Introduction of pediatric thoracoscopic lung resections in a low-volume center - feasibility, outcome and cost analysis.

BACKGROUND: Early series of pediatric thoracoscopic surgery have reported high conversion rates and significant complications. This study investigated the introduction of pediatric thoracoscopic lung resections in a low-volume center with reference to corresponding open thoracotomy procedures with regards to operative times, length of stay, cost of admission, and outcomes. METHODS: A single surgeon series. Data from the first 10 consecutive thoracoscopic lung resections were compared to a cohort of 10 consecutive open lung resections performed before the introduction of the thoracoscopic technique. All operations were performed between December 2015 and October 2021. The median follow-up was 34 months (range 4-65). RESULTS: The cohort included 14 lobectomies (8 thoracoscopic and 6 open) for congenital pulmonary airway malformation (CPAM), and 6 resections (mainly non-anatomic) of pulmonary sequestration (2 thoracoscopic and 4 open). One lobectomy required conversion to thoracotomy, and one patient required reinsertion of a chest drain after open lobectomy due to persistent air leak. No other complications were recorded. All patients were asymptomatic at their follow-up. There was no significant difference in the mean age, mean weight, operative times, and intraoperative blood loss between open and minimally invasive procedures. Thoracoscopic technique was associated with significantly shorter stay at pediatric intensive care unit and shorter overall inpatients stay. CONCLUSION: Thoracoscopic lung resections can be safely introduced in a low-volume center with comparable cost, operative time, and results and significantly shorter inpatient stay.

CYP1B1 Gene Polymorphism Based on Health Monitoring and Nursing Methods after Minimally Invasive Surgery for Lung Cancer.

The rapid development of science and technology has become an indispensable part of human life. Minimally invasive lung cancer surgery, that is, thoracoscopic surgery and da Vinci robotic surgery, has many advantages over previous surgeries, there is no need to make a large incision in the chest, the patient after such surgery, and recovery is also better and can also reduce the incision of the operation. Therefore, with the rapid development of science and technology today, how to detect changes in patients' health and establish an intelligent health monitoring system has become a development trend. This paper proposes to apply health monitoring in CYP1B1 gene polymorphism and nursing after clinical treatment of minimally invasive lung cancer surgery, after analyzing the society's demand for real-time health monitoring in this paper. It also studies the health monitoring system based on the advantages of smart phones. The system is suitable for the Android operating system and can monitor the temperature, weight, and other data of the human body. The experimental results show that the data value of the information displayed by the android software has a high degree of matching with the measured value, which basically keeps floating around 80, and the data consistency is strong.

Intraoperative margin assessment by wireless signals in thoracoscopic anterior (S3) segmentectomy using a radiofrequency identification marker.

Despite the use of near-infrared thoracoscopy with intravenous indocyanine green, intraoperative assessment of the surgical margin for the resection of non-palpable tumors located near the intersegmental plane requires highly advanced surgical skill for the prevention of local recurrence. Because the demarcation line is limited to the pleural surface, to overcome uncertainty in tumor palpation for deeply located small-sized lesions, other supplemental localization techniques have been proposed. Here, we present a novel surgical technique using radiofrequency identification markers for intraoperative assessment of the lateral surgical margin in segmentectomy.

Infrared thermography for assessment of thoracic paravertebral block: a prospective observational study.

BACKGROUND: There was no "gold standard" to assess the success or failure of thoracic paravertebral block (TPVB). Measurement of skin temperature with infrared thermography (IT) would be a reliable method to evaluate the effectiveness of regional blocks. This study aimed to explore the feasibility of using skin temperature difference (Td) determined by IT between the blocked and unblocked side to predict the spread of TPVB. METHODS: Sixty-one patients undergoing elective unilateral breast or thoracoscopic surgery were enrolled in this prospective observational study. TPVB was performed at T4 and T5 under real-time ultrasound guidance with 10 mL of 0.4% ropivacaine for each patient, respectively. Td between the blocked and unblocked side were measured with IT from T2 to T10 at the anterior chest wall before TPVB and 5 min, 10 min, 15 min and 20 min after TPVB. Pinprick test was performed at 20 min after TPVB. Successful TPVB was defined as no sensation to pinprick in 3 or more adjacent dermatomes corresponding to the site of injection at 20 min after TPVB. Td was compared to pinprick test for evaluating its effectiveness in predicting the success of TPVB. The sensitivity, specificity, and cut-off value of Td for predicting successful TPVB were determined by receiver operator characteristic (ROC) curve analysis. RESULTS: Compared with the baseline value before block, Td from T2 to T10 were significantly increased at each time point in successful blocks. In failed blocks, Td was not increased in any dermatome. The increase of Td at T4-T7 was more than 1 °C 20 min after successful TPVB. Fifteen minutes after block, Td increase at T4 had the greatest potential to predict block success. The area under the ROC curve was 0.960 at a cut-off value of 0.63 °C with a sensitivity of 83.3% and a specificity of 100.0%. CONCLUSIONS: This study suggested that the increase of Td at T4 dermatome determined by IT between the blocked and unblocked side is an early, quantitative, and reliable predictor of successful TPVB. TRIAL REGISTRATION: Clinical trial registration: NCT04078347 .

