Salvage surgery for recurrent transdiaphragmatic thymoma in a patient not eligible for chemotherapy.

The recurrence rate following thymoma surgery has been reported to be as high as 29%. In cases of localized recurrence, complete resection can result in prolonged patient survival. However, surgery is rarely considered in cases of invasive recurrent thymomas with high disease burden. Here, we present the case of a woman with type B2 thymoma (Masaoka-Koga stage IVa) treated with surgery, chemotherapy, and radiotherapy. The disease recurred 6 years later, with invasion of the left lung and the 12th thoracic vertebra, as well as extension into the retroperitoneum. Due to the development of chemotherapy-associated toxicity, she underwent surgery with complete tumor resection and has remained free of disease at a 12-months follow-up. Radical surgery for recurrent invasive thymoma extending through the diaphragm is a feasible and safe therapeutic option in highly selected patients who are not eligible for systemic treatments.

Management of complications after chest wall resection and reconstruction: a narrative review.

Background and Objective: Chest wall resection and reconstruction procedures carry high postoperative morbidity. Therefore, successful outcomes necessitate prevention, prompt identification, and appropriate management of ensuing complications. This narrative review aims to provide a comprehensive overview of evidence-based strategies for managing complications following chest wall resection and reconstruction. Methods: A literature search was conducted using the PubMed database for relevant English-language studies published since 1980. Key Content and Findings: Complications following chest wall resection and reconstruction can be broadly classified into surgical site-related, respiratory, or other systemic complications. Surgical site and respiratory complications are the most common, with reported incidence rates of approximately 40% across some series. Predisposing factors for respiratory morbidity include greater numbers of resected ribs and concurrent pulmonary lobectomy. Definitive correlations between specific prosthetic materials and complications remain elusive. Management should be tailored to the type and severity of the complication, surgical variables, and patient factors. Specific approaches for managing common complications are discussed in detail. Emerging preventive approaches, such as minimally invasive surgical techniques, are also briefly highlighted to help guide future research. Conclusions: An emphasis on anticipating and judiciously managing complications of chest wall resection and reconstruction, alongside a coordinated multidisciplinary approach, can optimize outcomes for patients undergoing this intrinsically complex surgery.

Learning curve of robotic surgery for lung cancer: analysis for two surgeons during the COVID-19 pandemic.

OBJECTIVE: To describe and compare the RATS learning curve between two surgeons in one department for lung cancer surgery using the CUSUM method. METHODS: Retrospective analysis using a prospective database on robotic-assisted lung resections performed by two different surgeons in one hospital. The CUSUM method was used to describe the learning curve. RESULTS: 366 consecutives cases were analysed (195 for the first surgeon and 171 for the second surgeon). A traditional 3-phase pattern learning curve was found with a diminution of the operating time throughout the different phases. For Surgeon 1, phase 1 was from case 1 to 59, phase 2 from case 60 to 99 and phase 3 started at case 100. For Surgeon 2, phase 1 was from 1 to 44, phase 2 from case 45 to 79 and phase 3 started at case 80. CONCLUSION: This study described our first experience with the Da Vinci Robotic System in our department. The curves had a similar shape which shows the learning curve of robotic surgery using the CUSUM method is reproducible. Furthermore, our results showed that the learning curve may improve after the programme starts in the department when the different team elements are all trained.

Resectability versus Operability in Early-Stage Non-Small Cell Lung Cancer.

PURPOSE OF REVIEW: With increased detection of early-stage non-small cell lung cancer (NSCLC) owing to screening, determining optimal management increasingly hinges on assessing resectability and operability. Resectability refers to the feasibility of achieving microscopically negative margins based on tumour size, location and degree of local invasion and achieving an anatomical lobar resection. Operability reflects the patient's tolerance for resection based on comorbidities, cardiopulmonary reserve and frailty. Standardized criteria help guide these assessments, but application variability contributes to practice inconsistencies. This review synthesizes a strategic approach to evaluating resectability and operability in contemporary practice. Standardization promises reduced care variability and optimized patient selection to maximize curative outcomes in this new era of early detection. RECENT FINDINGS: Recent pivotal trials demonstrate equivalency of sublobar resection to lobectomy for small, peripheral, node-negative NSCLC, expanding options for parenchymal preservation in borderline surgical candidates. Furthermore, recent phase 3 trials have highlighted the benefit of chemoimmunotherapy as a neoadjuvant treatment with an excellent pathological response and a down staging of the tumour, improving the resectability of the early-stage NSCLC. A good assessment of the operability and resectability is paramount in order to offer the best course of treatment for our patients. European and American societies have issued recommendations to help clinicians assess the cardiopulmonary function and predict the extension of pulmonary resection that could afford the patient. This operability assessment is closely linked with the evaluated tumour resectability which will determine the extension of pulmonary resection that is needed for the patient in order to achieve a good oncological outcome. Some major progresses have been done recently to improve the operability and resectability of patients. For instance, prehabilitation program allows better postoperative morbidity. Some studies have shown a potential good oncological outcome with sublobar resection expending access to surgery for patient with reduced lung function. Some others have identified the neoadjuvant immunochemotherapy as a potential solution for downstaging tumours. Work-up of early-stage NSCLC is a key moment and has to be done thoroughly and in full knowledge of the recent findings in order to propose the most appropriate treatment for the patient.

