Prospective Randomized Trial of Standard Left Anterolateral Thoracotomy Versus Modified Bilateral Clamshell Thoracotomy Performed by Emergency Physicians.

STUDY OBJECTIVE: Resuscitative thoracotomy is a time-sensitive, lifesaving procedure that may be performed by emergency physicians. The left anterolateral thoracotomy (LAT) is the standard technique commonly used in the United States to gain rapid access to critical intrathoracic structures. However, the smaller incision and subsequent limited exposure may not be optimal for the nonsurgical specialist to complete time-sensitive interventions. The modified bilateral anterior clamshell thoracotomy (MCT) developed by Barts Health NHS Trust clinicians at London's Air Ambulance overcomes these inherent difficulties, maximizes thoracic cavity visualization, and may be the ideal technique for the nonsurgical specialist. The aim of this study is to identify the optimal technique for the nonsurgical-specialist-performed resuscitative thoracotomy. Secondary aims of the study are to identify technical difficulties, procedural concerns, and physician preferences. METHODS: Emergency medicine staff and senior resident physicians were recruited from an academic Level I trauma center. Subjects underwent novel standardized didactic and skills-specific training on both the MCT and LAT techniques. Later, subjects were randomized to the order of intervention and performed both techniques on separate fresh, nonfrozen human cadaver specimens. Success was determined by a board-certified surgeon and defined as complete delivery of the heart from the pericardial sac and subsequent 100% occlusion of the descending thoracic aorta with a vascular clamp. The primary outcome was time to successful completion of the resuscitative thoracotomy technique. Secondary outcomes included successful exposure of the heart, successful descending thoracic aortic cross clamping, successful procedural completion, time to exposure of the heart, time to descending thoracic aortic cross-clamp placement, number and type of iatrogenic injuries, correct anatomic structure identification, and poststudy participant questionnaire. RESULTS: Sixteen emergency physicians were recruited; 15 met inclusion criteria. All participants were either emergency medicine resident (47%) or emergency medicine staff (53%). The median number of previously performed training LATs was 12 (interquartile range 6 to 15) and the median number of previously performed MCTs was 1 (interquartile range 1 to 1). The success rates of our study population for the MCT and LAT techniques were not statistically different (67% versus 40%; difference 27%; 95% confidence interval -61% to 8%). However, staff emergency physicians were significantly more successful with the MCT compared with the LAT (88% versus 25%; difference 63%; 95% CI 9% to 92%). Overall, the MCT also had a significantly higher proportion of injury-free trials compared with the LAT technique (33% versus 0%; difference 33%; 95% CI 57% to 9%). Physician procedure preference favored the MCT over the LAT (87% versus 13%; difference 74%; 95% CI 23% to 97%). CONCLUSION: Resuscitative thoracotomy success rates were lower than expected in this capable subject population. Success rates and procedural time for the MCT and LAT were similar. However, the MCT had a higher success rate when performed by staff emergency physicians, resulted in less periprocedural iatrogenic injuries, and was the preferred technique by most subjects. The MCT is a potentially feasible alternative resuscitative thoracotomy technique that requires further investigation.

Right Place at the Right Time: Thoracotomies at Level I Trauma Centers Have Associated Improved Survival.

BACKGROUND: Early thoracotomy (ET) is a procedure performed on patients in extremis. Identifying factors associated with ET survival may allow for optimization of guidelines and improved patient selection. OBJECTIVES: The objective of this study was to assess whether ETs performed at Level I trauma centers (TC) are associated with improved survival. METHODS: This was a retrospective study utilizing the National Trauma Databank 2014-2015. We included all thoracotomies performed within 1 h of hospital arrival. Patients were stratified according to TC designation level. Patient demographics, outcomes, and center characteristics were compared. We conducted multivariable regression with survival as the outcome. RESULTS: There were 3183 ETs included in this study; 2131 (66.9%) were performed at Level I TCs. Patients treated at Level I and non-Level I TCs had similar median injury severity scores, as well as signs of life and systolic blood pressures on admission. Patients treated at Level I TCs had significantly higher survival rates (21.6% vs. 16.3%, p < 0.001), with 40% greater odds of survival after controlling for injury-specific factors and emergency medical services transportation time (adjusted odds ratio 1.40, 95% confidence interval 1.04-1.89, p = 0.03). Penetrating injuries had 23.1% survival after ET vs. 12.9% for blunt injuries (adjusted odds ratio 1.86, 95% confidence interval 1.37-2.53, p < 0.001). CONCLUSIONS: ETs performed at Level I TCs were associated with 40% greater odds of survival compared with ETs at non-Level I TCs. This demonstrates that factors extrinsic to the patient may play a role in survival of severely injured patients.