Eficacia y seguridad del drenaje pleural con SET de drenaje torácico digital en pacientes adultos con derrame pleural maligno o fístula pulmonar / Efficacy and safety of pleural drainage with digital chest drainage SET in adult patients with malignant pleural effusion or pulmonary fistula

INTRODUCCIÓN: El presente documento de evaluación de tecnología sanitaria (ETS) expone la evaluación de la eficacia y seguridad del drenaje pleural con set de drenaje torácico digital (SDTD) en pacientes adultos con derrame pleural maligno (DPM) o fístula pulmonar en comparación con el set de drenaje torácico convencional (SDTC). El derrame pleural maligno (DPM) y las fistulas broncopleurales (FBP) son condiciones amenazantes para la vida del paciente. El DPM es una condición que ocurre en su mayoría en pacientes en etapas avanzadas de cáncer y cuya expectativa de vida es muy baja. Por otro lado, las FBP son comunicaciones patológicas entre el árbol bronquial y espacio pulmonar, que aparecen como consecuencia de una cirugía de reseccion pulmonar, por lo general por causas oncológicas, y con menor frecuencia debido a quimioterapias y radioterapias. El DPM y las FBP pueden producir la invasión de colecciones líquidas y aire en el espacio pleural; causando desestabilización de su presión negativa1 y consecuentemente colapso pulmonar y disnea respiratoria. Ambas condiciones deben ser tratadas a tiempo para favorecer el restablecimiento del espacio pleural y reexpansión pulmonar. Uno de los tratamientos del DPM o las FBP es el drenaje pleural, que permite descomprimir el espacio pleural del exceso de líquido o aire, permitiendo una mejor respiración, así como menor compromiso de otros órganos vitales. En el contexto de EsSalud, los pacientes con diagnóstico de DPM o FBP son tratados con la tecnología set de drenaje torácico convencional (SDTC); sin embargo, los médicos especialistas del Hospital Nacional Edgardo Rebagliati Martins (HNERM) han solicitado la incorporación al Petitorio de EsSalud de la tecnología sanitaria set de drenaje torácico digital (SDTD). La justificación de la inclusión de esta tecnología según los especialistas es que el SDTC requiere de un sistema de succión de pared, que limitaría la movilidad del paciente. Además, la lectura de los indicadores de drenaje y fuga aérea con esta tecnología debe ser realizada cualitativamente por un profesional, pudiendo existir subjetividad de la evaluación, así como variabilidad interobservador. Por el contrario, señalan que el SDTD cuenta con un sistema de succión portátil, y además, permite un registro digital evolutivo de los indicadores de ausencia de drenaje y fuga aérea en estos pacientes, lo que podría traducirse en un mayor beneficio clínico para ellos, en términos de recuperación y tiempo de estancia hospitalaria. METODOLOGÍA: Se realizó una búsqueda sistemática de información con el objetivo de identificar la mejor evidencia disponible a la fecha (02 de marzo de 2020) sobre la eficacia y seguridad del drenaje pleural con SDTD, comparado con SDTC, en pacientes adultos con DPM o FBP. Se realizó una búsqueda bibliográfica avanzada en las bases de datos de PubMed, Cochrane Database of Systematic Reviews y Literatura Latinoamericana y del Caribe en Ciencias de la Salud (LILACS). La búsqueda sistemática fue suplementada con una búsqueda manual en la lista de referencias bibliográficas de la evidencia incluida en el presente dictamen. Además, se realizó una búsqueda de literatura gris en el motor de búsqueda Google, a fin de poder identificar GPC y ETS de relevancia que pudiesen haber sido omitidas por la estrategia de búsqueda o que no hayan sido publicadas en las bases de datos consideradas. Asimismo, se realizó una búsqueda dentro de bases de datos pertenecientes a grupos que realizan ETS y GPC, incluyendo, el National Institute for Health and Care Excellence (NICE), la Canadian Agency for Drugs and Technologies in Health (CADTH), la Haute Autorité de Santé (HAS), el Institut für Qualitát und Wirtschaftlichkeit im Gesundheitswesen (IQWiG), además de la Base Regional de Informes de Evaluación de Tecnologías en Salud de las Américas (BRISA) y páginas web de sociedades especializadas en el manejo del DPM y las FBP. Por último, se realizó una búsqueda de estudios clínicos en ejecución o aún no publicados en las páginas web de ClinicalTrials.gov y del International Clinical Trial Registry Platform (ICTRP). RESULTADOS: A través de la búsqueda bibliográfica en las bases de datos, se identificaron 420 