Comparison of Quality of Life after Robotic, Video-Assisted, and Open Surgery for Lung Cancer.

Post-operative quality of life (QOL) has become crucial in choosing operative approaches in thoracic surgery. However, compared to VATS and thoracotomy, QOL results post-RATS are limited. We compared QOL before and after RATS and between RATS, VATS, and thoracotomy. We conducted a retrospective review of lung cancer surgical patients from 2015 to 2020. Patients completed validated EORTC QOL questionnaires (QLQ-C30 and QLQ-LC13). Results were analysed using the EORTC Scoring Guide, with statistical analysis. A total of 47 (94%) pre- and post-RATS questionnaires were returned. Forty-two patients underwent anatomical lung resections. In addition, 80% of patients experienced uncomplicated recovery. All global and functional QOL domains improved post-operatively, as did most symptoms (13/19). Only four symptoms worsened, including dyspnoea (p = 0.017), with two symptoms unchanged. Of the 148 returned questionnaires for all approaches (open-22/VATS-79/RATS-47), over 70% showed a high pre-operative performance status. Most patients underwent anatomical lung resection, with only VATS patients requiring conversion (n = 6). Complications were slightly higher in RATS, with one patient requiring re-intubation. RATS patients demonstrated the highest global and functional QOL. Physical QOL was lowest after thoracotomy (p = 0.002). RATS patients reported the fewest symptoms, including dyspnoea (p = 0.046), fatigue (p < 0.001), and pain (p = 0.264). Overall, RATS results in a significantly better post-operative QOL and should be considered the preferred surgical approach for lung cancer patients.

Long-Term Oncologic Outcomes in Robot-Assisted and Video-Assisted Lobectomies for Non-Small Cell Lung Cancer.

This study compares long-term outcomes in patients undergoing video-assisted thoracic surgery (VATS) and robotic-assisted thoracic surgery (RATS) lobectomy for non-small cell lung cancer (NSCLC); all consecutive patients who underwent RATS or VATS lobectomy for NSCLC between July 2015 and December 2021 in our center were enrolled in a single-center prospective study. The primary outcomes were overall survival (OS), disease-free survival (DFS), and recurrence rate. The secondary outcomes were complication rate, length of hospitalization (LOS), duration of chest tubes (LOD), and number of lymph node stations harvested. A total of 619 patients treated with RATS (n = 403) or VATS (n = 216) were included in the study. There was no significant difference in OS between the RATS and VATS groups (3-year OS: 75.9% vs. 82.3%; 5-year OS: 70.5% vs. 68.5%; p = 0.637). There was a statistically significant difference in DFS between the RATS and VATS groups (3-year DFS: 92.4% vs. 81.2%; 5-year DFS: 90.3% vs. 77.6%; p < 0.001). Subgroup analysis according to the pathological stage also demonstrated a significant difference between RATS and VATS groups in DFS in stage I (3-year DFS: 94.4% vs. 88.9%; 5-year DFS: 91.8% vs. 85.2%; p = 0.037) and stage III disease (3-year DFS: 82.4% vs. 51.1%; 5-year DFS: 82.4% vs. 37.7%; p = 0.024). Moreover, in multivariable Cox regression analysis, the surgical approach was significantly associated with DFS, with an HR of 0.46 (95% CI 0.27-0.78, p = 0.004) for RATS compared to VATS. VATS lobectomy was associated with a significantly higher recurrence rate compared to RATS (21.8% vs. 6.2%; p < 0.001). LOS and LOD, as well as complication rate and in-hospital and 30-day mortality, were similar among the groups. RATS lobectomy was associated with a higher number of lymph node stations harvested compared to VATS (7 [IQR:2] vs. 5 [IQR:2]; p < 0.001). In conclusion, in our series, RATS lobectomy for lung cancer led to a significantly higher DFS and significantly lower recurrence rate compared to the VATS approach. RATS may allow more extensive nodal dissection, and this could translate into reduced recurrence.

