Fluorescence-Guided Identification of the Thoracic Duct by VATS for Treatment of Postoperative Chylothorax: A Short Case Series.

Background: Chylothorax is a relatively rare complication after surgery of the mediastinum. The occurrence and the results of surgical treatment of this condition are difficult to foresee due to the wide heterogeneity in thoracic duct anatomy. Case summary: We report two cases of postoperative chylothorax treated with ligation by video-assisted thoracoscopic surgery (VATS). The first patient developed a massive left chylothorax shortly after discharge, following radical excision of a seminoma-involved left para-aortic lymphadenopathy. The second patient developed a high-output right chylothorax following VATS upper bilobectomy. In both cases, a surgical revision by VATS was performed. Inguinal injection of indocyanine green allowed an easy visualization of the lymphatic leakage point. In both cases, oral feeding was rapidly restarted after surgery. No recurrence of chylothorax was observed. Conclusion: The use of indocyanine green may greatly improve the identification of the thoracic duct during surgical ligation by VATS, with a favorable impact on the postoperative course and overall admission costs.

Hybrid minimally invasive treatment of intralobar pulmonary sequestration: a single-centre experience.

Pulmonary sequestrations are rare congenital malformations. They are often located in the lower lobes, and they are supplied by an aberrant systemic vessel arising from the thoracic aorta or abdominal arteries. These pulmonary malformations are divided into intra- and extralobar sequestrations, depending on the respective lack or presence of an independent pleural covering. Pulmonary sequestration can be asymptomatic or lead to recurrent pulmonary infections. The goal of this study was to analyse the feasibility and safety of a hybrid sequential approach. We report a small series of intralobar pulmonary sequestrations, from November 2017 to December 2018, successfully treated with a hybrid minimally invasive approach consisting of endovascular embolization of the aberrant arterial branch followed by video-assisted thoracoscopic lobectomy the day after. Thoracic pain following endovascular embolization was noted in all cases. Patients were discharged early in the absence of major postoperative complications. Prolonged air leak was observed in only 1 case. Despite the presence of sequestration-related pulmonary inflammation, in our experience, hybrid treatment for intralobar pulmonary sequestration is a safe and reproducible approach in terms of postoperative complications and hospital stay.

Video-assisted thoracoscopic lobectomy after neoadjuvant chemotherapy for non-small cell lung cancer: a multicenter propensity-matched study.

BACKGROUND: The role of video-assisted thoracoscopic surgery for the treatment of non-small-cell lung cancer after neoadjuvant chemotherapy remains controversial. The aim of this study is to demonstrate the reliability of video-assisted lobectomy compared to the open approach by evaluating perioperative and long-term outcomes. METHODS: In this retrospective, multicentric study from January 2010 to December 2018, we included all patients with non-small-cell lung cancer who underwent lobectomy through the video-assisted or open approach after neoadjuvant chemotherapy. The perioperative outcomes, including data concerning the feasibility of the surgical procedure, the occurrence of any medical and surgical complications and long-term oncological evidence, were collected and compared between the two groups. To minimize selection bias, propensity score matching was performed. RESULTS: A total of 286 patients were enrolled: 193 underwent thoracotomy lobectomy, and 93 underwent VATS lobectomy. The statistical analysis showed that surgical time (P < 0.001), drainage time (P < 0.001), days of hospitalization (P < 0.001) and VAS at discharge (P = 0.042) were lower in the VATS group. The overall survival and disease-free survival were equivalent for the two techniques on long-term follow-up. CONCLUSIONS: VATS lobectomy represents a valid therapeutic option in patients affected by non-small-cell lung cancer after neoadjuvant chemotherapy. The VATS approach in our experience seems to be superior in terms of the perioperative outcomes, while maintaining oncological efficacy.

Thymomectomy plus total thymectomy versus simple thymomectomy for early-stage thymoma without myasthenia gravis: a European Society of Thoracic Surgeons Thymic Working Group Study.