documentos. Luego de eliminar los documentos duplicados, 401 fueron elegibles para tamizaje por título y resumen. De ellos, 20 documentos fueron elegibles para evaluación a texto completo. Finalmente, dos documentos fueron elegidos para incluirse en el presente dictamen. Como producto de la búsqueda bibliográfica y selección sistemática de la evidencia, se han incluido dos GPC que emiten recomendaciones para el tratamiento de pacientes con DPM (Tabla 1). No se encontraron RS con o sin MA, ECA o estudios observacionales elegibles para evaluación. A continuación se reporta brevemente el cuerpo de evidencia de acuerdo con la pirámide de jerarquía de Haynes, siguiendo lo indicado en los criterios de elegibilidad. CONCLUSIONES: El presente dictamen preliminar tuvo por objetivo realizar una síntesis de la mejor evidencia disponible a la fecha (02 de marzo del 2021) sobre la eficacia y seguridad del drenaje pleural empleando SDTD en comparación con SDTC en pacientes con DPM o FBP con indicación de drenaje pleural. En el contexto de EsSalud, los pacientes con DPM o FBP son tratados con drenaje pleural empleando SDTC; sin embargo, los especialistas de la entidad han propuesto la incorporación de SDTD debido a que este superaría algunos potenciales inconvenientes de la tecnología de uso actual en EsSalud, como el riesgo de evaluación subjetiva de ausencia de drenaje y fuga aérea, y la necesidad de estar conectada a un sistema de succión de pared. Por ello, se realizó una evaluación de la eficacia y seguridad de SDTD, en comparación con SDTC, para el manejo de estos pacientes. Luego de la búsqueda sistemática de información (02 de marzo del 2021) se incluyeron dos GPC sobre el manejo de pacientes con DPM para su evaluación (National Institute for Health and Care Excellence 2019, Feller-Kopman et al. 2018). No se encontraron GPC sobre el manejo de pacientes con FBP. Tampoco se encontraron ECA, RS con o sin MA, o estudios obseservacionales que comparen a las tecnologías SDTD y SDTC en procedimientos de drenaje pleural en pacientes con DPM o FBP. Ninguna de las GPC evaluadas mencionó al SDTD o SDTC entre sus recomendaciones de drenaje pleural para el manejo paliativo de pacientes con DPM. Aunque una de las GPC recomienda la colocación de catéter permanente (tecnología que puede ser conectada a SDTD o SDTC) para realizar el drenaje pleural, no se mencionó a qué sistema de drenaje se debe conectarse el dispositivo para realizar el procedimiento (Feller-Kopman et al. 2018). Asimismo, ninguno de los estudios empleados como sustento para estas recomendaciones menciona que sistema de drenaje se utilizó para llevar a cabo el drenaje pleural. En consecuencia, existe incertidumbre sobre cuál es el sistema de drenaje de elección (SDTD o SDTC) para llevar a cabo estos procedimientos. Durante la búsqueda de la literatura se observaron estudios de bajo nivel metodológico (reportes de casos y resúmenes de congreso) que evaluaron el uso de la tecnología SDTD en pacientes con DPM o FBP. Esto se condice con lo mencionado por la literatura acerca de la escasa evidencia de alto nivel metodológico para el cuidado paliativo de pacientes, como es el caso de pacientes con DPM. En ese sentido, para realizar una evaluación objetiva de la eficacia y seguridad de la tecnología SDTD es necesario contar con ECA bien diseñados. Por otro lado, aunque existen estudios de alto nivel metodológico (i.e. ECA) que comparan a las tecnologías SDTD y SDTC, estos fueron realizados en pacientes con marcadas diferencias en la fisiopatología, pronóstico, necesidad de tratamiento y objetivo del drenaje pleural, en comparación con la población de pacientes con DPM o FBP. Por lo tanto, los resultados de estos estudios no pueden extrapolarse a los pacientes con DPM o FBP. De igual manera, es preciso señalar que, según el fabricante de la tecnología SDTD solicitada, la indicación de uso de la misma es para drenaje torácico y pleural de pacientes sometidos a cirugía torácica o cardiaca, la cual difiere de la población de interés para la PICO, y explicaría la ausencia de estudios de alto nivel metodológico en esta población. Por todo lo expuesto, debido a que a la fecha no existen argumentos técnicos que apoyen el uso de la tecnología SDTD en pacientes con DPM o FBP, y que además, la indicación de uso de la tecnología no incluye a esta población, sino a pacientes sometidos a cirugía torácica y cardiaca, el IETSI no aprueba el uso de SDTD en pacientes adultos con derrame pleural maligno o fístula pulmonar.

