Prevention of Seroma Formation and Its Sequelae After Axillary Lymph Node Dissection: An Up-to-Date Systematic Review and Guideline for Surgeons.

INTRODUCTION: Seroma formation after axillary lymph node dissection (ALND) remains a troublesome complication with significant morbidity. Numerous studies have tried to identify techniques to prevent seroma formation. The aim of this systematic review and network meta-analysis is to use available literature to identify the best intervention for prevention of seroma after standalone ALND. METHODS: A literature search was performed for all comparative articles regarding seroma formation in patients undergoing a standalone ALND or ALND with breast-conserving surgery in the last 25 years. Data regarding seroma formation, clinically significant seroma (CSS), surgical site infections (SSI), and hematomas were collected. The network meta-analysis was performed using a random effects model and the level of inconsistency was evaluated using the Bucher method. RESULTS: A total of 19 articles with 1962 patients were included. Ten different techniques to prevent seroma formation were described. When combining direct and indirect comparisons, axillary drainage until output is less than 50 ml per 24 h for two consecutive days results in significantly less CSS. The use of energy sealing devices, padding, tissue glue, or patches did not significantly reduce the incidence of CSS. When comparing the different techniques with regard to SSIs, no statistically significant differences were seen. CONCLUSIONS: To prevent CSS after ALND, axillary drainage is the most valuable and scientifically proven measure. On the basis of the results of this systematic review with network meta-analysis, removing the drain when output is < 50 ml per 24 h for two consecutive days irrespective of duration seems best. Since drainage policies vary widely, an evidence-based guideline is needed.

Seroma formation after mastectomy: A systematic review and network meta-analysis of different flap fixation techniques.

Flap fixation is the most promising solution to prevent seroma formation after mastectomy. In this systematic review with network meta-analysis (NMA), three different techniques were compared. The NMA included 25 articles, comprising 3423 patients, and revealed that sutures are superior to tissue glue in preventing clinically significant seroma. In addition, running sutures seemed to be superior to interrupted sutures. An RCT comparing these suture techniques seems necessary, given the quality and nature of existing literature.

Delayed presentation of manubriosternal dislocation after thoracolumbar spondylodesis in a polytrauma patient - a case report.

BACKGROUND: Manubriosternal dislocations are a rare entity and frequently associated with thoracic spine fractures and, in minority of cases, with cervical or thoracolumbar fractures. METHODS: Our case represents a 38-year-old male who fell from a height resulting in multiple fractures, amongst others of the first lumbar vertebra. At primary survey and computed tomography scan no manubriosternal injury was apparent. After posterior stabilization of the thoracolumbar vertebrae a manubriosternal dislocation was identified and stabilized using plate-and-screw fixation. RESULTS: Clinical findings of a manubriosternal dislocation are not always obvious, allowing them to be missed at initial assessment. CONCLUSIONS: Manubriosternal dislocations can be missed at the initial investigation, even on cross-sectional imaging, and only become visible after spine stabilization because of the tight relationship between sternum and vertebrae in the thoracic cage. There is no unanimity in literature for surgical treatment of manubriosternal dislocations, although plate fixation is generally considered a safe and effective treatment option.

Outcomes after hybrid minimally invasive treatment of Boerhaave syndrome: a single-institution experience.