OBJECTIVES: Resection of thymic tumours including the removal of both the tumour and the thymus gland (thymothymectomy; TT) is the procedure of choice and is recommended in most relevant articles in the literature. Nevertheless, in recent years, some authors have suggested that resection of the tumour (simple thymomectomy; ST) may suffice from an oncological standpoint in patients with early-stage thymoma who do not have myasthenia gravis (MG) (non-MG). The goal of our study was to compare the short- and long-term outcomes of ST versus TT in non-MG early-stage thymomas using the European Society of Thoracic Surgeons thymic database. METHODS: A total of 498 non-MG patients with pathological stage I thymoma were included in the study. TT was performed in 466 (93.6%) of 498 patients who had surgery with curative intent; ST was done in 32 (6.4%). The completeness of resection, the rate of complications, the 30-day mortality, the overall recurrence and the freedom from recurrence were compared. We performed crude and propensity score-adjusted comparisons by surgical approach (ST vs TT). RESULTS: TT showed the same rate of postoperative complications, 30-day mortality and postoperative length of stay as ST. The 5-year overall survival rate was 89% in the TT group and 55% in the ST group. The 5-year freedom from recurrence was 96% in the TT group and 79% in the ST group. CONCLUSION: Patients with early-stage thymoma without MG who have a TT show significantly better freedom from recurrence than those who have an ST, without an increase in postoperative morbidity rate.

The Role of Obesity in Early and Long-Term Outcomes after Surgical Excision of Lung Oligometastases from Colorectal Cancer.

Obesity correlates with better outcomes in many neoplastic conditions. The aim of this study was to assess its role in the prognosis and morbidity of patients submitted to resection of lung oligometastases from colorectal cancer. Seventy-six patients undergoing a first pulmonary metastasectomy were retrospectively included in the study. Seventeen (22.3%) were obese (body mass index (BMI) >30 kg/m2). Assessed outcomes were overall survival, time to recurrence, and incidence of post-operative complications. Median follow-up was 33 months (IQR 16-53). At follow-up, 37 patients (48.6%) died, whereas 39 (51.4%) were alive. A significant difference was found in the 3-year overall survival (obese 80% vs. non-obese 56.8%, p = 0.035). Competing risk analysis shows that the cumulative incidence of recurrence was not different between the two groups. Multivariate analysis reveals that the number of metastases (p = 0.028), post-operative pneumonia (p = 0.042), and DFS (p = 0.007) were significant predictors of death. Competing risk regression shows that no independent risk factor for recurrence has been identified. The complication rate was not different between the two groups (17.6% vs. 13.6%, p = 0.70). Obesity is a positive prognostic factor for survival after pulmonary metastasectomy for colorectal cancer. Overweight patients do not experience more post-operative complications. Our results need to be confirmed by large multicenter studies.

The Impact of Preoperative Inflammatory Markers on the Prognosis of Patients Undergoing Surgical Resection of Pulmonary Oligometastases.

The aim of this study was to assess the prognostic value of preoperative neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP) levels in patients undergoing resection of pulmonary oligometastases. A retrospective analysis on 141 patients undergoing a first pulmonary metastasectomy in a single center was carried out. Two distinct analysis were performed subdividing patients according to their NLR ratio and CRP level. The main outcomes were survival and time to recurrence. At completion of follow-up 74 patients were still alive (52.5%). Subdividing patients according to their NLR yielded a significant difference in five-year progression-free survival (PFS, NLR < 4:32% vs. NLR ≥ 4:18%, p = 0.01). When subdivided by their CRP levels, patients with preoperative CRP < 5 mg/L demonstrated higher values of five-year overall survival (OS, 57% vs. 34%, p = 0.006) and five-year PFS (35% vs. 22%, p = 0.04). At multivariate analysis, level of neutrophils (p = 0.009) and lung comorbidities (p = 0.021) were independent predictors of death, whereas preoperative CRP (p = 0.002), multiple metastases (p = 0.003) and presence of lung comorbidities (p = 0.001) were independent predictors of recurrence. NLR and CRP are important predictors of prognostic outcome in patients undergoing pulmonary metastasectomy.

Management of pulmonary ground-glass opacities: a position paper from a panel of experts of the Italian Society of Thoracic Surgery (SICT).