Assessment and review of treatment for secondary spontaneous pneumothorax using medical thoracoscopy-assisted argon plasma coagulation in association with autologous blood pleurodesis.

AIMS: To evaluate the efficacy of medical thoracoscopy-assisted argon plasma coagulation in association with autologous blood pleurodesis in spontaneous pneumothorax. PATIENTS AND METHODS: Three male patients with spontaneous pneumothorax were treated; medical thoracoscopy-assisted argon plasma coagulation combined with autologous blood pleurodesis was conducted for all patients whose duration of the air leak exceeded 7 days. We systematically reviewed all of the relevant literature to analyze and sum up the treatments of secondary spontaneous pneumothorax. RESULTS: The air leaks were all sealed and no recurrence of pneumothorax was reported. No complications of fever, bleeding, or signs of infection were observed during the process. CONCLUSION: The authors believe that the combination of medical thoracoscopy-assisted argon plasma coagulation and autologous blood pleurodesis is safe and effective. However, due to the number of patients included in this uncontrolled case study, more cases will be collected in the future.The reviews of this paper are available via the supplemental material section.

The use of the Scar Cosmesis Assessment and rating scale to evaluate the cosmetic outcomes of totally thoracoscopic cardiac surgery.

BACKGROUND: Conventional median sternotomy is widely used in cardiac surgery, while thoracoscopic cardiac surgery, which is considered to have aesthetic advantages, is being performed increasingly more often in China because patients' requests for minimally invasive procedures yielding aesthetically pleasing results have significantly increased. Few studies have been conducted to assess surgical scars after cardiac surgery. Compared to the median sternotomy approach, multiple-incision totally thoracoscopic cardiac surgery requires smaller but numerous and scattered incisions. In addition to two working ports on the upper and lower margins of the right breast, an inguinal incision and an axillary incision are made. Therefore, does totally thoracoscopic cardiac surgery truly have aesthetic advantages? This study has the following objectives: (a) to compare median sternotomy cardiac surgery and total thoracoscopic cardiac surgery in terms of the long-term cosmetic outcomes of post-operative scars and (b) to evaluate the effectiveness of the Scar Cosmesis Assessment and Rating scale in combination with the numeric rating scale in the assessment of surgical scars after cardiac surgery. METHODS: Consecutive patients who visited our institution from January 2019 to May 2019 for cardiac surgery via median sternotomy or the totally thoracoscopic approach and followed up for at least one year were included. Inter-rater reliability, internal consistency and convergent validity were evaluated for the Scar Cosmesis Assessment and Rating scale and the numeric rating scale. Clinical characteristics and the scores of the two scales were compared between the two groups using Student's t test or the Mann-Whitney U test. RESULTS: Thirty-one patients underwent cardiac surgery via the totally thoracoscopic approach, and 42 patients underwent cardiac surgery via the median sternotomy approach. No significant differences were found in the demographic or clinical data between the two groups. The validity and reliability of the two scales were satisfactory. For the Scar Cosmesis Assessment and Rating scale, the median sternotomy group scored statistically significantly higher than did the totally thoracoscopic group on the "overall impression" and "patient question" subscales (P < 0.05). The overall scores of the Scar Cosmesis Assessment and Rating scale and numeric rating scale were statistically significantly different (P < 0.05). CONCLUSIONS: The Scar Cosmesis Assessment and Rating scale in combination with the numeric rating scale is an effective tool for the assessment of scar aesthetics after cardiac surgery. Surgical scars of totally thoracoscopic cardiac surgery can yield desirable cosmetic outcomes in Chinese individuals, especially in susceptible individuals with a high risk of keloid and hypertrophic scars. Patients with appropriate indications can undergo cardiac surgery with the totally thoracoscopic approach and exhibit a satisfactory scar appearance.

Clinical and economic benefits associated with the use of powered and tissue-specific endoscopic staplers among the patients undergoing thoracoscopic lobectomy for lung cancer.