Three-Dimensional Printing Applications in Thoracic Surgery.

Advances in technology allowing the combination of medical imaging and three-dimensional printing have greatly benefitted thoracic surgery, allowing for the creation of complex prostheses. Surgical education is also a significant application of three-dimensional printing, especially for the development of simulation-based training models. Aiming to show how three-dimensional printing can benefit patients and clinicians in thoracic surgery, an optimized method to create patient-specific chest wall prosthesis using three-dimensional printing was developed and clinically validated. An artificial chest simulator for surgical training was also developed, replicating the human anatomy with high realism and accurately simulating a minimally invasive lobectomy.

A cost analysis of robotic vs. video-assisted thoracic surgery: The impact of the learning curve and the COVID-19 pandemic.

Introduction: Robot-assisted thoracoscopic surgery (RATS) is an alternative to video-assessed thoracoscopic surgery (VATS) for the treatment of lung cancer but concern exists regarding the high associated costs. The COVID-19 pandemic added further financial pressure to healthcare systems. This study investigated the impact of the learning curve on the cost-effectiveness of RATS lung resection and the financial impact of the COVID-19 pandemic on a RATS program. Methods: Patients undergoing RATS lung resection between January 2017 and December 2020 were prospectively followed. A matched cohort of VATS cases were analyzed in parallel. The first 100 and most recent 100 RATS cases performed at our institution were compared to assess the learning curve. Cases performed before and after March 2020 were compared to assess the impact of the COVID-19 pandemic. A comprehensive cost analysis of multiple theatre and postoperative data points was performed using Stata statistics package (v14.2). Results: 365 RATS cases were included. Median cost per procedure was £7,167 and theatre cost accounted for 70%. Major contributing factors to overall cost were operative time and postoperative length of stay. Cost per case was £640 less after passing the learning curve (p < 0.001) largely due to reduced operative time. Comparison of a post-learning curve RATS subgroup matched to 101 VATS cases revealed no significant difference in theatre costs between the two techniques. Overall cost of RATS lung resections performed before and during the COVID-19 pandemic were not significantly different. However, theatre costs were significantly cheaper (£620/case; p < 0.001) and postoperative costs were significantly more expensive (£1,221/case; p = 0.018) during the pandemic. Discussion: Passing the learning curve is associated with a significant reduction in the theatre costs associated with RATS lung resection and is comparable with the cost of VATS. This study may underestimate the true cost benefit of passing the learning curve due to the effect of the COVID-19 pandemic on theatre costs. The COVID-19 pandemic made RATS lung resection more expensive due to prolonged hospital stay and increased readmission rate. The present study offers some evidence that the initial increased costs associated with RATS lung resection may be gradually offset as a program progresses.

Robotic versus Video-Assisted Thoracic Surgery for Lung Cancer: Short-Term Outcomes of a Propensity Matched Analysis.

Robot-assisted thoracic surgery (RATS) has gained popularity for the treatment of lung cancer, but its quality outcome measures are still being evaluated. The purpose of this study was to compare the perioperative outcomes of lung cancer resection using RATS versus video-assisted thoracic surgery (VATS). To achieve this aim, we conducted a retrospective analysis of consecutive patients who underwent lung cancer surgery between July 2015 and December 2020. A propensity-matched analysis was performed based on patients' performance status, forced expiratory volume in 1 s% of predicted, diffusing capacity of the lungs for carbon monoxide% of predicted, and surgical procedure (lobectomy or segmentectomy). Following propensity matching, a total of 613 patients were included in the analysis, of which 328 underwent RATS, and 285 underwent VATS, with satisfactory performance indicators. The results of the analysis indicated that RATS had a significantly longer operating time than VATS (132.4 ± 37.3 versus 122.4 ± 27.7 min; mean difference of 10 min 95% CI [confidence interval], 4.2 to 15.9 min; p = 0.001). On the other hand, VATS had a significantly higher estimated blood loss compared to RATS (169.7 ± 237.2 versus 82.2 ± 195.4 mL; mean difference of 87.5 mL; 95% CI, 48.1 to 126.8 mL; p < 0.001). However, there were no significant differences between the groups in terms of the duration of chest tubes, length of hospital stay, low- and high-grade complications, as well as readmissions and mortality within 30 days after surgery. Moreover, the number of dissected lymph-node stations was significantly higher with VATS than RATS (5.9 ± 1.5 versus 4.8 ± 2.2; mean difference of 1.2; 95% CI, 0.8 to 1.5; p = 0.001). Nonetheless, the percentage of patients who were upstaged after histopathological analysis of the resected lymph nodes was similar between the two groups. In conclusion, RATS and VATS yielded comparable results for most of the short-term outcomes assessed. Further research is needed to validate the implementation of RATS and identify its potential benefits over VATS.