BACKGROUND: Spontaneous esophageal perforation or Boerhaave syndrome is a life-threatening emergency, associated with significant morbidity and mortality. In this retrospective series we describe our single-center experience with a hybrid minimally invasive treatment approach for the treatment of Boerhaave syndrome. METHODS: Clinical data of all patients who presented with spontaneous esophageal rupture between January 2009 and December 2019 were analyzed. All patients underwent esophageal endoscopic stenting to seal the perforation and debridement of the contaminated mediastinal and pleural cavity through video-assisted thoracoscopic surgery (VATS). Primary outcome measure was defined as in-hospital death and 30-day mortality. RESULTS: Twelve patients were included with a median age of 63 years (interquartile range [IQR] 51-74 years) of whom 58% (n = 7) were male. The median Pittsburg perforation severity score was 6.5 (IQR 6-9). Endoscopic reintervention was required in 8 patients (67%), primarily due to stent dislocation. In addition, 5 patients (42%) required re-VATS due to empyema formation. Thirty-day mortality and in-hospital mortality were respectively 17% (n = 2) and 25% (n = 3). CONCLUSION: Endoscopic stenting in combination with thoracoscopic debridement is an effective and safe minimally invasive hybrid approach for the treatment of Boerhaave syndrome. This is depicted by the relatively low mortality rates, even among patients with high perforation severity scores. The relatively low mortality rates may be attributed to the combined approach of rapidly sealing the defect and decontamination of the thorax. Future studies should aim to corroborate this evidence which is limited by its sample size and retrospective nature.

Editor's Choice - Extending Aortic Replacement Beyond the Proximal Arch in Acute Type A Aortic Dissection: A Meta-Analysis of Short Term Outcomes and Long Term Actuarial Survival.

OBJECTIVE: The extent of aortic replacement during surgery for acute type A aortic dissection (ATAAD) is an important matter of debate. This meta-analysis aimed to evaluate the short and long term outcomes of a proximal aortic repair (PAR) vs. total arch replacement (TAR) in the treatment of ATAAD. DATA SOURCES: A systematic search of PubMed and Embase was performed. Studies comparing PAR to TAR for ATAAD were included. REVIEW METHODS: The primary outcomes were early death and long term actuarial survival at one, five, and 10 years. Random effects models in conjunction with relative risks (RRs) were used for meta-analyses. RESULTS: Nineteen studies were included, comprising 5 744 patients (proximal: n = 4 208; total arch: n = 1 536). PAR was associated with reduced early mortality (10.8% [95% confidence interval (CI) 8.4 - 13.7] vs. 14.0% [95% CI 10.4 - 18.7]; RR 0.73 [95% CI 0.63 - 0.85]) and reduced post-operative renal failure (10.4% [95% CI 7.2 - 14.8] vs. 11.1% [95% CI 6.7 - 17.5]; RR 0.77 [95% CI 0.66 - 0.90]), but there was no difference in stroke (8.0% [95% CI 5.9 - 10.7] vs. 7.3% [95% CI 4.6 - 11.3]; RR 0.87 [95% CI 0.69 - 1.10]). No statistically significant difference was found for survival after one year (83.2% [95% CI 77.5 - 87.7] vs. 78.6% [95% CI 69.7 - 85.5]; RR 1.05 [95% CI 0.99 - 1.11]), which persisted after five years (75.4% [95% CI 71.2 - 79.2] vs. 74.5% [95% CI 64.7 - 82.3]; RR 1.02 [95% CI 0.91 - 1.14]). After 10 years, there was a significant survival benefit for patients who underwent TAR (64.7% [95% CI 61.1 - 68.1] vs. 72.4% [95% CI 67.5 - 76.7]; RR 0.91 [95% CI 0.84 - 0.99]). CONCLUSION: PAR appears to lead to an improved early mortality rate and a reduced complication rate. In the current meta-analysis, the suggestion of an improved 10 year survival benefit of TAR was found, which should be interpreted in the context of potential confounders such as age at presentation, comorbidities, and haemodynamic stability. In any case, PAR seems to be intuitive in older patients with limited dissections, and in those presenting in less stable conditions.

Three-Dimensional Imaging of the Chest Wall: A Comparison Between Three Different Imaging Systems.