Background: Thoracoscopic lobectomy for lung cancer is a complex procedure where endoscopic staplers play a critical role in transecting the lung parenchyme, vasculature, and bronchus. This retrospective study was performed to investigate the economic benefits of powered and tissue-specific endoscopic staplers such as gripping surface technology (GST) and powered vascular stapler (PVS) compared to standard staplers.Methods: Two hundred and seventy-five patients who received a thoracoscopic lobectomy between 2008 and 2016 were included. Group 1 (n = 117) consisted of patients who received the operation with manual endoscopic staplers, whereas Group 2 (n = 158) consisted of patients who received the operation with GST and PVS.Results: Patient demographics and clinical characteristics were comparable, except smoking history, pulmonary function, and pleural adhesion. All patients received the operation successfully without mortalities and broncho-pleural fistula. Operation time and blood loss were higher in Group 1. Pleurodesis was performed less in Group 2 than in Group 1 (18.0% vs 3.8%, p < 0.0001). Group 2 had statistically significant lower adjusted hospital costs (Korean Won, 14,610,162 ± 4,386,628 vs 12,876,111 ± 5,010,878, p < 0.0001), lower adjusted hemostasis related costs (198,996 ± 110,253 vs 175,291 ± 191,003, p = 0.0101); lower cartridge related adjusted costs (1,105,091 ± 489,838 vs 839,011 ± 307,894, p < 0.0001) compared to Group 1. As well, Group 2 showed ∼12% lower adjusted total hospital costs compared to Group 1. Multivariable analysis revealed that Group 1 was related to increased hospital costs.Conclusions: This study showed that thoracoscopic lobectomy with powered and tissue-specific endoscopic staplers were associated with better clinical outcomes and reduced adjusted hospital costs when compared in Korean real-world settings.

Hybrid thoracoscopic surgical and transvenous catheter ablation versus transvenous catheter ablation in persistent and longstanding persistent atrial fibrillation (HARTCAP-AF): study protocol for a randomized trial.

BACKGROUND: Success rates with conventional transvenous endocardial pulmonary vein isolation in patients with persistent and longstanding persistent atrial fibrillation (AF) are variable due to advanced electrical and structural remodeling of the atria. As a consequence, more extensive endocardial lesions, minimally invasive thoracoscopic surgical techniques, and hybrid ablation (combining thoracoscopic epicardial surgical and endocardial catheter ablation) have been developed. HYPOTHESIS: The HARTCAP-AF trial hypothesizes that hybrid AF ablation is more effective than (repeated) transvenous endocardial catheter ablation in (longstanding) persistent AF, without increasing the number of associated major adverse events. METHODS: This randomized controlled trial will include 40 patients with persistent or longstanding persistent AF who will be 1:1 randomized to either hybrid ablation or (repeated) catheter ablation. The procedures and follow-up are conducted according to the guidelines. The primary effectiveness endpoint is freedom from any supraventricular arrhythmia lasting longer than 5 min without the use of Vaughan-Williams class I or III antiarrhythmic drugs through 12 months of follow-up after the last procedure. In the catheter ablation arm, a second procedure planned within 6 months after the index procedure is allowed for obtaining the primary endpoint. Additionally, adverse events, cost-effectiveness, and quality of life data will be recorded. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02441738 . Registered on 12 May 2015.

Current status of robot-assisted thoracoscopic surgery for lung cancer.

The robotic surgical system was designed to overcome the drawbacks of conventional endoscopic surgery. Since national health insurance in Japan began covering robotic-assisted thoracoscopic surgery (RATS) for malignant lung and mediastinal tumors in 2018, the number of RATS procedures being performed domestically has increased rapidly. This review evaluates the advantages and disadvantages of RATS for patients with lung cancers, based on an electronic literature search of PubMed. The main advantages of RATS are its ability to achieve excellent lymph-node removal with low morbidity and mortality, and minimal postoperative pain. Conversely, its disadvantages include a long operation time and the need for specialized instruments. However, the learning curve for RATS is reported to be shorter than that for VATS: some studies recommend that a surgeon needs to perform 18-22 robotic operations to attain sufficient skill. RATS for lung cancer is more expensive than VATS and the cost of training is high. Although the main disadvantage of RATS is that it reduces operator's tactile senses, the endoscope, which is directly manipulated by the surgeon at the console, using various magnifications, and 3D HD images on the monitor, may compensate for this. Ultimately, RATS offers better maneuverability, accuracy, and stability over VATS.

The cost and quality of life outcomes in developing a robotic lobectomy program.

