Subcostal Specimen Removal in Completely Portal Robotic Lobectomy.

The Completely Portal Robotic Lobectomy (CPRL-4) technique is increasingly favored for lobectomy procedures due to its advancements over traditional robot-assisted lobectomy (RAL). CPRL-4 integrates a fourth robotic arm and CO2 insufflation, resulting in superior visualization within the intrathoracic cavity owing to enhanced lung deflation. While CPRL-4 effectively achieves pulmonary resection, extracting specimens typically necessitates an intercostal utility thoracotomy, which may pose risks. To address potential damage associated with this method, we introduced a subcostal trans-diaphragmatic access port during resection, later enlarging it for specimen removal post-lobectomy. This study evaluated the efficacy and feasibility of this subcostal trans-diaphragmatic specimen removal approach following CPRL-4 procedures for pulmonary malignancies, all performed by a single surgical team. The findings suggest that subcostal specimen removal post-CPRL-4 offers several advantages, including reduced risk of thoracotomy-related complications, making it a practical, feasible, and safe method. This innovation has the potential to improve outcomes and patient care in pulmonary malignancy surgeries significantly.

Impact of preoperative scores on postoperative process in bronchiectasis surgery.

Background: In this study, we aimed to investigate the relationship between bronchiectasis criteria, scores, and indices used today and surgical interventions due to bronchiectasis. Methods: Between January 2009 and December 2018, a total of 106 patients (53 males, 53 females; mean age: 39.1±12.3 years; range, 14 to 68 years) with non-cystic fibrous bronchiectasis were retrospectively analyzed. We determined symptom improvement and complications as main factors. We divided the patients into two main groups: those who had symptom improvement after pulmonary resection (Group 1, n=89) and those who did not (Group 2, n=17). We further analyzed patients who had postoperative complications (n=27) with those who did not (n=79). The following scores and criteria were used in this study: modified Reiff score, Gudbjerg criteria, Naidich criteria, Bronchiectasis Severity Index, and FACED scoring. Results: There was a statistically significant difference between the groups in terms of the modified Reiff scores and FACED scores. As the modified Reiff score increased, there was a higher rate of symptom relief (p=0.04). Contrary to this, an increase in the FACED score predicted a poorer postoperative outcome (p=0.03). Considering complications, a significant difference was observed in the Gudjberg criteria, and higher grade suggested a higher risk of complication (p=0.02). Conclusion: The grading and scoring systems related to bronchiectasis may have some predictive value in terms of surgical outcomes. A high modified Reiff score and a low FACED score can predict postoperative success, whereas Gudbjerg criteria can indicate postoperative complications.

Completely portal robotic lobectomy in lung cancer: is subcostal specimen removal necessary?

BACKGROUND: The best place for specimen extraction is a relevant question since either after robotic or video-thoracoscopic lobectomy, both intercostal and subcostal routes can be potential extraction routes. In this study, we studied completely portal robotic lobectomies (CPRL-4) for pulmonary neoplasms to investigate the efficacy and feasibility of subcostal specimen removal by comparing the two techniques. MATERIAL AND METHODS: Between January 2014 and July 2021, data from 90 patients who underwent robotic thoracic surgery with a Da Vinci Surgical System SI (Intuitive Surgical Inc., Mountain View, California, USA) were collected and retrospectively analyzed. Out of 90 patients, we analyzed 36 CPRL-4 cases. We removed specimens traditionally via intercostal utility thoracotomy in the first 22 patients (group A) and via subcostal incision in the next consecutive 14 patients (group B). Operative parameters, postoperative parameters, the visual analog scale (VAS) and SF36 life quality scoring were comparatively analyzed. RESULTS: The mean docking time was significantly higher in group B than in group A (26.2 ± 5.3 vs 17.8 ± 4.1) (p = .001). In terms of early-stage postoperative pain, group B had significantly lower pain scores compared to group A (p < .05). There was no significant difference between the groups in terms of SF36 life quality scoring. CONCLUSION: We can conclude that performing a subcostal incision is not a sophisticated process, though it significantly prolongs the docking time. Although our study is based on a small group, we noticed that removing the specimen through the subcostal incision after CPRL-4 is potentially useful, has several advantages and it is a practical, feasible, and safe method. CLINICAL REGISTRATION NUMBER: 2018/57.