BACKGROUND: Three-dimensional (3D) imaging is being used progressively to create models of patients with anterior chest wall deformities. Resulting models are used for clinical decision-making, surgical planning, and analysis. However, given the broad range of 3D imaging systems available and the fact that planning and analysis techniques are often only validated for a single system, it is important to analyze potential intrasystem and intersystem differences. The objective of this study was to investigate the accuracy and reproducibility of three commercially available 3D imaging systems that are used to obtain images of the anterior chest wall. METHODS: Among 15 healthy volunteers, 3D images of the anterior chest wall were acquired twice per imaging device. Reproducibility was determined by comparison of consecutive images acquired per device while the true accuracy was calculated by comparison of 3D image derived and calipered anthropometric measurements. A maximum difference of 1.00 mm. was considered clinically acceptable. RESULTS: All devices demonstrated statistically comparable (P = 0.21) reproducibility with a mean absolute difference of 0.59 mm. (SD: 1.05), 0.54 mm. (SD: 2.08), and 0.48 mm. (SD: 0.60) for the 3dMD, EinScan Pro 2X Plus, and Artec Leo, respectively. The true accuracy was, respectively, 0.89 mm. (SD: 0.66), 1.27 mm. (SD: 0.94), and 0.81 mm. (SD: 0.71) for the 3dMD, EinScan, and Artec device and did not statistically differ (P = 0.085). CONCLUSIONS: Three-dimensional imaging of the anterior chest wall utilizing the 3dMD and Artec Leo is feasible with comparable reproducibility and accuracy, whereas the EinScan Pro 2X Plus is reproducible but not clinically accurate.

Photographic documentation and severity quantification of pectus excavatum through three-dimensional optical surface imaging.

Conventional photography is commonly used to visually document pectus excavatum and objectively assess chest wall changes over time without repeated exposure to ionising radiation, as in our centre since 2008. However, as conventional photography is labour-intensive and lacks three-dimensional (3D) information that is essential in 3D deformities like pectus excavatum, we developed a novel imaging and processing protocol based on 3D optical surface imaging. The objective of this study was to report our developed protocol to visually document pectus excavatum through 3D imaging. We also investigated the absolute agreement of the 3D image- and conventional photography-derived pectus excavatum depth to investigate whether both techniques could be used interchangeably to measure pectus excavatum depth and assess its evolution. The protocol consisted of three consecutive steps: patient positioning and instructions, data acquisition, and data processing. Three-dimensional imaging through the developed protocol was feasible for all 19 participants. The 3D image- and photography-derived pectus excavatum depth demonstrated good to excellent agreement (intraclass correlation coefficient: 0.97; 95%-confidence interval: 0.88 to 0.99; p < 0.001). In conclusion, 3D imaging through the developed protocol is a feasible and attractive alternative to document the surface geometry of pectus excavatum and can be used interchangeably with conventional photography to determine pectus severity. Clinical registration number: NCT04185870.

Intercostal nerve cryoablation versus thoracic epidural analgesia for minimal invasive Nuss repair of pectus excavatum: a protocol for a randomised clinical trial (ICE trial).

INTRODUCTION: Epidural analgesia is currently considered the gold standard in postoperative pain management for the minimally invasive Nuss procedure for pectus excavatum. Alternative analgesic strategies (eg, patient-controlled analgesia and paravertebral nerve block) fail in accomplishing adequate prolonged pain management. Furthermore, the continuous use of opioids, often prescribed in addition to all pain management strategies, comes with side effects. Intercostal nerve cryoablation seems a promising novel technique. Hence, the primary objective of this study is to determine the impact of intercostal nerve cryoablation on postoperative length of hospital stay compared with standard pain management of young pectus excavatum patients treated with the minimally invasive Nuss procedure. METHODS AND ANALYSIS: This study protocol is designed for a single centre, prospective, unblinded, randomised clinical trial. Intercostal nerve cryoablation will be compared with thoracic epidural analgesia in 50 young pectus excavatum patients (ie, 12-24 years of age) treated with the minimally invasive Nuss procedure. Block randomisation, including stratification based on age (12-16 years and 17-24 years) and sex, with an allocation ratio of 1:1 will be performed.Postoperative length of hospital stay will be recorded as the primary outcome. Secondary outcomes include (1) pain intensity, (2) operative time, (3) opioid usage, (4) complications, including neuropathic pain, (5) creatine kinase activity, (6) intensive care unit admissions, (7) readmissions, (8) postoperative mobility, (9) health-related quality of life, (10) days to return to work/school, (11) number of postoperative outpatient visits and (12) hospital costs. ETHICS AND DISSEMINATION: This protocol has been approved by the local Medical Ethics Review Committee, METC Zuyderland and Zuyd University of Applied Sciences. Participation in this study will be voluntary and informed consent will be obtained. Regardless of the outcome, the results will be disseminated through a peer-reviewed international medical journal. TRIAL REGISTRATION NUMBER: NCT05731973.

