.5) between groups. Complications were frequent but not significantly different between the two groups (p=.3). CONCLUSION: VATS is equally effective as thoracotomy with respect to fusion rate, major curve correction, and functional outcome scores. Although a decrease in operative blood loss was seen in the VATS patients, this was not clinically significant.

A propensity score analysis for comparison of T-3b and VATET in myasthenia gravis.

OBJECTIVE: We performed propensity score (PS) models to compare the outcome of patients with myasthenia gravis (MG) submitted to 2 different surgical approaches: extended transsternal (T-3b) or thoracoscopic extended thymectomy (VATET). METHODS: Patients' clinical data were retrieved from the MG database of the C. Besta Neurologic Institute Foundation. In the PS analysis, a matching ratio of 1:1 of the main clinical variables was obtained for the 2 groups of patients and treatment effect was estimated by comparing their outcome. RESULTS: A total of 210 patients met the inclusion criteria, by having a complete set of clinical data, and were included in the PS model; a matched dataset of 122 participants (61 per group) showed an adequate balance of all the covariates. Our analysis demonstrated that 68.9% of patients who had thymectomy by the VATET technique reached the pharmacologic remission/remission status at 2 years from thymectomy compared to 34.4% of those operated on by the T-3b technique (p < 0.001), had a lower INCB-MG score (p < 0.001), and had less muscle fatigability (p = 0.004). Similar results were found considering only nonthymomatous patients with MG. Results were also confirmed by paired statistical tests. CONCLUSIONS: Our PS matching analysis showed that VATET is a reliable and effective surgical approach alternative to T-3b in patients with MG who are candidates for thymectomy. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that for patients with MG, VATET is more effective than T-3b thymectomy.

Preliminary Study of Video-Based Pediatric Endoscopic Surgical Skill Assessment Using a Neonatal Esophageal Atresia/Tracheoesophageal Fistula Model.

PURPOSE: Thoracoscopic esophageal atresia/tracheoesophageal fistula (EA/TEF) repair in neonates is technically difficult because of the small working space and fragility of tissues. This study aimed to show the construct validity of the neonatal EA/TEF simulator by video-based assessment of endoscopic suturing skill. MATERIALS AND METHODS: A rapid-prototyped neonatal chest model with an artificial esophagus model similar to the actual neonatal esophagus was developed. Forty pediatric surgeons performed an endoscopic intracorporeal suturing task and a knot-tying task using the model, and a questionnaire survey was administered. Each task was video recorded and assessed using two skill assessment methods (the 29-point checklist method and the error assessment sheet method). The task completion time and the number of manipulations were measured. RESULTS: With regard to experience in performing thoracoscopic TEF repair, the experienced surgeons (ESs, ≥3 EA/TEF repair experiences, n = 6) were significantly superior to the inexperienced surgeons (ISs, <3 experiences, n = 34) in all metrics. Upon comparison by the pediatric Endoscopic Surgical Skill Qualification (ESSQ) status, there were no significant differences in all metrics between the ESSQ-qualified (n = 15) and nonqualified (n = 25) surgeons. The qualified ESs (n = 6) were significantly superior to the qualified ISs (n = 9) in all metrics. CONCLUSION: Video-based endoscopic surgical skill assessment using the neonatal EA/TEF simulator could differentiate ESs from ISs. The construct validity of the simulator was demonstrated, and the simulator would be useful especially for practicing thoracoscopic EA/TEF procedures.

The use and development of medical thoracoscopy in the United Kingdom over the past 5 years.

INTRODUCTION: Medical thoracoscopy is a safe, reliable and therapeutic procedure used in the management of pleural disease. For reasons that are unclear it is under utilised in the United Kingdom (UK) when compared to the rest of Europe. We have studied its development and use over the past 5 years. METHOD: We have performed national postal surveys in 1999 and 2004 to assess the provision of medical thoracoscopy, its indications for use, local practices as well as, training and audit issues. RESULTS: 11 centres in 1999 and 17 centres in 2004 perform medical thoracoscopy, there were more district general hospitals providing this service than teaching hospitals. Twenty-seven centres in 1999 and 54 centres in 2004 stated plans to begin providing a service. Centres were performing between 10 and 30 thoracoscopies per year. There were differences between centres in local practices and training received. The majority of currently performing centres offered training and were interested in national audit. DISCUSSION: This study has shown there are still only a small proportion of UK respiratory centres performing medical thoracoscopy. There is a growing interest in the procedure, however, issues regarding standardisation of care across the UK, on going competency and training have been highlighted. A British Thoracic Society (BTS) working group has been set up to address these.

Different outcomes between two sides after bilateral sympathetic ganglion interruption for hyperhidrosis.

BACKGROUND: Although the determination of the correct ganglion under direct vision through thoracoscopy by an experienced surgeon is almost unerring, there is still a 4.3% rate of clipping at the unintended level. METHODS: Through the review of the most recent patients (N = 117) with various sympathetic disorders undergoing thoracoscopic sympathetic interruption over different ganglions by clipping, we found that 5 cases were clipped at the unplanned level. The immediate manifestations were the different outcomes between both sides of the face, trunk, and extremities. The postoperative chest radiographs demonstrated the error. RESULTS: All patients received a second operation in which the unintended clip was removed, and a new one was applied to the appropriate ganglion. The results were satisfactory. CONCLUSIONS: Although the authors in this study have the experience of more than 1000 cases of hyperhidrosis, such an error is still inevitable. Luckily, by using the clipping method, the error is detectable and amendable.

[Current status and evaluation of thoracoscopic esophagectomy for thoracic esophageal cancer].

The current status and evaluation of esophagectomy by thoracoscopic approach for thoracic esophageal cancer are described. The esophagectomy by thoracoscopic approach for thoracic esophageal cancer have been reported in some Instituts since 1996 in Japan. In 10 years, series consisting a large number of esophageal cancer patients have been treated with esophagectomy by thoracoscopic approach and evaluated about operative safety, curabirity and postoperative morbidity. Now, the establishment of training system is the most important subject to achieve the standardization of thoracoscopic esophagectomy for thoracic esophageal caner.