How to facilitate concurrent lower lobectomy after coronary artery bypass grafting via median sternotomy without adding anterolateral thoracotomy?

BACKGROUND AND AIM: Median sternotomy is an unfavourable approach for performing lung resection and mediastinal lymphadenectomy. Some studies have speculated that concurrent pulmonary resections other than upper lobectomy, necessitate anterolateral thoracotomy in addition to sternotomy. In this study, we aimed to discuss the feasibility and advantages of concomitant video-thoracoscopy (VATS) assisted lower lobectomy after coronary artery bypass grafting (CABG). METHODS: We analysed 21 patients who underwent a single combined procedure that includes CABG followed by anatomical pulmonary resection and divided them into two groups: patients who underwent upper lobectomy via median sternotomy incision (Group A, n = 12) and patients who underwent lower lobectomy with video-thoracoscopic assistance (VATS) next to sternotomy incision (Group B, n = 9). RESULTS: There were no significant differences between the groups in age, sex, comorbidities, tumour side or size, tumour stage, tumour histopathology, number of dissected lymph node stations, N status, CABG type, number of grafts used, operative time, hospitalization and complication rates. CONCLUSION: The feasibility of upper lobectomies via median sternotomy is clear; however, performing lower lobectomies is challenging. In our study, we concluded that the operative feasibility of concurrent lower lobectomy by VATS assistance showed no essential difference to that of concurrent upper lobectomy by presenting that there was no statistically significant difference between the groups in terms of any studied parameters. We can speculate that median sternotomy with VATS assistance should be especially considered instead of anterolateral thoracotomy for lower lobectomies at centres where VATS lobectomies are performed.

Survival impact of unexpected N2 in stage IIIB/N2 non-small cell lung cancer patients.

BACKGROUND: We investigated the effect of unexpected N2 on survival in stage IIIB/N2 cases. METHODS: We retrospectively analyzed 1803 non-small cell lung cancer patients between 2010 and 2016. There were 89 patients (4.9%) with unexpected N2 (pathological (p) IIIB/N2 group), whereas 49 patients (2.7%) with cN2 (clinical (c) IIIB/N2 group). Although pIIIB/N2 group underwent surgery followed by adjuvant therapy, the cIIIB/N2 group of patients had multimodality treatment including induction chemotherapy ± radiotherapy followed by surgery. RESULTS: The five-year overall survival (OS) for all patients was 36.0% [median survival time (MST) 27.9 months], and disease-free survival (DFS) was 28.9% (MST, 18.2 months). The OS was 39.6% (MST: 34.4 months) and the median DFS time was 31.1% (Median: 23.1 months) in the pIIIB/N2 group, whereas it was 29.2% (MST: 23.0 months) for OS and 22% (median: 12.4 months) for DFS in the cIIIB/N2 group. There were no significant OS and DFS differences between the pIIIB/N2 group and the cIIIB/N2 group (p = 0.124 and p = 0.168, respectively). CONCLUSIONS: In stage IIIB/N2 cases, the fact that N2 could not be detected preoperatively with minimally invasive or invasive methods and was detected in the pathological examination after surgery does not provide a survival advantage.

Does mediastinal lymph node involvement influence the surgical outcome in malign pleural mesothelioma?