The use of the robotic platform is increasingly being utilized for lung resections. Our aim was to compare outcomes of thoracoscopic (VATS) versus robotic-assisted thoracoscopic (RATS) lobectomy early in a program's adoption of robotic surgery, including perioperative outcomes, cost, and long-term quality of life. A prospective database was retrospectively reviewed for all patients undergoing minimally invasive lobectomy by either VATS or RATS techniques from 2010 to 2012. Patients' operative, post-operative complications, cost (operating room and hospital) and quality of life were compared between the two resection techniques. Long-term follow-up including assessment using the European Organization for Research and Treatment of Cancer quality of life questionnaire was documented. During the first 25 RATS lobectomies, there were 73 VATS lobectomies performed, for a total of 98 cases. There was no significant difference in cancer stage, operative time, estimated blood loss, lymph node count, or hospital length of stay. The RATS resections had significantly higher operative and total hospital cost (p < 0.0001 and p < 0.05). At a median of 65-month follow-up, 29 patients (9 robotic; 20 VATS) completed the EORTC questionnaire. The global health status and symptom scale median scores were similar to the general population and did not significantly differ between groups. While transitioning from thoracoscopic to robotic lobectomy incurs increased operative and total hospital cost, equivalent operative outcomes, length of hospitalization, and long-term quality of life can be maintained during this transition. With increasing patient and surgeon interest in robotic resection, it appears both safe and feasible to adopt this approach while maintaining outcomes.

Is there any role for thoracoscopy in the diagnosis of benign pleural effusions.

Thoracoscopy in the endoscopy suite, has a high diagnostic yield of undiagnosed pleural effusions with minimal and mild complications. Whereas relatively minimal invasive techniques, such as thoracentesis, image-guided pleural biopsy or blind pleural biopsy, can yield sufficient cell or tissue material to establish the diagnosis of the underlying condition, more definite invasive diagnostic and therapeutic procedure, such as thoracoscopy, may be required for accurate sampling and diagnosis, and further provide real-time treatment options in same procedure. If thoracoscopy is considered the gold standard for the diagnosis is a fact in case. The current review aims to provide informations on thoracoscopy indications in benign pleural diseases according to up to date publications.

Utility of minimally invasive thoracoscopy for assessment of residual mediastinal lymphoma.

BACKGROUND: Patients with primary mediastinal lymphomas frequently present with a residual mass after completion of first-line therapy. Although a positron emission tomography scan is usually recommended, it fails to distinguish between persistent lymphoma and inflammation. Although percutaneous biopsy may have a high diagnostic yield for the initial diagnosis of mediastinal lymphomas, this biopsy has poor accuracy for detecting persistent disease in a residual mass given the heterogeneity of these residual masses. Because persistent disease has important therapeutic implications, we evaluated the role of operative biopsy in detecting lymphoma in the residual mass. METHODS: Between 2009 and 2015, consecutive patients (n = 77) undergoing tissue biopsy for initial diagnosis as well as for a positron emission tomography-positive residual mass were included. Tissue biopsy for a residual mass was repeated until frozen section was diagnostic or at least the mass on the ipsilateral hemi-mediastinum was resected. RESULTS: Of the initial 77 patients, 34 underwent operative restaging for a residual mass after chemotherapy, while 43 had a complete response. In these 34 patients, operative biopsy revealed the presence of lymphoma in 53%, predominantly Hodgkin's disease and diffuse large B-cell lymphoma. There was no significant difference in tumor volume (51% versus 39%) and a decrease in the positron emission tomography-standardized uptake valuemax (68% vs 60%) in patients with or those without persistent lymphoma. There were no surgical complications and the duration of stay for all patients undergoing thoracoscopy was <24 hours. Residual lymphoma was treated with second-line therapy guided by the pathologic analysis. CONCLUSION: A large proportion of patients with residual positron emission tomography-avidity after first-line chemotherapy of mediastinal lymphomas have residual disease that can be detected safely using minimally invasive thoracoscopy.

Recent developments in the management of pleural infection: A comprehensive review.

OBJECTIVES: Pleural infection is a condition commonly encountered by the respiratory physician. This review aims to provide the reader with an update on the most recent data regarding the epidemiology, microbiology, and the management of pleural infection. DATA SOURCE: Medline was searched for articles related to pleural infection using the terms "pleural infection," "empyema," and "parapneumonic." The search was limited to the years 1997-2017. Only human studies and reports in English were included. RESULTS: A rise in the incidence of pleural infection is seen worldwide. Despite the improvement in healthcare practices, the mortality from pleural infection remains high. The role of oral microflora in the etiology of pleural infection is firmly established. A concise review of the recent insights on the pathogenesis of pleural infections is presented. A particular focus is made on the role of tPA, DNAse and similar substances and their interaction with inflammatory cells and how this affects the pathogenesis and treatment of pleural infection. CONCLUSION: Pleural infection is a common disease with significant morbidity and mortality, as well as a considerable economic burden. The role of medical management is expanding thanks to the widespread use of newer treatments.

Safety Assessment for Thoracoscopic Day Case Surgery in Children with Congenital Pulmonary Malformation.