Comparison Between Pressure-Regulated Volume-Controlled and Volume-Controlled Ventilation on Oxygenation Parameters, Airway Pressures, and Immune Modulation During Thoracic Surgery.

OBJECTIVES: To compare 2 different ventilatory strategies: pressure-regulated volume-controlled (PRVC) versus volume-controlled ventilation during thoracotomy. DESIGN: Prospective randomized study. SETTING: University hospital. PARTICIPANTS: The study comprised 70 adult patients undergoing thoracic surgery. INTERVENTIONS: Evaluation of oxygenation parameters, airway pressures, and immune modulation. MEASUREMENTS AND MAIN RESULTS: The primary outcome was arterial oxygen tension/fraction of inspired oxygen (PaO2/FIO2) ratio, whereas secondary outcomes included arterial and central venous blood gases, deadspace volume/tidal volume ratio, peak inspiratory pressure, mean inspiratory pressure, and plateau inspiratory pressure obtained at the following 4 time points: 20 minutes after total lung ventilation (T0), 20 minutes after 1-lung ventilation (T1), 20 minutes after return to total lung ventilation (T2), and at the end of surgery (T3). Furthermore, alveolar and plasma levels of interleukin-8 and tumor necrosis factor-α and changes in alveolar albumin levels and cell numbers were measured at the same time points. Oxygenation parameters (PaO2/FIO2 and PaO2) were significantly better in the PRVC group (PaO2/FIO2 ratio at T1 was 176 v 146 in the PRVC and volume-controlled groups, respectively, with a p value of 0.004). Deadspace volume/tidal volume ratio and inspiratory airway pressures were significantly lower in the PRVC group. Furthermore, all inflammatory parameters (alveolar and plasma interleukins, alveolar albumin levels, and cell numbers) were significantly lower in the PRVC group. CONCLUSIONS: The PRVC mode during 1-lung ventilation in thoracic surgery caused a favorable effect on oxygenation parameters, respiratory mechanics, and immune modulation during thoracic surgery.

Learning minimally invasive mitral valve surgery: a cumulative sum sequential probability analysis of 3895 operations from a single high-volume center.

BACKGROUND: Learning curves are vigorously discussed and viewed as a negative aspect of adopting new procedures. However, very few publications have methodically examined learning curves in cardiac surgery, which could lead to a better understanding and a more meaningful discussion of their consequences. The purpose of this study was to assess the learning process involved in the performance of minimally invasive surgery of the mitral valve using data from a large, single-center experience. METHODS AND RESULTS: All mitral (including tricuspid, or atrial fibrillation ablation) operations performed over a 17-year period through a right lateral mini-thoracotomy with peripheral cannulation for cardiopulmonary bypass (n=3907) were analyzed. Data were obtained from a prospective database. Individual learning curves for operation time and complication rates (using sequential probability cumulative sum failure analysis) and average results were calculated. A total of 3895 operations by 17 surgeons performing their first minimally invasive surgery of the mitral valve operation at our institution could be evaluated. The typical number of operations to overcome the learning curve was between 75 and 125. Furthermore, >1 such operation per week was necessary to maintain good results. Individual learning curves varied markedly, proving the need for good monitoring or mentoring in the initial phase. CONCLUSIONS: A true learning curve exists for minimally invasive surgery of the mitral valve. Although the number of operations required to overcome the learning curve is substantial, marked variation exists between individual surgeons. Such information could be very helpful in structuring future training and maintenance of competence programs for this kind of surgery.

Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest.

This multiorganizational literature review was undertaken to provide an evidence base for determining whether or not recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care, because the evidence suggests that either death or a poor outcome is inevitable.

Practical translation of hemorrhage control techniques to the civilian trauma scene.

This article examines how established and innovative techniques in hemorrhage control can be practically applied in a civilian physician-based prehospital trauma service. A "care bundle" of measures to control hemorrhage on scene are described. Interventions discussed include the implementation of a system to achieve simple endpoints such as shorter scene times, appropriate triage, careful patient handling, use of effective splints and measures to control external hemorrhage. More complex interventions include prehospital activation of massive hemorrhage protocols and administration of on-scene tranexamic acid, prothrombin complex concentrate, and red blood cells. Radical resuscitation interventions, such as prehospital thoracotomy for cardiac tamponade, and the potential future role of other interventions are also considered.

Innovative, simplified orthotopic lung transplantation in rats.