BACKGROUND: This study examined the effect of metastatic mediastinal lymph node involvement on the prognosis of patients with malignant pleural mesothelioma (MPM) who underwent extrapleural pneumonectomy (EPP) or extended pleurectomy (E/P) and also to assess the effect of metastatic mediastinal lymph node involvement on the prognosis of patients with MPM in these group of patients. METHODS: This retrospective study included 84 patients with MPM (66 men [78.6%] and 18 women [21.4%]) who underwent EPP (n = 44) or E/P (n = 40) at our institution between January 2001 and July 2019. Survival analyses were performed according to histopathology, nodal status, and surgical approach. RESULTS: In the EPP group, patients with T2-N2 status had a significantly better mean survival (17 ± 2.1 months) than patients with T3-N2 (7.3 ± 1.6 months) or T4-N2 (3.2 ± 1.1 months) status (p = .001). In the E/P group, patients with T2-N2 status had a mean survival of 18 ± 1.1 months, while patients with T3-N2 and T4-N2 status had mean survival durations of 6.6 ± 1.6 and 4.8 ± 1.2 months, respectively (p = .159). In both treatment groups, the survival rates of patients with epithelial tumors were better than those of patients with non-epithelial tumors, independent of N status. None of the patients with N2 disease survived until 5 years postoperatively. CONCLUSION: In summary, our results suggested that mediastinal lymph node metastasis negatively influenced the prognosis of patients with T3 MPM, regardless of treatment by EPP or E/P. Under these circumstances, preoperative cervical mediastinoscopy or endobronchial ultrasound-guided transbronchial needle aspiration may be considered for patients with high-stage MPM who are scheduled for surgery with curative intent. In our study, N2 status was spotted as a significant factor affecting survival, nevertheless its significance in survival of pleural mesothelioma patients should be analyzed in multi-centered studies.

Role of surgery in high-grade neuroendocrine tumors of the lung.

Background: This study aims to evaluate the surgical results for high-grade neuroendocrine carcinomas and to identify factors that influence prognosis. Methods: Between January 2009 and December 2017, a total of 71 patients (58 males, 13 females; mean age: 62±9.6 years; range, 38 to 78 years) with a high-grade neuroendocrine carcinoma of the lung were retrospectively analyzed. Overall survival and five-year overall survival rates were evaluated. Results: The mean overall survival was 60.7±6.9 months with a five-year survival rate of 44.3%. The mean overall survival and five-year overall survival rates according to disease stage were as follows: Stage 1, 67±10.8 months (46%); Stage 2, 61.4±10.8 months (45%); and Stage 3, 33.2±8.6 months (32%) (p=0.02). The mean overall survival and five-year overall survival rate according to histological types were as follows: in large cell neuroendocrine carcinoma, 59.4±9.2 months (45%); in small cell neuroendocrine carcinoma, 68.6±12.2 months (43%); and in combined-type neuroendocrine carcinoma, 40.9±10.1 months (35%) (p=0.34). Conclusion: Thoracic surgeons should be very selective in performing pulmonary resection in patients with Stage 3 high-grade neuroendocrine carcinomas and combined cell subtype tumors.

Clinical and surgical approaches for malignant pulmonary lesions after a previous extrapulmonary malignancy.

BACKGROUND: In our study, since the operative histopathological distinction of new malignant pulmonary lesions as either a primary lung cancer or a pulmonary metastasis is difficult, we aimed to identify the clinical variables which might allow distinction between a new lung cancer and a pulmonary metastasis, and the appropriate surgical management. METHODS: We divided 55 cases into two groups: patients with new lung cancer (NLC, n = 32) and patients with pulmonary metastases (PM, n = 23). Based on the primary organ, the previous malignancy was classified into four categories: head and neck, colorectal, genitourinary, and breast cancer. The parameters included in the study were age, sex, smoking history, a family history of cancer, disease-free interval, primary organ, treatments for previous malignancies, size, and SUV max of the lung lesion on 18F-fluorodeoxyglucose positron emission tomography scan and high-resolution computed tomography findings of the lung lesion. RESULTS: A predisposition for larger lesions was found in the NLC group. In addition, in the NLC group, disease-free interval was noted to be longer, patients were significantly older and SUV-max values of solitary pulmonary lesions were significantly higher than in the PM group. Pulmonary lesions in patients with prior head and neck cancers were more likely to develop NLC. No significant difference in statistical analysis was observed between the groups in terms of sex, smoking, a family history of cancer, a history of adjuvant therapy, radiological pulmonary lesions signs, and localization. CONCLUSION: PL monitoring on CT surveillance is essential, particularly in patients with previous head and neck cancers, who appear to have a higher risk for NLC. If pathological MLN accompanies PL in a patient with previous extrapulmonary malignancy, cervical mediastinoscopy may help acquire a possible PL diagnosis besides mediastinal staging. Intraoperative frozen section may have difficulty in distinguishing between PM and NLC when the lesion is of the same histological type as the previous malignancy. When precise distinction cannot be achieved by frozen section, we speculate that DFI, age, and radiological findings of the PL may help thoracic surgeons take initiative peroperatively while designating the subsequent surgical intervention. Lastly, pulmonary segmentectomy is also better be considered along with lobectomy in NLC cases.

