Three-Dimensional Holographic-Guided Robotic Lung Segmentectomy for Deep Pulmonary Nodules: Technique and Initial Results.

Background: Diagnosis and treatment of small and isolated lung nodules remain challenging issues. Purpose: The aim of this article is to report the technique of real-time navigation using holographic reconstruction technology combined with a robot assisted thoracic surgery (RATS) platform for lung resection in patients with small deep nodules.Research Design: The pre-surgery 3D planning was based on the chest CT scan. The reconstruction was uploaded to a head-mounted display for real-time navigation during mini invasive robot assisted surgery performed with an open console platform. We evaluated this technique with the success rate of diagnosis, the operative time and the post-operative course.Study Sample: This technique was performed in 6 patients (4 female, mean age 65 years) to date.Results: The precision of the head-mounted display based localization system was effective in all cases without the need of open conversion. The mean diameter of the nodules was 8 mm (6-9). The diagnosis was a lung cancer (n = 5) and tuberculoma (n = 1). The mean operative time was 125 min (100-145). The mean hospital stay was 2.5 days (1-3).Conclusions: In conclusion, the intraoperative navigation using the 3D holographic assistance was an helpful tool for mini invasive RATS lung segmentectomy without the need of preoperative localization.

An Unusual Presentation of Mycotic Popliteal Artery Pseudoaneurysm due to Pasteurella multocida Infection.

Pasteurella multocida , a zoonotic infectious pathogen, is a rare cause of mycotic aneurysms in human hosts. A 76-year-old man was admitted at our emergency unit for a superinfection of his right limb. The patient was initially treated for a knee arthritis. After a first-line antibiotherapy, the patient was referred to the vascular department for the management of a right acute limb ischemia. The work-up revealed a ruptured pseudoaneurysm of the popliteal artery. The ruptured artery was surgically explanted, and a femoropopliteal bypass was then performed. Pasteurella multocida was detected after bacterial analysis of the aneurysm. The postoperative course was uneventful. This case is the first reported case, to our knowledge, of a popliteal artery pseudoaneurysm due to Pasteurella multocida infection.

Long-term survival following lung surgery for cancer in high-risk patients after perioperative pulmonary rehabilitation.

OBJECTIVES: The benefits of a rehabilitation programme before lung surgical resection for cancer remain to be defined. The purpose of this observational study was to assess the efficacy of preoperative rehabilitation and postoperative rehabilitation on short- and long-term outcomes in patients who were at high operative risk. METHODS: Between January 2010 and December 2012, 20 consecutive non-operable patients (16 men and 4 women, mean age 66 years) with clinical N0 lung cancer were included. Eligibility criteria were lung function below guideline thresholds and/or associated severe comorbidities. The protocol included a cardiorespiratory perioperative rehabilitation programme. These patients were followed up at 5 years. RESULTS: The average increase in forced expiratory volume (FEV)1 and of VO2max preoperatively was 12% and 3.5 ml/kg/min, respectively. All patients underwent a pulmonary surgical resection procedure. The morbidity and mortality rates were 20% and 5%, respectively. Nineteen patients returned home upon the completion of postoperative rehabilitation. After 5-year follow-up, the Kaplan-Meier 5-year survival rate was 52%. CONCLUSIONS: Perioperative pulmonary rehabilitation seems to allow surgical management of lung cancer by lung resection in first-line, non-eligible patients. The long-term survival of operated high-risk patients is encouraging despite the high complication rate.

Early acute respiratory distress syndrome after pneumonectomy: Presentation, management, and short- and long-term outcomes.

OBJECTIVE: Postpneumonectomy acute respiratory failure leading to invasive mechanical ventilation carries a severe prognosis, especially when acute respiratory distress syndrome develops. The aim of this study was to describe the risk factors, management, and outcome of postpneumonectomy acute respiratory distress syndrome. METHODS: We retrospectively reviewed the clinical files of patients undergoing pneumonectomy in a single center between 2005 and 2015. Risk factors for acute respiratory distress syndrome, management characteristics, and short- and long-term outcomes were assessed. RESULTS: Among the 543 patients undergoing pneumonectomy, 89 (16.4%) needed reintubation within the 30th postoperative day, including 60 (11%) who developed acute respiratory distress syndrome. At multivariate analysis, right-side pneumonectomy (odds ratio [OR], 2.75; 95% confidence interval [CI], 1.51-5.02; P = .0009) and higher Charlson Comorbidity Index (OR, 1.26; 95% CI, 1.07-1.49; P = .007) were identified as independent risk factors for acute respiratory distress syndrome. Operative mortality was 8.1% for all pneumonectomies, 43.8% (n = 39/89) in intubated patients, and 56.7% (34/60) in patients with acute respiratory distress syndrome. Mortality was higher in severe (25/36, 69.4%) than in mild or moderate acute respiratory distress syndrome (9/24, 37.5%, P = .014). Logistic regression identified 3 independent predictors of operative mortality in patients with acute respiratory distress syndrome: age (OR, 1.08; 95% CI, 1.01-1.15; P = .02), right pneumonectomy (OR, 5.97; 95% CI, 1.33-26.71; P = .02), and severe acute respiratory distress syndrome (OR, 7.19; 95% CI, 1.74-29.73; P = .006). Five-year survival was 17.6% for patients with acute respiratory distress syndrome. CONCLUSIONS: Acute respiratory distress syndrome is a severe early complication of pneumonectomy with a poor outcome. The low survival underlines the need for novel management strategies.