The use of intravenous indocyanine green in minimally invasive segmental lung resections: a systematic review.

Background: To identify intersegmental planes (ISPs) in video/robot-assisted thoracoscopic segmentectomies, indocyanine green (ICG) is commonly used. The aim of this systematic review is to evaluate the efficacy of intravenous ICG in the identification of ISP. Methods: A systematic search was performed. Studies evaluating patients who underwent a video/robot-assisted thoracoscopic segmentectomy using intravenous ICG were included. The primary outcome measure was the frequency and percentage of patients in whom the ISP was adequately visualized. Secondary outcomes encompassed the ICG dose, time to visualization, time to maximum ICG visualization, time to disappearance of ICG effect and adverse reactions to ICG. Results: Eighteen studies were included for systematic review, enrolling a total of 1,090 patients. Irrespective of the injected dose, intravenous ICG identified the ISP in 94% of the cases (range, 30-100%). Overall, there was a considerable amount of heterogeneity regarding the injected dose of ICG (range, 5-25 mg or 0.05-0.5 mg/kg). The mean time before first effect of ICG was visible ranged from 10 to 40 seconds. The mean total time of ICG visibility ranged from 90 to 140 seconds after a bolus injection and was 170 seconds after continuous infusion. No adverse reactions were reported. Conclusions: After administration of intravenous ICG, visualization of the ISP is successful in up to 94% of cases, even after administration of a low dose (0.05 mg/kg) of ICG. The use of intravenous ICG is safe with no reported adverse effects in the immediate peri-operative period.

Treatment of traumatic rib fractures: an overview of current evidence and future perspectives.

Operative management of rib fractures has gained significant popularity over the last years, however, it remains a controversial topic, due to the substantial heterogeneity among rib fracture patients with considerable differences in epidemiology. Hence, the present narrative review aims to provide an overview of the treatment and (long-term) outcomes of rib fractures, with an emphasis on the surgical treatment. Nowadays, computed tomography (CT) has been shown to be most practical and sensitive for detecting rib fractures, of which up to 50% is missed on other imaging modalities. Non-operative treatment by patient-tailored multimodal pain management remains the cornerstone. Still, in the presence of-amidst others-chest wall instability or displaced fractures with physiologic derangements, operative treatment is indicated and should be performed within 72 hours after injury. Here, traumatic brain injury (TBI) and pulmonary contusion are no strict contra-indications, while plate osteosynthesis is considered the standard mode for surgical stabilization. To date, surgical stabilization of rib fractures (SSRF) only benefits selected groups of patients, awaiting results of ongoing studies. Future directions may include the sole use of percutaneous cryoablation of the intercostal nerves as part of conservative management, as well as the application of three-dimensional (3D) printing and use of bio-absorbable materials in the surgical treatment of rib fractures.

Pectus excavatum and carinatum: a narrative review of epidemiology, etiopathogenesis, clinical features, and classification.