BACKGROUND: No data exist evaluating the utilization and safety of outpatient thoracoscopy in children. The aim of this study was to investigate the safety of outpatient thoracoscopy and to assess parental opinions on the advantages and disadvantages of a pediatric thoracoscopy outpatient setting. METHODS: A retrospective review of data from patients treated by thoracoscopy for congenital pulmonary malformation between 2013 and 2016 was performed. Study focused on patients who underwent outpatient thoracoscopy. All were placed in a flank position and underwent a three-port (5-mm optical trocar and two 5-mm trocars) thoracoscopy. Insufflation pressure required was 5 mmHg with bilateral lung ventilation. Pain control was provided with multimodal postoperative analgesia and the use of paravertebral block for regional analgesia. No drain was inserted. Outcomes of interest included 30-day overall morbidity, readmission, reoperation, and parental opinions through a phone call questionnaire. RESULTS: A total of 37 thoracoscopies were identified; 11 (30%) with a median age of 5.3 months (4.2-12.3) were performed as an outpatient procedure (10 sequestration, 1 bronchogenic cyst). Median operating time was 51 minutes (34-87). No conversion and no transfusion occurred. No complications occurred (no morbidity, no readmission, and no reoperation). According to parents' view the outpatient setting has no disadvantages. CONCLUSION: This first analysis of a small monocentric dataset demonstrates that pediatric patients can safely undergo thoracoscopy, an outpatient procedure, with a high rate of parental satisfaction.

Efficacy and Cost of Awake Thoracoscopy and Video-Assisted Thoracoscopic Surgery in the Undiagnosed Pleural Effusion.

BACKGROUND: The study aim is to compare the diagnostic yield, safety, and cost of outpatient awake thoracoscopy (AT) with video-assisted thoracoscopic surgery (VATS) pleural biopsy in undiagnosed pleural effusions. METHODS: The diagnostic yield of pleural biopsy performed by AT or VATS in patients with undiagnosed exudative pleural effusions at a tertiary thoracic surgery center in Canada between 2011 and 2015 was retrospectively evaluated. Test sensitivity, specificity, positive predictive value, and negative predictive value were compared. Procedure safety, hospital length of stay, additional pleural-based interventions, and procedure-related costs were compared. RESULTS: Patients underwent either AT (n = 78) or VATS (n = 99) during the study period. Sensitivity, specificity, positive predictive value, and negative predictive value were 85%, 100%, 100%, and 79% for AT and 93%, 94%, 99%, and 76% for VATS, with no significant difference in diagnostic test performance. There was no difference in the rate of major complications (2 AT [2.6%] versus 4 VATS [4.0%], p = 0.696), minor complications (14 AT [17.9%] versus 16 VATS [16.2%], p = 0.841) or need for additional pleural-based procedures (20 AT [25.6%] versus 18 VATS [18.2%], p = 0.270). The VATS was associated with longer median hospital stay (VATS 3 days [interquartile range: 1 to 4] versus AT 0 days [interquartile range: 0 to 1], z = 6.98, p < 0.001) and a higher procedure-related average cost (VATS Canadian dollars $7,962 [95% confidence interval: $7,134 to $8,790] versus AT Canadian dollars $2,815 [95% confidence interval: $2,010 to $3,620], p < 0.001). CONCLUSIONS: Awake thoracoscopy and VATS have similar diagnostic yield and safety profiles in the assessment of undiagnosed pleural effusions; however, AT is associated with shorter length of stay and lower average per-procedure cost. In the appropriate clinical setting, AT may be the diagnostic test of choice.

Short-term outcomes after transition from Sweet to thoracoscopic esophagectomy: Our experience and cost analysis.

OBJECTIVE: Thoracoscopic esophagectomy (TSE), as a minimally invasive technique, has obtained wide acceptance for treating esophageal cancer. In this study, we report our experience of the transfer from open sweet esophagectomy (OSE) to TSE and compare cost associated with the two approaches for esophageal cancer. PATIENTS AND METHODS: Data were taken through a retrospective review of operative outcomes, complications and cost of 91 patients who underwent OSE or TSE for esophageal cancer from January 2012 to June 2014. RESULTS: Among 91 patients, 48 patients underwent TSE, and 43 patients underwent OSE. Patients dealt with TSE had significantly less blood loss (152 ml vs. 204 ml, P = 0.004), shorter chest drainage time (3.3 days vs. 4.5 days, P < 0.001), less patients admitted to the Intensive Care Unit after surgery (6.3% vs. 30.2%, P = 0.003), and lower incidence of respiratory complications (16.7% vs. 37.2%, P = 0.026). However, the operative time was statistically longer in TSE group (276.0 min vs. 207.4 min, P < 0.001). The total cost (¥61,817 vs. ¥48,712, P < 0.001) and the day of surgery cost (¥29,701 vs. ¥19,446, P < 0.001) were significantly higher in the TSE group. CONCLUSION: This study shows that TSE is a safe and acceptable alternative to OSE. TSE will be more competitive if its cost can be reduced.