Preoperative prognostic factors for 5-year survival following pulmonary metastasectomy from colorectal cancer: a systematic review and meta-analysis.

OBJECTIVES: We seek to identify preoperative prognostic factors and measure their effect on 5-year survival following pulmonary metastasectomy (PM) for Colorectal Cancer (CRC). METHODS: We systematically reviewed the databases of Cochrane Library, MEDLINE, Embase and Google Scholar from January 2000 to April 2021 to identify preoperative factors that have been investigated for their prognostic effect on survival following PM. Quality assessment was performed using the QUIPS tool. The prognostic effect of each identified factor on 5-year survival post-PM was estimated using random-effects meta-analyses. RESULTS: We identified 115 eligible articles which included 13 294 patients who underwent PM from CRC. The overall 5-year survival after resection of the lung metastasis was 54.1%. The risk of bias of the included studies was at least moderate in 93% (107/115). Seventy-seven preoperative factors had been investigated for their prognostic effect. Our analysis showed that 11 factors had favourable and statistically significant prognostic effect on 5-year survival post-PM. These included solitary metastasis, size <2 cm, unilateral location, N0 thoracic disease, no history of extra-thoracic or liver metastasis, normal carcinoembryonic antigen levels both before PM and CRC excision, no neo-adjuvant chemotherapy before PM, CRC T-stage < T4 and no p53 mutations on CRC. Disease-free interval at 24 months did not appear to affect 5-year survival. CONCLUSIONS: Despite the considerable risk of bias in the literature, our study consolidates the available evidence on preoperative prognostic factors for PM from CRC. These findings can complement both clinical practice and the design of future research on the field of PM.

A paradigm shift for diaphragmatic and chest wall reconstruction using a bovine acellular dermal matrix: an analysis versus synthetic meshes.

OBJECTIVES: Recently, biologic meshes have gained increasing popularity in soft tissue reconstruction. The aim of this study was to investigate the use of a bovine acellular dermal matrix (SurgiMend, Integra LifeSciences, Princeton, NJ, USA) in diaphragmatic and chest wall reconstruction by comparing it with synthetic meshes. METHODS: Consecutive patients who underwent diaphragmatic and/or chest wall reconstruction at a single center from 2016 to 2021 were retrospectively reviewed. Outcome measures included surgical site complications, readmission, and reoperation. RESULTS: Sixty-six patients underwent diaphragmatic and/or chest wall reconstruction for a malignant (74.2%) or benign (25.8%) disease. SurgiMend was used in 26 (39.4%) patients and a synthetic mesh in 40 (60.6%) patients. There were no significant differences in baseline characteristics between the groups. Surgical site complications included prolonged air leak (12.1%), pleural effusion (9.1%), pneumothorax (3%), empyema (1.5%), and wound infection (1.5%). The patients in the synthetic mesh group developed a significantly higher rate of surgical site complications compared to those in the SurgiMend group (37.5% vs. 11.5%; p = 0.025). Similarly, the readmission rate was significantly higher in the synthetic mesh group (17.5% vs. 0%; p = 0.037), with causes including pleural effusion (n = 3), pneumothorax (n = 2), empyema (n = 1), and pneumonia (n = 1). Among the study cohort, only 1 patient with a synthetic mesh underwent reoperation (p > 0.99). CONCLUSIONS: The use of surgiMend in diaphragmatic and chest wall reconstruction is associated with fewer surgical site complications and readmissions compared to synthetic meshes.

Complete Surgical Resection of a Giant Invasive Thymoma with Right Pneumonectomy and Graft Reconstruction of the Superior Vena Cava and Left Brachiocephalic Vein: A Case Report.