Background and Objective: A wide variety of congenital chest wall deformities that manifest in infants, children and adolescents exists, among which are pectus excavatum and pectus carinatum. Numerous studies have been conducted over the years aiming to better understand these deformities. This report provides a brief overview of what is currently known about the epidemiology, etiopathogenesis, clinical presentation, and classification of these deformities, and highlights the gaps in knowledge. Methods: A search was conducted for all the above-described domains in the PubMed and Embase databases. Key Content and Findings: A total of 147 articles were included in this narrative review. Estimation of the true incidence and prevalence of pectus excavatum and carinatum is challenging due to lacking consensus on a definition of both deformities. Nowadays, several theories for the development of pectus excavatum and carinatum have been suggested which focus on intrinsic or extrinsic pathogenic factors, with the leading hypothesis focusing on overgrowth or growth disturbance of costal cartilages. Furthermore, genetic predisposition to the deformities is likely to exist. Pectus excavatum is frequently associated with cardiopulmonary symptoms, while pectus carinatum patients mostly present with cosmetic complaints. Both deformities are classified based on the shape or severity of the deformity. However, each classification system has its limitations. Conclusions: Substantial progress has been made in the past few decades in understanding the development and symptomatology of pectus excavatum and carinatum. Current hypotheses on the etiology of the deformities should be confirmed by biomedical and genetic studies. For clinical purposes, the establishment of a clear definition and classification system for both deformities based on objective morphologic features is eagerly anticipated.

Advancements in preoperative imaging of pectus excavatum: a comprehensive review.

Pectus excavatum, the most common pectus deformity, varies in severity and has been associated with cardiopulmonary impairment and psychological distress. Since its initial documentation, a multitude of imaging techniques for preoperative evaluation (i.e., diagnosis, severity classification, functional assessment, and surgical planning) have been reported. Conventional imaging techniques encompass computed tomography (CT), chest radiography, magnetic resonance imaging (MRI), echocardiography and medical photography, while three dimensional (3D) optical surface imaging is a promising emerging technique in the preoperative assessment of pectus excavatum. This narrative review explores the current insights and advancements of these imaging modalities. CT imaging allows for the calculation of pectus indices and evaluation of cardiac compression and displacement. Recent developments focus on automated calculations, minimizing radiation exposure and improving surgical planning. Chest radiography offers a radiation-reducing alternative for pectus index measurement, but is unsuitable for disproportionally asymmetric chest deformations. MRI is a radiation-free imaging method, and allows for the calculation of pectus indices as well as the assessment of cardiac function. Real-time MRI provides dynamic insights, while exercise MRI shows promise for comprehensive evaluation of cardiac function but requires additional developments. Using echocardiography, structural cardiac changes can be identified, but its use in evaluating cardiac function in pectus excavatum patients is limited. Medical photography combined with caliper measurements complements other imaging methods for qualitative and quantitative documentation of pectus excavatum. Emerging as an innovative technique, 3D optical surface imaging offers a rapid, radiation-free assessment of the deformity which correlates with conventional pectus indices. Potential applications include quantifying other morphological features and predicting cardiac compression. However, standardization and validation are needed for its widespread use. This review provides an overview of preoperative imaging of pectus excavatum, highlighting the current developments in conventional methods and the potential of the emerging 3D optical surface imaging technique. These advancements hold promise for the future of the assessment and surgical planning of pectus excavatum.

Management of soft tissue sarcomas of the chest wall: a comprehensive overview.

Sarcomas of the chest wall are rare and their current treatment regimen is diverse and complex due to the heterogeneity of these tumors as well as the variations in tumor location and extent. They only account for 0.04% of newly diagnosed cancers of whom about 45% comprise soft tissue sarcomas. Larger cohort studies are scarce and often focus on one specific treatment item. We therefore aim to provide helicopter view for clinicians treating patients with sarcomas of the chest wall, focusing mainly on soft tissue sarcomas. This overview includes the value of neoadjuvant systemic or radiotherapy, surgical resection, approaches for thoracic wall reconstruction, and the need for follow-up. Provided the heterogeneity and relative rarity, we recommend that treatment decisions in soft tissue sarcoma of the chest wall are discussed in a multidisciplinary tumor board at a reference sarcoma center or within sarcoma networks to ensure personalized, rational decision making. A surgical oncologist specialized in sarcoma surgery is crucial, and for extensive resections involving the thoracic cavity we recommend involvement of a thoracic surgeon. In addition, a specialized medical- and radiation oncologist as well as a plastic surgeon is required to ensure the best multimodality treatment plan to optimize patient outcome.