What is the impact of a previously failed Robicsek repair in the subsequent treatment of sternal dehiscence with thermoreactive nitinol clips?

BACKGROUND: In this study, we conducted a retrospective review of patients at our institution with noninfectious sternal dehiscence (NISD) after median sternotomy who received thermoreactive nitinol clips (TRNC) treatment during a 10-year period. The purpose of the study was to analyze the impact of previous Robicsek repair on the later treatment of sternal dehiscence with TRCN to establish which method was better in high-risk patients with NISD. METHODS: Between December 2009 and January 2020, out of 283 patients with NISD who underwent refixation, we studied 34 cases who received TRNC treatment. We divided these 34 cases into two groups: patients who had a previously failed Robicsek procedure before TRNC treatment (group A, n = 11) and patients who had been directly referred to TRCN treatment (group B, n = 23). High-risk patients were defined as those having three or more risk factors. RESULTS: Postoperative complication rate was significantly higher in group A (p = .026). Hospitalization duration was significantly longer in group A due to the higher complication rate (p = .001). Operative time was significantly shorter and blood loss was significantly lower in group B (p = .001). CONCLUSION: The Robicsek procedure is considered an effective method in the treatment of NISD but, in case of its failure, subsequent TRNC treatment might become cumbersome in high-risk patients. In our study, a previously failed Robicsek procedure caused significantly higher morbidity, additional operative risk and lower success rate in later TRNC treatment of high-risk cases. Ultimately, we speculate that a direct TRNC treatment for NISD is favorable in high-risk patients.

The Significance of Skip Mediastinal Lymph Node Metastasis in the Prognosis of Patients with Resected Non-Small-Cell Lung Carcinoma: Is It Really a Better N2 Disease Subtype?

OBJECTIVE: In this study, we aimed to reveal the prognostic differences between skip and non-skip metastasis mediastinal lymph node (MLN) metastasis. METHODS: A total of 202 patients (179 males and 23 females; mean age, 59.66 ± 9.89 years; range: 29-84 years) who had ipsilateral single-station MLN metastasis were analyzed in two groups retrospectively between January 2009 and December 2017: "skip ipsilateral MLN metastasis" group (sN2) (n = 55,27.3%) [N1(-), N2(+)], "non-skip ipsilateral MLN metastasis" group (nsN2) (n = 147,72.7%) [N1(+), N2(+)]. RESULTS: The mean follow-up was 42.63 ± 34.91 months (range: 2-117 months). Among all patients, and in the sN2 and nsN2 groups, the median overall survival times were 63.5 ± 4.56, 68.8 ± 7, and 59.3 ± 5.35 months, respectively, and the 5-year overall survival rates were 38.2%, 46.3%, and 36.4%. CONCLUSION: Skip metastasis did not take its rightful place in TNM classification; thus, further studies will be performed. To detect micrometastasis, future studies on skip metastasis should examine non-metastatic hilar lymph nodes (LNs) through staining methods so that heterogeneity in patient groups can be avoided, that is, to ensure that only true skip metastasis cases are included. Afterwards, more accurate and elucidative studies on skip metastasis can be achieved to propound its prognostic importance in the group of N2 disease.

A prospective study on long-term trace metal accumulation in hair: Is there any difference between minimally invasive repair of pectus excavatum and carinatum?