Background: Complete surgical resection represents one of the most important prognostic factors for thymomas. However, surgery is usually not considered when there is invasion of the pulmonary hilum and mediastinal veins because of technical considerations or potential perioperative morbidity and mortality. Case Presentation. We present the case of a 37-year-old woman with a giant thymoma infiltrating the superior vena cava, left brachiocephalic vein, and most of the right lung. Following 3 cycles of chemotherapy with minimal tumour response, she was hospitalised with COVID-19 and refused further systemic treatment. She subsequently underwent surgery after a thorough preoperative evaluation. Surgical resection of the tumour was performed with concomitant right pneumonectomy and reconstruction of the superior vena cava and left brachiocephalic vein using expanded-polytetrafluoroethylene grafts through a median sternotomy combined with a clamshell incision. Histopathological analysis of the resected specimens demonstrated a type B2, Masaoka-Koga stage IVa thymoma that was completely resected. Following an uneventful course, she was discharged home on the ninth postoperative day with anticoagulation therapy. She has remained free of disease or adverse events after a 12-month follow-up. Conclusions: Complete surgical resection of invasive thymomas with concomitant pneumonectomy and venous graft reconstruction is a feasible and safe procedure. Careful patient selection and adequate postoperative anticoagulation are crucial for successful clinical outcomes.

Lymphoepithelioma-Like Carcinoma of the Lung Associated With Epstein-Barr Virus in a Caucasian Patient: A Case Report.

Primary pulmonary lymphoepithelioma-like carcinoma (LELC) is a rare tumour that is histologically identical to the lymphoepithelioma originally described in the nasopharynx. It mostly occurs in endemic regions in Asia, where it is associated with Epstein-Barr virus (EBV) infection. The incidence of primary pulmonary LELC is even lower in the Western population, in which an association with EBV is not typically observed. In this report, we present the case of a 78-year-old Caucasian woman who was diagnosed with EBV-positive pulmonary LELC following lingulectomy and histopathological examination of the tumour. Metastasis from the nasopharynx was excluded clinically and radiologically. Due to the absence of regional lymph node involvement, the patient did not receive adjuvant therapy. She remained free of disease at the one-year follow-up. Reporting cases of primary pulmonary LELC in non-Asian patients can help to elucidate the association with EBV infection and its potential implications for diagnosis, treatment, and follow-up.

Evaluation of the safety and effectiveness of neoadjuvant combined chemoimmunotherapy in the treatment of locally advanced esophageal squamous cell carcinoma: a retrospective single-arm cohort study.

Background: Transforming potentially resectable advanced esophageal squamous cell carcinoma (ESCC) into resectable ESCC through preoperative induction therapy is an important component of ESCC comprehensive treatment. Immune checkpoint inhibitor (ICI) therapy has been shown to have significant effects in the treatment of advanced ESCC, but its role in the neoadjuvant treatment of potentially resectable ESCC is unclear. This study aims to investigate the safety and effectiveness of camrelizumab combined with chemotherapy in the neoadjuvant treatment of ESCC. Methods: We recruited consecutive patients with potentially resectable ESCC who received preoperative camrelizumab in combination with chemotherapy. Data including demographic data, clinicopathological characteristics, neoadjuvant treatment regimens, lesion changes observed by imaging, and surgical details were retrospectively collected through specially designed forms. Toxic effects of neoadjuvant therapy on hematology, gastrointestinal tract, liver, kidney, skin, and thyroid were also collected. Imaging assessments were performed every 1-2 treatment cycles. Follow-up is based on the patient's regular admission to the hospital for examination and treatment, at least 3 months after surgery. Results: A total of 66 patients with locally advanced ESCC were included in this study, including 8 patients with stage II, 29 patients with stage III, and 29 patients with stage IVA. The objective response rate (ORR) of the neoadjuvant immunotherapy combined with chemotherapy was 75.76% (50/66), and no one developed disease progression. A total of 60 patients underwent surgery, and the R0 resection rate was 98.3% (59/60). The pathological complete remission (pCR) rate and the major pathological response (MPR) rate was 6.7% (4/60) and 20% (12/60), respectively. There were 14 cases of treatment-related adverse reactions >3, but no perioperative deaths occurred. Conclusions: Neoadjuvant immunotherapy combined with chemotherapy followed by surgical resection may be an available treatment for patients with locally advanced ESCC.