Uniportal versus multiportal video-assisted thoracoscopic surgery for spontaneous pneumothorax.

BACKGROUND: Multiportal video-assisted thoracic surgery (mVATS) is the standard approach for the surgical treatment of spontaneous pneumothorax. However, uniportal VATS (uVATS) has emerged as an alternative aiming to minimize surgical morbidity. This study aims to strengthen the evidence on the safety and efficiency of uVATS compared to mVATS. METHODS: From January 2004 to December 2020, records of patients who had undergone surgical treatment for primary or secondary spontaneous pneumothorax were evaluated for eligibility. Patients who had undergone pleurectomy combined with bullectomy or apical wedge resection via uVATS or mVATS were included. Surgical characteristics and postoperative data were compared between patients who had undergone surgery via uVATS or mVATS. Univariable and multivariable analyses were performed to determine whether the surgical approach was associated with any complication (primary outcome), major complications (i.e., Clavien-Dindo ≥ 3), recurrence, prolonged hospitalization or prolonged chest drainage duration (secondary outcomes). RESULTS: A total of 212 patients were enrolled. Patients treated via uVATS (n = 71) and mVATS (n = 141) were significantly different in pneumothorax type (secondary spontaneous; uVATS: 54 [76%], mVATS: 79 [56%]; p = 0.004). No significant differences were observed in (major) complications and recurrence rates between both groups. Multivariable analyses revealed that the surgical approach was no significant predictor for the primary or secondary outcomes. CONCLUSIONS: This study indicates that uVATS is non-inferior to mVATS in the surgical treatment of spontaneous pneumothorax regarding safety and efficiency, and thus the uVATS approach has the potential for further improvements in the perioperative surgical care for spontaneous pneumothorax.

Development of Prediction Models for Cardiac Compression in Pectus Excavatum Based on Three-Dimensional Surface Images.

In pectus excavatum, three-dimensional (3D) surface imaging provides an accurate and radiation-free alternative to computed tomography (CT) to determine severity. Yet, it does not allow for cardiac evaluation since 3D imaging solely captures the chest wall surface. The objective was to develop a 3D image-based prediction model for cardiac compression in patients evaluated for pectus excavatum. A prospective cohort study was conducted including consecutive patients referred for pectus excavatum who received a thoracic CT. Additionally, 3D images were acquired. The external pectus depth, its length, craniocaudal position, cranial slope, asymmetry, anteroposterior distance and chest width were calculated from 3D images. Together with baseline patient characteristics they were submitted to forward multivariable logistic regression to identify predictors for cardiac compression. Cardiac compression on CT was used as reference. The model's performance was depicted by the area under the receiver operating characteristic (AUROC) curve. Internal validation was performed using bootstrapping. Sixty-one patients were included of whom 41 had cardiac compression on CT. A combination of the 3D image derived external pectus depth and external anteroposterior distance was identified as predictive for cardiac compression, yielding an AUROC of 0.935 (95% confidence interval [CI]: 0.878-0.992) with an optimism of 0.006. In a second model for males alone, solely the external pectus depth was identified as predictor, yielding an AUROC of 0.947 (95% CI: 0.892-1.000) with an optimism of 0.0002. We have developed two 3D image-based prediction models for cardiac compression in patients evaluated for pectus excavatum which provide an outstanding discriminatory performance between the presence and absence of cardiac compression with negligible optimism.

Modification of the Abramson procedure for minimally invasive repair of pectus carinatum: introduction of a pectus carinatum compression system.