BACKGROUND: Various techniques of orthotopic single lung transplantation in rats have been reported; however, their widespread use has been limited owing to the complexity of the procedure. We report a novel microsurgical lung transplantation model in rats with a high survival rate that can be performed by one surgeon alone. METHODS: A total of 90 left lung allografts were transplanted from Fischer to Wistar Kyoto rats. We developed a triple axis precision system to place and stabilize the vascular clips intrathoracically to clamp the bronchovascular structures, thereby avoiding interference with the heart and contralateral lung movement. A single-suture bronchial anastomosis technique and proximal cuffing approach for vascular anastomosis was used, rendering surgical assistance unnecessary. RESULTS: In our recent series, both short-term (12 h) and long-term (21 d) survival was 100%. The lungs showed excellent perfusion and ventilation immediately on transplantation. Blood gas samples drawn from the left pulmonary vein and the histologic sections revealed excellent graft function. The donor operation lasted 20 ± 2 min, donor left lung dissection required 20 ± 2 min, and implantation required 90 ± 5 min. CONCLUSIONS: The present innovative method of left orthotopic single lung transplantation can be performed by one experienced surgeon alone, with excellent results and a high degree of reproducibility.

[Optimization of surgical strategy in trauma of the chest: correlation of thoracoscopy and thoracotomy].

The authors analyzed an experience with treatment of 4372 patients. Videothoracoscopy allowed the number of usual drainages of the pleural cavity to be reduced in closed trauma from 16.3% to 2.3%, in wounds--from 3.9% to 0.4%. Persistent hemo- and airstasis were obtained by coagulation of the vessels of the thoracic wall and lung, suturing lung wounds. The coagulated hemothorax was removed, diaphragm wounds were sutured, the pericardium wounds were revised, the character of intrathoracic lesions was reliably determined in 98% of cases. Conversion into thoracotomy was fulfilled in 91 (5.5%) patients. Thoracotomy was fulfilled in 344 (8%) patients with indications to operative interventions and severe condition and unstable hemodynamics. The number of thoracotomies and lethality in patients with penetrating wounds of the chest became 1.5-2 times less, was not considerably changed in closed traumas.

Augmenting prehospital care.

INTRODUCTION: The challenging environment of prehospital casualty care demands providers to make prompt decisions and to engage in lifesaving interventions, occasionally without them being adequately experienced. Telementoring based on augmented reality (AR) devices has the potential to decrease the decision time and minimise the distance gap between an experienced consultant and the first responder. The purpose of this study was to determine whether telementoring with AR glasses would affect chest thoracotomy performance and self-confidence of inexperienced trainees. METHODS: Two groups of inexperienced medical students performed a chest thoracotomy in an ex vivo pig model. While one group was mentored remotely using HoloLens AR glasses, the second performed the procedure independently. An observer assessed the trainees' performance. In addition, trainees and mentors evaluated their own performance. RESULTS: Quality of performance was found to be superior with remote guidance, without significant prolongation of the procedure (492 s vs 496 s, p=0.943). Moreover, sense of self-confidence among participant was substantially improved in the telementoring group in which 100% of the participants believed the procedure was successful compared with 40% in the control group (p=0.035). CONCLUSION: AR devices may have a role in future prehospital telementoring systems, to provide accessible consultation for first responders, and could thus positively affect the provider's confidence in decision-making, enhance procedure performance and ultimately improve patient prognosis. That being said, future studies are required to estimate full potential of this technology and additional adjustments are necessary for maximal optimisation and implementation in the field of prehospital care.

[Approaches to the pre-operative functional assessment of patients with lung cancer and preoperative rehabilitation]. / Bilan fonctionnel préopératoire du cancer bronchique et réhabilitation préopératoire.

Surgery is the best treatment for early lung cancer but requires a preoperative functional evaluation to identify patients who may be at a high risk of complications or death. Guideline algorithms include a cardiological evaluation, a cardiopulmonary assessment to calculate the predicted residual lung function, and identify patients needing exercise testing to complete the evaluation. According to most expert opinion, exercise tests have a very high predictive value of complications. However, since the publication of these guidelines, minimally-invasive surgery, sublobar resections, prehabilitation and enhanced recovery after surgery (ERAS) programmes have been developed. Implementation of these techniques and programs is associated with a decrease in postoperative mortality and complications. In addition, the current guidelines and the cut-off values they identified are based on early series of patients, and are designed to select patients before major lung resection (lobectomy-pneumonectomy) performed by thoracotomy. Therefore, after a review of the current guidelines and a brief update on prehabilitation (smoking cessation, exercise training and nutritional aspects), we will discuss the need to redefine functional criteria to select patients who will benefit from lung surgery.

Impact of cardiopulmonary resuscitation time on the effectiveness of emergency department thoracotomy after blunt trauma.