Patients experiencing early acute respiratory failure have high postoperative mortality after pneumonectomy.

OBJECTIVE: Post-pneumonectomy acute respiratory failure leading to invasive mechanical ventilation carries a severe prognosis especially when acute respiratory distress syndrome occurs. The aim of this study was to describe risk factors and outcome of acute respiratory failure. METHODS: We retrospectively reviewed clinical files of all patients who underwent pneumonectomy in a single center between 2005 and 2015. Risk factors and outcome of acute respiratory failure were assessed in univariate and multivariate analysis. RESULTS: Among the 543 patients who underwent pneumonectomy in the period of study, 89 (16.4%) needed reintubation within the 30th postoperative day and 60 of these (11% of all pneumonectomies) developed acute respiratory distress syndrome. In multivariate analysis, right-side of pneumonectomy (odds ratio [OR], 2.29; 95% confidence interval [CI], 1.24-4.22), chronic cardiac disease (OR, 2.15; 95% CI, 1.08-4.25), Charlson Comorbidity Index (OR, 1.35; 95% CI, 1.14-1.61), carinal resection (OR, 3.23; 95% CI, 1.26-8.29), and extrapleural pneumonectomy (OR, 8.36; 95% CI, 3.31-21.11) were identified as independent risk factors of reintubation. Thirty-day mortality was 7.7% for all pneumonectomies, 41.6% (37/89) in the invasive ventilation group, and 53.3% (32/60) in patients with acute respiratory distress syndrome. In non-reintubated patients, 30-day mortality was 1.1% (5/454). In reintubated patients, 5-year survival was 27.1% (95% CI, 17.8-41.4). CONCLUSIONS: Early acute respiratory failure requiring reintubation remains a severe complication of pneumonectomy with a poor outcome.

Complete thoracoscopic lobectomy for cancer: comparative study of three-dimensional high-definition with two-dimensional high-definition video systems †.

OBJECTIVES: Common video systems for video-assisted thoracic surgery (VATS) provide the surgeon a two-dimensional (2D) image. This study aimed to evaluate performances of a new three-dimensional high definition (3D-HD) system in comparison with a two-dimensional high definition (2D-HD) system when conducting a complete thoracoscopic lobectomy (CTL). METHODS: This multi-institutional comparative study trialled two video systems: 2D-HD and 3D-HD video systems used to conduct the same type of CTL. The inclusion criteria were T1N0M0 non-small-cell lung carcinoma (NSCLC) in the left lower lobe and suitable for thoracoscopic resection. The CTL was performed by the same surgeon using either a 3D-HD or 2D-HD system. Eighteen patients with NSCLC were included in the study between January and December 2013: 14 males, 4 females, with a median age of 65.6 years (range: 49-81). The patients were randomized before inclusion into two groups: to undergo surgery with the use of a 2D-HD or 3D-HD system. We compared operating time, the drainage duration, hospital stay and the N upstaging rate from the definitive histology. RESULTS: The use of the 3D-HD system significantly reduced the surgical time (by 17%). However, chest-tube drainage, hospital stay, the number of lymph-node stations and upstaging were similar in both groups. CONCLUSIONS: The main finding was that 3D-HD system significantly reduced the surgical time needed to complete the lobectomy. Thus, future integration of 3D-HD systems should improve thoracoscopic surgery, and enable more complex resections to be performed. It will also help advance the field of endoscopically assisted surgery.

Totally thoracoscopic major pulmonary resections: an analysis of perioperative complications.