Pectus carinatum is characterized by a protruding sternum. This deformity can be surgically corrected through the minimally invasive Abramson technique. In this procedure, a presternal metal correctional bar, secured to rib-attached stabilizers, is implanted to redress the sternum to a neutral position. To anticipate the intended position of the sternum, manual compression is applied over the sternal deformity. We describe a modified version of the Abramson procedure, encompassing a table-mounted PectusAssist™ System which generates a constant mechanical compression over the protruding sternum. The PectusAssist™ System, most importantly, eliminates the necessity of manually applying repetitive pressure on the deformity, and therefore maintains a more stable sternal position. This will ensure accuracy of the template used to bend the bar into its desired configuration. The modification we propose also simplifies presternal tunnel creation as the two bilateral retromuscular tunnels, that need to be connected presternally, are potentially better aligned due to a more stable and reduced position of the sternum. The PectusAssist™ System makes the procedure less labor intensive and reduces variability without interfering with the safety of the procedure. Therefore, we advise standard use of the PectusAssist™ System during minimally invasive repair of pectus carinatum by the Abramson procedure.

Uniportal video-assisted thoracoscopic surgery for lobectomy: the learning curve.

OBJECTIVES: Prior reported learning curves for uniportal video-assisted thoracoscopic lobectomy were predominantly based on surgery duration, while reports on complications are limited. Therefore, our study assessed the learning curve based on both technique-related complications and surgery duration. METHODS: We retrospectively collected data from patients who had undergone uniportal video-assisted thoracoscopic lobectomy between 2015 and 2020. Exclusion criteria were concomitant procedures other than ipsilateral wedge resection, discontinued procedures, or lost to follow-up (less than 30 days). Learning curves were constructed per surgeon who performed over 20 procedures using non-risk adjusted cumulative sum (CUSUM) analysis for technique-related complications and cumulative sum analysis for surgery duration. Based on the literature, an acceptable complication rate was set at 30%, an unacceptable complication rate at 45%, and a mean surgery duration of 145 min. RESULTS: Learning curves were constructed for three thoracic surgeons and one fellow who performed 324 uniportal video-assisted thoracoscopic lobectomies in total. Each surgeon was experienced in multiportal video-assisted thoracoscopic lobectomy, the fellow was familiar with basic multiportal video-assisted thoracoscopic procedures. Cumulative sum charts of three surgeons reached a statistically significant technique-related complication rate below 30% between 50 and 96 procedures. Regarding surgery duration, typical learning curves were observed for three surgeons with a transition point between 14 and 26 procedures. CONCLUSIONS: Learning of uniportal video-assisted thoracoscopic surgery for lobectomy is safe without unacceptable complication rates and has a declining surgery duration over time for thoracic surgeons with experience in multiportal video-assisted thoracoscopic lobectomies. However, it remains unknown when the different stages of mastery are completed.

Predicting Aesthetic Outcome of the Nuss Procedure in Patients with Pectus Excavatum.

Patients suffering from pectus excavatum often experience psychosocial distress due to perceived anomalies in their physical appearance. The ability to visually inform patients about their expected aesthetic outcome after surgical correction is still lacking. This study aims to develop an automatic, patient-specific model to predict aesthetic outcome after the Nuss procedure. Patients prospectively received preoperative and postoperative 3-dimensional optical surface scanning of their chest during the Nuss procedure. A prediction model was composed based on nonlinear least squares data-fitting, regression methods and a 2-dimensional Gaussian function with adjustable amplitude, variance, rotation, skewness, and kurtosis components. Morphological features of pectus excavatum were extracted from preoperative images using a previously developed surface analysis tool to generate a patient-specific model. Prediction accuracy was evaluated through cross-validation, utilizing the mean root squared deviation and maximum positive and negative deviations as performance measures. The prediction model was evaluated on 30 (90% male) prospectively imaged patients. The model achieved an average root mean squared deviation of 6.3 ± 2.0 mm, with average maximum positive and negative deviations of 12.7 ± 6.1 and -10.2 ± 5.7 mm, respectively, between the predicted and actual postoperative aesthetic result. Our developed 2-dimensional Gaussian model based on 3-dimensional optical surface images is a clinically promising tool to predict postsurgical aesthetic outcome in patients with pectus excavatum. Prediction of the aesthetic outcome after the Nuss procedure potentially improves information provision and expectation management among patients. Further research should assess whether increasing the sample size may reduce deviations and improve performance.