Catheter Ablation versus Thoracoscopic Surgical Ablation in Long Standing Persistent Atrial Fibrillation (CASA-AF): study protocol for a randomised controlled trial.

BACKGROUND: Atrial fibrillation is the commonest arrhythmia which raises the risk of heart failure, thromboembolic stroke, morbidity and death. Pharmacological treatments of this condition are focused on heart rate control, rhythm control and reduction in risk of stroke. Selective ablation of cardiac tissues resulting in isolation of areas causing atrial fibrillation is another treatment strategy which can be delivered by two minimally invasive interventions: percutaneous catheter ablation and thoracoscopic surgical ablation. The main purpose of this trial is to compare the effectiveness and safety of these two interventions. METHODS/DESIGN: Catheter Ablation versus Thoracoscopic Surgical Ablation in Long Standing Persistent Atrial Fibrillation (CASA-AF) is a prospective, multi-centre, randomised controlled trial within three NHS tertiary cardiovascular centres specialising in treatment of atrial fibrillation. Eligible adults (n = 120) with symptomatic, long-standing, persistent atrial fibrillation will be randomly allocated to either catheter ablation or thoracoscopic ablation in a 1:1 ratio. Pre-determined lesion sets will be delivered in each treatment arm with confirmation of appropriate conduction block. All patients will have an implantable loop recorder (ILR) inserted subcutaneously immediately following ablation to enable continuous heart rhythm monitoring for at least 12 months. The devices will be programmed to detect episodes of atrial fibrillation and atrial tachycardia ≥ 30 s in duration. The patients will be followed for 12 months, completing appropriate clinical assessments and questionnaires every 3 months. The ILR data will be wirelessly transmitted daily and evaluated every month for the duration of the follow-up. The primary endpoint in the study is freedom from atrial fibrillation and atrial tachycardia at the end of the follow-up period. DISCUSSION: The CASA-AF Trial is a National Institute for Health Research-funded study that will provide first-class evidence on the comparative efficacy, safety and cost-effectiveness of thoracoscopic surgical ablation and conventional percutaneous catheter ablation for long-standing persistent atrial fibrillation. In addition, the results of the trial will provide information on the effects on patients' quality of life. TRIAL REGISTRATION: ISRCTN Registry, ISRCTN18250790 . Registered on 24 April 2015.

Two-step method for creating a gastric tube during laparoscopic-thoracoscopic Ivor-Lewis esophagectomy.

AIM: To introduce a two-step method for creating a gastric tube during laparoscopic-thoracoscopic Ivor-Lewis esophagectomy and assess its clinical application. METHODS: One hundred and twenty-two patients with middle or lower esophageal cancer who underwent laparoscopic-thoracoscopic Ivor-Lewis esophagectomy at Liaoning Cancer Hospital and Institute from March 2014 to March 2016 were included in this study, and divided into two groups based on the procedure used for creating a gastric tube. One group used a two-step method for creating a gastric tube, and the other group used the conventional method. The two groups were compared regarding the operating time, surgical complications, and number of stapler cartridges used. RESULTS: The mean operating time was significantly shorter in the two-step method group than in the conventional method group [238 (179-293) min vs 272 (189-347) min, P < 0.01]. No postoperative death occurred in either group. There was no significant difference in the rate of complications [14 (21.9%) vs 13 (22.4%), P = 0.55] or mean number of stapler cartridges used [5 (4-6) vs 5.2 (5-6), P = 0.007] between the two groups. CONCLUSION: The two-step method for creating a gastric tube during laparoscopic-thoracoscopic Ivor-Lewis esophagectomy has the advantages of simple operation, minimal damage to the tubular stomach, and reduced use of stapler cartridges.

CT imaging in pre-therapeutic assessment of lung cancer.

Lung cancer, the most frequent cancer worldwide, is the fourth most frequent cancer in France, with an overall 5-year survival rate of about 15%, directly correlated to the stage of disease at the time of diagnosis and its treatment. The objective of this article is to describe the role, contributions and pitfalls of computed tomography (CT) in clinical TNM staging, primarily to identify patients eligible for curative surgery. TNM staging criteria, last updated in 2009, are discussed along with the new proposals for the 8th edition to be published late 2016. The most crucial CT features for pre-therapy assessment are highlighted.