OBJECTIVES: A significant gap in our knowledge of how to manage pulmonary ground-glass opacities (GGOs) still exists. Accordingly, there is a lack of consensus among clinicians on this topic. The Italian Society of Thoracic Surgery (Società Italiana di Chirurgia Toracica, SICT) promoted a national expert meeting to provide insightful guidance for clinical practice. Our goal was to publish herein the final consensus document from this conference. METHODS: The working panel of the PNR group (Pulmonary Nodules Recommendation Group, a branch of the SICT) together with 5 scientific supervisors (nominated by the SICT) identified a jury of expert thoracic surgeons who organized a multidisciplinary meeting to propose specific statements (n = 29); 73 participants discussed and voted on statements using a modified Delphi process (repeated iterations of anonymous voting over 2 rounds with electronic support) requiring 70% agreement to reach consensus on a statement. RESULTS: Consensus was reached on several critical points in GGO management, in particular on the definition of GGO, radiological and radiometabolic evaluation, indications for a non-surgical biopsy, GGO management based on radiological characteristics, surgical strategies (extension of pulmonary resection and lymphadenectomy) and radiological surveillance. A list of 29 statements was finally approved. CONCLUSIONS: The participants at this national expert meeting analysed this challenging topic and provided a list of suggestions for health institutions and physicians with practical indications for GGO management.

Surgery versus stereotactic radiotherapy for treatment of pulmonary metastases. A systematic review of literature.

It is not clear as to which is the best treatment among surgery and stereotactic radiotherapy (SBRT) for lung oligometastases. A systematic review of literature with a priori selection criteria was conducted on articles on the treatment of pulmonary metastases with surgery or SBRT. Only original articles with a population of patients of more than 50 were selected. After final selection, 61 articles on surgical treatment and 18 on SBRT were included. No difference was encountered in short-term survival between pulmonary metastasectomy and SBRT. In the long-term surgery seems to guarantee better survival rates. Mortality and morbidity after treatment are 0-4.7% and 0-23% for surgery, and 0-2% and 4-31% for SBRT. Surgical metastasectomy remains the treatment of choice for pulmonary oligometastases.

VATS-US1: Thoracoscopic ultrasonography for the identification of nodules during lung metastasectomy.

Open thoracotomy during pulmonary metastasectomy allows lung palpation and may discover unexpected further nodules. We assess the validity of intraoperative lung ultrasonography via thoracoscopy in identifying lung nodules. A first surgeon will perform an ultrasonographic investigation on the deflated lung by thoracoscopy. A second surgeon will then perform a manual exploration of the organ by thoracotomy. Data on number and localization of nodules will be matched and compared with final histology report. Sensitivity and specificity will be assessed. Concordance will be assessed with Cohen K test. Calculated sample size is 89 patients. This study might have an important role in shifting the surgical practice towards a less invasive approach, with consequent benefits for the patient. Protocol is registered on clinicaltrials.gov. Protocol registration number: NCT03864874.

Chest wall reconstruction using a new titanium mesh: a multicenters experience.

BACKGROUND: Many new surgical techniques and materials have been introduced in the last decade for chest wall reconstruction or stabilization with the purpose of improving the incorporation, maintaining chest wall stability with reduction of infections. However, none of them are yet considered a gold standard procedure. The aim of this work is to evaluate the initial experience using a new titanium mesh for chest wall reconstruction in four Italian Thoracic Surgery Departments. METHODS: A review was performed of all patients undergoing chest wall reconstruction using a new titanium mesh between January 2014 and September 2018. Surgical indications, the location and size of the chest wall defect, intraoperative variables and postoperative complications were analyzed. RESULTS: A total of 26 consecutive patients were included. The most common indications for surgery were primary or secondary chest wall tumors (38%) followed by lung cancer invading chest wall (31%). The most common localization of chest wall defect was anterolateral (46%). Sternal reconstruction was required in 3 patients (12%). The average size of the defect was 9.3×7.8 cm. The median number of resected ribs was 3.6. No perioperative deaths occurred. Mean hospital stay was 11.9 days. Overall morbidity was 19%. One failure of reconstruction (4%) was reported during follow up. CONCLUSIONS: In our early clinical experience chest wall reconstruction using titanium mesh can be performed as a safe and effective surgical procedure. This mesh has excellent biomechanical characteristics between rigid and malleable materials, it's easy to trim and fix for optimal adaptation without necessity of dedicated instruments. The early and mid-term results are satisfactory with low incidence of complications related to the titanium mesh implant.

Lymphadenectomy during pulmonary metastasectomy: Impact on survival and recurrence.