BACKGROUND: To date, there is no study about trace metal level increases in hair after stainless steel pectus bar implantation. We aimed to determine whether there was any significant increase in the levels of trace metals in the hair of children who underwent minimally invasive repair of pectus excavatum (MIRPE) and minimally invasive repair of pectus carinatum (MIRPC). MATERIALS AND METHODS: In this prospective study, we collected the data of 223 patients who underwent MIRPE and MIRPC between November 2013 and August 2020. The levels of main components of the stainless steel pectus bar ("PES", Medxpert GmbH, Escbach, Germany) namely Cr, Fe, Ni, and Mo in hair were analyzed. The study involved two study groups: A group of patients who underwent MIRPE with a single bar (n = 112) and a group of patients who underwent MIRPC (n = 71). Both groups were analyzed in two different timelines: A group of consecutive patients prior to bar implantation and a group of the same patients who underwent bar removal after a mean time of 34.6 ± 5.1 months. RESULTS: Statistically significant increases in all studied trace metal levels were observed in the single-bar MIRPE group. In the MIRPC group, the accumulation of studied trace metals was no statistically significant. The double-bar MIRPE group had higher trace metal increase rates compared to single-bar MIRPE group (p>0.05). CONCLUSION: In our study; increases in iron, chrome, nickel and molybdenum levels were observed in both MIRPE and MIRPC patients by hair trace metal analysis; but these increases were statistically significant in only MIRPE group.

The effect of transcutaneous electric nerve stimulation on chronic postoperative pain and long-term quality of life.

BACKGROUND: This study aims to investigate the effects of transcutaneous electrical nerve stimulation on early-stage postoperative pain and long-term quality of life in patients undergoing thoracotomy. METHODS: Between January 2019 and September 2019, a total of 100 patients (76 males, 24 females; mean age: 57.9±11.9 years; range, 51 to 79 years) who underwent thoracotomy due to benign or malignant lesions were included. The patients were divided into two groups: 50 patients who received transcutaneous electrical nerve stimulation (Group 1) and a control group of 50 patients who did not receive transcutaneous electrical nerve stimulation (Group 2). The Short Form-36 life quality scale was used to evaluate patients' quality of life at one month before and after surgery. RESULTS: The mean length of hospital stay was 4.9±3.1 days in Group 1 and 6.2±4.6 days in Group 2 (p=0.008). There were no statistically significant differences in early-stage postoperative pain scores between the groups (p>0.05). Compared to Group 2, Group 1 had significantly lower pain scores and higher life quality scores pre- and postoperatively (p<0.05). CONCLUSION: Transcutaneous electrical nerve stimulation is an effective method to manage chronic pain in the postoperative period. On the other hand, it does not effectively reduce early-stage postoperative pain or affect complication rates. The prevention of chronic postoperative pain by transcutaneous electrical nerve stimulation improves long-term quality of life of patients.

Robot-assisted lobectomy versus completely portal robotic lobectomy: What is the difference?

BACKGROUND: This study aims to compare robot-assisted lobectomy versus completely portal robotic lobectomy. METHODS: Between January 2014 and December 2019, a total of 41 patients (10 males, 31 females; median age 62 years; range, 50 to 68 years) underwent robotic anatomical pulmonary resection in our institution were retrospectively analyzed. The patients were consecutively divided into two groups: the first 20 (48.8%) patients underwent pulmonary resection by robot-assisted lobectomy technique, while the next 21 (51.2%) patients underwent pulmonary resection by completely portal robotic lobectomy with four arms. Data including age, sex, diagnosis, surgery type and duration, rate of conversion to open surgery, and length of stay of the patients were recorded. The operation time, docking time, console time, and closure duration for each patient were also noted. RESULTS: There was no statistically significant difference in age, sex, comorbidities, complications, length of hospital stay, adequate lymph node staging, or tumor size and side between the two groups (p>0.05). However, the mean console and operation times were statistically significantly shorter in the patients receiving completely portal robotic lobectomy with four arms (p=0.001). CONCLUSION: The advantage of completely portal robotic lobectomy with four arms is relative, although it significantly shortens the operation time. Based on our experiences, this technique may be preferred in case of inadequate lung deflation, as carbon dioxide insufflation allows sufficient workspace for robotic lung resection.