BACKGROUND: Reports of recent large series support the safety of video-assisted thoracoscopic major pulmonary resections (MPR). However, although their rate of postoperative complications is low, the real incidence of intraoperative complications is unknown. METHODS: Clinical data from patients who underwent MPR through a full thoracoscopic approach between 2007 and 2012 were reviewed. Data were collected prospectively and analyzed retrospectively. RESULTS: A thoracoscopic MPR was attempted in 338 patients; 68.6% of the patients underwent a lobectomy and 31.4%, an anatomic segmentectomy. The mean operation time was 182 minutes (range, 80 to 300), and the mean intraoperative blood loss was 80 mL (range, 10 to 400 mL). Inhospital mortality rate was 0.3%. The overall complication rate was 32.8%. Intraoperative adverse events and conversion to open thoracotomy occurred in 2.7% and 5.6% of patients, respectively. Risk factors for conversion were preoperative forced expiratory volume of air in 1 second (p<0.001) and a fused fissure (p=0.001). A fused fissure (p=0.007) and surgical experience (p=0.022) were independent factors associated with a longer duration of operation. Major adverse events and reoperation occurred, respectively, in 8.9% and 3% of cases. Surgical complications were mostly vascular injury (n=9), laryngeal nerve palsy (n=5), chylothorax (n=3), and bronchus injury (n=1). On multivariate analysis, the only independent risk factors for major postoperative complications were smoking status and surgical experience. CONCLUSIONS: Although its overall rate of complications is low, a complete thoracoscopic approach might cause unusual adverse events. Surgeons must be aware of these complications to prevent them and anticipate their handling.

Totally thoracoscopic pulmonary anatomic segmentectomies: technical considerations.

BACKGROUND: While video-assisted thoracic surgery (VATS) lobectomies are being increasingly accepted, VATS segmentectomies are still considered as technically challenging. With the renewed interest for sublobar resection in the management of early stage lung carcinomas, the thoracoscopic approach may have a major role in a near future. We report our technique and results. PATIENTS AND METHODS: Totally thoracoscopic anatomic segmentectomiy, i.e., using only endoscopic instrumentation and video-display without utility incision, was attempted on 117 patients (51 males and 66 females), aged 18 to 81 years (mean: 62 years). The indication was a clinical N0 non-small cell lung carcinoma in 69 cases, a solitary metastasis in 17 cases and a benign lesion in 31 cases. The following segmentectomies were performed: right apicosuperior [26] right superior [10], right basilar [18], lingula sparing left upper lobectomy [15], left apicosuperior [11], lingula [7], left superior [14], left basilar [13] and subsegmental resection [3]. Segmentectomy was associated with a radical lymphadenectomy in 69 cases. RESULTS: There were 5 conversions to thoracotomy. The mean operative time was 181±52 minutes, the mean intraoperative blood loss was 77±81 cc. There were 12 postoperative complications (11.7%). The median postoperative stay was 5.5±2.2 days. Out of the 69 patients operated on for a cN0 lung carcinoma, 6 were finally upstaged. CONCLUSIONS: Totally thoracoscopic anatomic pulmonary segmentectomies are feasible and have a low complication rate.

Predictive factors for complications of anatomical pulmonary segmentectomies.

OBJECTIVES: The role of anatomical pulmonary segmentectomy is increasing, but there are few data about its complication rate. We have analysed the postoperative morbidity, mortality and risk factors in a consecutive series of 228 segmentectomies performed in our department. METHODS: Between January 2007 and December 2011, 221 patients underwent 228 segmentectomies. There were 99 women (45%) and 122 men (55%). The mean age was 61 years (range 18-86 years). The mean forced expiratory volume in 1 s (FEV1) was 87%, and 30 patients had an FEV1 of ≤60%. Fifty-seven patients had a previous history of pulmonary resection. Indications for segmentectomy were: primary lung cancer (111 cases), metastases (71 cases), benign non-infectious (25 cases) and benign infectious diseases (21 cases). The approach was a posterolateral thoracotomy (Group PLT) in 146 patients (64%) and a thoracoscopy (Group TS) in 82 (36%). The two groups were homogenous in terms of age, gender, indications of surgery and type of segmentectomy. RESULTS: The mortality rate at 3 months was 1.3% (3 patients). The overall complication rate was 34%. Ten patients were reoperated for the following reasons: haemothorax (4 cases), ischaemia of the remaining segment (3 cases), active bleeding (1 case), prolonged air leak (1 case) and dehiscence of thoracotomy (1 case). The average duration of drainage was 5 days (range 1-34 days) and the average length of stay was 9 days (range 3-126 days). On univariate analysis, FEV1, male gender and thoracotomy were statistically significant risk factors for complications. On multivariate analysis, the same three predictive factors of complications independently of age were found statistically significant: preoperative FEV1 < 60% [odds ratio (OR) = 5.9, 95% CI (2.5-13.7), P < 0.001] male gender [OR = 2.04, 95% CI (1.2-3.6), P < 0.013] and thoracotomy [OR = 2.14, 95% CI (1.33-3.46), P = 0.001]. CONCLUSIONS: Pulmonary anatomical segmentectomies have an acceptable morbidity rate. Postoperative complications are more likely to develop in male gender patients, with FEV1 ≤ 60% and operated by open surgery.