A No-Chest-Drain Policy After Video-assisted Thoracoscopic Surgery Wedge Resection in Selected Patients: Our 12-Year Experience.

BACKGROUND: Postoperative pleural drainage omission after video-assisted thoracoscopic surgery (VATS) for wedge resections may facilitate faster recovery. This retrospective cohort study presents our 12-year experience with omitting thoracic drainage in patients who underwent a VATS wedge resection, aiming to assess its safety and efficacy. METHODS: Records from consecutive patients who underwent a VATS wedge resection at our hospital between February 2008 and October 2020 were retrospectively reviewed and assessed for eligibility. Patient and surgical characteristics as well as postoperative data were collected and compared between patients who received a chest drain (CD) or received no chest drain (NCD) after surgery. Univariable and multivariable analyses were performed to determine whether drain placement was associated with complications (primary outcome), and major complications requiring pleural drainage or length of hospital stay (secondary outcomes). RESULTS: Data of 348 patients were analyzed. The drainless group (n = 98) and drain group (n = 237) were significantly different in the following baseline and surgical characteristics: sex, pulmonary function, interstitial lung disease, final pathology, number of wedges, and surgical approach. No significant differences were detected in postoperative complications (NCD 8.2%, CD 14.8%; P = .10), major complications (NCD 5.1%, CD 5.1%; P > .99), or complications requiring pleural drainage (NCD 5.1%, CD 3.8%; P = .56). The drainless group did show a significantly shorter hospitalization (NCD 2 ± 2, CD 3 ± 2 days; P < .001). Multivariable analyses revealed that drain placement was not significantly correlated with postoperative complications. In contrast, prolonged hospitalization was significantly influenced by drain placement. CONCLUSIONS: Our findings suggest that a no-chest-drain policy after VATS wedge resections can safely fast-track rehabilitation for selected patients.

Preoperative imaging of clinically relevant intrathoracic abnormalities in pectus excavatum patients.

Background: Preoperative radiological imaging in pectus excavatum sometimes coincidentally yields additional intrathoracic abnormalities. In the context of a larger research project investigating replacement of CT scans by 3D-surface scanning as routine preoperative work-up for pectus excavatum, this study aims to quantify the incidence of clinically relevant intrathoracic abnormalities found incidentally using conventional CT in pectus excavatum patients. Methods: A single-center retrospective cohort study was conducted including pectus excavatum patients, receiving CT between 2012 and 2021 as part of their preoperative evaluation. Radiology reports were reviewed for additional intrathoracic abnormalities and scored into three subclasses: non-clinically relevant, potentially clinically relevant or clinically relevant findings. Also, two-view plain chest radiographs reports, if available, were evaluated for those patients with a clinically relevant finding. Subgroup analysis was performed to compare adolescents and adults. Results: In total, 382 patients were included, of whom 117 were adolescents. Although in 41 patients (11%) an additional intrathoracic abnormality was found, only two patients (0.5%) presented with a clinically relevant abnormality requiring additional diagnostics, postponing surgical correction. In only one of the two patients, plain chest radiographs were available, which did not show the abnormality. Subgroup analyses revealed no differences in (potentially) clinically relevant abnormalities between adolescents and adults. Conclusions: The prevalence of clinically relevant intrathoracic abnormalities in pectus excavatum patients was low, supporting the notion that CT and plain radiographs can be safely replaced by 3D-surface scanning in the preoperative work-up for pectus excavatum repair.