Transcervical mediastinoscopy in patients with a permanent tracheostomy: is it feasible?

OBJECTIVES: Cervical mediastinoscopy may become essential in patients with pathological lymph nodes at mediastinum after laryngectomy. However, having had a previous tracheostomy has been reported to be a contraindication for cervical mediastinoscopy. METHODS: Between January 2010 and December 2017, cervical mediastinoscopy was performed for lung cancer staging in 1985 patients at the Department of Thoracic Surgery, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul, Turkey. Eighteen of these patients (1%) had a permanent tracheostomy after total laryngectomy and cervical radiotherapy due to laryngeal carcinoma. RESULTS: Cervical mediastinoscopy was performed in 18 patients with a permanent tracheostomy after total laryngectomy. The negative predictive value of cervical mediastinoscopy was 13/14 (93%). The average operative time was 63 min (SD 12.0, range 50-90 min). The negative predictive value of endobronchial ultrasonography was 4/7 (57%). Positron emission tomography-computed tomography had a positive predictive value of 3/15 (20%) and a negative predictive value of 2/3 (67%). CONCLUSIONS: Contrary to the claims of 2 textbooks, cervical mediastinoscopy is a viable method for patients with a tracheostomy after laryngectomy. The negative predictive values of standard cervical mediastinoscopy and mediastinoscopy for patients with a tracheostomy after total laryngectomy are approximately equivalent. Our results indicate that cervical mediastinoscopy is a feasible method in patients with a permanent tracheostomy when applied by experienced thoracic surgeons in specialized hospitals.

Unexpected conversion to thoracotomy during thoracoscopic lobectomy: a single-center analysis.

BACKGROUND: The aim of this study was to discuss indications and outcomes for conversion to thoracotomy during thoracoscopic lobectomy. MATERIALS AND METHODS: Patients who underwent lobectomy for non-small cell lung cancer between January 2012 and December 2016 were evaluated retrospectively. The study included 129 patients who underwent video-assisted thoracoscopic lobectomy (group-V) and 18 patients converted from thoracoscopic lobectomy to thoracotomy due to unexpected intraoperative complications (group-T). RESULTS: The two patient groups showed no statistical differences in terms of demographic characteristics. Causes of unexpected conversions to thoracotomy were hemorrhage in six patients, dense pleural adhesions in seven patients, fused fissure in one patient, and fibrocalcified lymph nodes around the vascular structures in four patients. Operative time was 180.37 ± 68.6 min in group-V and 235 ± 72.6 min in group-T (p = 0.003). Intraoperative blood loss was 263.9 ± 180.6 mL in group-V, compared to 562.7 ± 296.2 mL in group-T (p < 0.001). Patient age ≥ 70 years was a significant risk factor for conversion to thoracotomy (p = 0.015, odds ratio 4.73). The 5-year survival rate in group-V was 71.4% {mean: 65.2 months [95% confidence interval (CI) 59.6-70.8]}, while that in group-T was 80% [mean 54.9 months (95% CI 45.9-63.8)] (p = 0.548). CONCLUSION: Advanced age was identified as the main risk factor for conversion to thoracotomy. However, early- and long-term outcomes were similar in the two groups, indicating that video-assisted thoracoscopic surgery is a safe and applicable method.

Synchronous chondrosarcoma originating from two distant ribs.

A chondrosarcoma is a rare bone tumour derived from cartilage-producing malignant mesenchymal cells. A 25- year-old male patient was operated upon to treat a chondrosarcoma arising in the left 2nd and 6th ribs. The tumour underwent en bloc wide resection in collaboration with a plastic surgeon for reconstruction of the resected area. Costal chondrasarcoma is very rare but chondrosarcoma arising from two ribs at the same time has not been reported before in the literature.