BACKGROUND AND OBJECTIVES: Lymphadenectomy during pulmonary metastasectomy (PM) is widely carried out. We assessed the potential benefit on patient survival and tumor recurrence of this practice. METHODS: One hundred eighty-one patients undergoing a first PM were studied. Eighty-six patients (47.5%) underwent lymphadenectomy (L+ group) whereas 95 (52.5%) did not undergo nodal harvesting (L-group). Main outcomes were overall survival (OS) and disease-free survival (DFS). Median follow-up was 25 months (interquartile range [IQR], 13-49). RESULTS: At follow-up 84 patients (46.4%) died, whereas 97 (53.6%) were still alive with recurrence in 78 patients (43%). There was no difference in 5-year survival (L+ 30.0% vs L- 43.2%; P = .87) or in the 5-year cumulative incidence of recurrence (L + 63.2% vs L-80%; P = .07) between the two groups. Multivariable analysis indicated that disease-free interval (DFI) less than 29 months (P < .001) and lung comorbidities (P = .003) were significant predictors of death. Metastases from non-small-cell lung cancer increased the risk of lung comorbidities by a factor of 19.8, whereas the risk of DFI less than 29 months was increased nearly 11-fold. Competing risk regression identified multiple metastases (P = .004), head/neck primary tumor (P = .009), and age less than 67 years (P = .024) as independent risk factors for recurrence. CONCLUSION: Associated lymphadenectomy showed not to give any additional advantage in terms of survival and recurrence after PM.

Small incisions, major complications: video-assisted thoracoscopic surgery management of intraoperative complications.

The object of our study is to show the causes leading to conversion, in order to observe the responsible variables and analyses if conversion influences the patient's outcome. Between January 2013 and December 2016, Udine Thoracic Department performed 180 video-assisted thoracoscopic surgery (VATS) lobectomies, and 24 cases were converted to thoracotomy due to an intra-operative complication such as arterial or venous bleeding, airway and other injuries. The VATS lobectomies' number increased over the three years: from 27 in 2013 to 55 in 2015 and 48 in 2016. While conversion's rate decreased from 33% in 2013 to 5.5% in 2015 and 10% in 2016. We performed a univariate and a multivariate analysis looking for the variables affecting the conversion rate. This was significantly related to intraoperative bleeding and airway injuries (P<0,001). Seventy-year older patients were not associated to a higher conversion rate, instead they showed an increased risk of post-operative complications (P<0,018, RR =1.8). We have focused our attention on all the variables leading to conversion and conditioning the patient's outcome in terms of post-operative complications and length of stay. The best strategy to face VATS complication is to prevent them. Young surgeons at the beginning of their learning curve should perform VATS lobectomies under close supervision of a skilled VATS surgeon. Moreover, conversion to open thoracotomy should be not considered a failure of VATS, but rather a procedure for patient's safety.

Long-term outcome for early stage thymoma: comparison between thoracoscopic and open approaches.

BACKGROUND: Complete surgical excision is the most important long-term prognostic factor of thymomas. Although video-assisted thoracoscopic surgery (VATS) has been reported as an effective treatment to excise mediastinal thymic lesions, it has not replaced median sternotomy as the standard approach because of the lack of long-term follow-up studies. The objective of this study was to analyze and to compare the outcome of VATS extended thymectomy with the traditional open approach. METHODS: This is a single center's retrospective study of 27 patients submitted to surgery for early stage thymomas between 1995 and 2007. Histologic subtype and clinicopathologic staging were classified, respectively, according to World Health Organization and Masaoka criteria. Patients with preoperative computed tomography scan evidence of clinical Masaoka stage 1 thymomas were selected for VATS thymectomy with unilateral technique. RESULTS: All patients successfully underwent surgery: 3 with VATS and 4 with an open approach. There were no differences in time of surgery and postoperative complication between the two groups. Patients who had VATS had shorter postoperative hospital stay than patients who had open technique. After a median follow-up of 123 months, there were no postoperative recurrences. CONCLUSION: VATS is a safe operation and has comparable effectiveness to the open technique in terms of oncological radicality for small, early stage thymoma.

Gastrointestinal bleeding in lung leiomyosarcoma history: report of a case.

The paper presents an unusual case of single small bowel metastasis from primary lung leiomyosarcoma (PLL) presenting with abdominal pain and gastrointestinal (GI) bleeding successfully treated by surgery with radical aim.