PURPOSE: Debate remains about the threshold cardiopulmonary resuscitation (CPR) duration associated with futile emergency department thoracotomy (EDT). To validate the CPR duration associated with favorable outcomes, we investigated the relationship between CPR duration and return of spontaneous circulation (ROSC) after EDT in blunt trauma. METHODS: A retrospective observational study was conducted at three tertiary centers over the last 7 years. We included bluntly injured adults who were pulseless and required EDT at presentation, but excluded those with devastating head injuries. After multivariate logistic regression identified the CRP duration as an independent predictor of ROSC, receiver operating characteristic curves were used to determine the threshold CPR duration. Patient data were divided into short- and long-duration CPR groups based on this threshold, and we developed a propensity score to estimate assignment to the short-duration CPR group. The ROSC rates were compared between groups after matching. RESULTS: Forty patients were eligible for this study and ROSC was obtained in 12. The CPR duration was independently associated with the achievement of ROSC [odds ratio 1.18; 95% confidence interval (CI) 1.01-1.37, P = 0.04], and the threshold CPR duration was 17 min. Among the 14 patients with a short CPR duration, 13 matched with the patients with a long CPR duration, and a short CPR duration was significantly associated with higher rates of ROSC (odds ratio 8.80; 95% CI 1.35-57.43, P = 0.02). CONCLUSIONS: A CPR duration < 17 min is independently associated with higher ROSC rates in patients suffering blunt trauma.

Benchmarking emergency department thoracotomy: Using trauma video review to generate procedural norms.

INTRODUCTION: Emergency department thoracotomy (EDT) must be rapid and well-executed. Currently there are no defined benchmarks for EDT procedural milestones. We hypothesized that trauma video review (TVR) can be used to define the 'normative EDT' and generate procedural benchmarks. As a secondary aim, we hypothesized that data collected by TVR would have less missingness and bias than data collected by review of the Electronic Medical Record (EMR). METHODS: We used continuously recording video to review all EDTs performed at our centre during the study period. Using skin incision as start time, we defined four procedural milestones for EDT: 1. Decompression of the right chest (tube thoracostomy, finger thoracostomy, or clamshell thoracotomy with transverse sternotomy performed in conjunction with left anterolateral thoracotomy) 2. Retractor deployment 3. Pericardiotomy 4. Aortic Cross-clamp. EDTs with any milestone time ≥ 75th percentile of time or during which a milestone was omitted were identified as outliers. We compared rates of missingness in data collected by TVR and EMR using McNemar's test. RESULTS: 44 EDTs were included from the study period. Patients had a median age of 30 [IQR 25-44] and were predominantly African-American (95%) males (93%) with penetrating trauma (95%). From skin incision, median times in minutes to milestones were as follows: right chest decompression: 2.11 [IQR 0.68-2.83], retractor deployment 1.35 [IQR 0.96-1.85], pericardiotomy 2.35 [IQR 1.85-3.75], aortic cross-clamp 3.71 [IQR 2.83-5.77]. In total, 28/44 (64%) of EDTs were either high outliers for one or more benchmarks or had milestones that were omitted. For all milestones, rates of missingness for TVR data were lower than EMR data (p < 0.001). CONCLUSIONS: Video review can be used to define normative times for the procedural milestones of EDT. Steps exceeding the 75th percentile of time were common, with over half of EDTs having at least one milestone as an outlier. Data quality is higher using TVR compared to EMR collection. Future work should seek to determine if minimizing procedural technical outliers improves patient outcomes.

Video-assisted thoracoscopic surgery compared with thoracotomy: early and late follow-up of radiographical and functional outcome.

BACKGROUND CONTEXT: Video-assisted thoracoscopic surgery (VATS) is a new technique that allows for access to anterior spinal pathology using a minimally invasive approach. Proponents of this procedure argue that anterior thoracic spine surgery can be performed with the same accuracy and completeness as is possible by the conventional open approach but through much smaller skin and muscle incisions. Advantages of VATS include decreased blood loss, shorter hospital stay, and improved cosmesis. PURPOSE: To detect if VATS is equally as effective as open thoracotomy, both combined with instrumented posterior spinal fusion, with respect to fusion rate, percent curve correction, and functional outcome. STUDY DESIGN: Retrospective case control. PATIENT SAMPLE: Seventeen patients underwent VATS/instrumented posterior spinal fusion for thoracic curvatures exceeding 50 degrees . A control cohort of patients that were age matched, sex matched, and curve magnitude matched underwent open thoracotomy/instrumented posterior spinal fusion. OUTCOME MEASURES: Percentage of curve correction, fusion rate, intraoperative and postoperative clinical parameters, and functional outcome scores. METHODS: Preoperative and postoperative radiographs were analyzed to calculate the percentage of major curve correction in the coronal and sagittal planes as well as the rate of fusion. In addition, operative reports and medical records were analyzed for the following outcomes: estimated operative blood loss, length of surgery, chest tube output, length of hospitalization, and complications. Average follow-up time was 26 months in the VATS group and 27 months in the thoracotomy group. Finally, functional outcome was assessed using the Scoliosis Research Society (SRS-22) and Oswestry Disability Index (ODI) scoring system. RESULTS: The VATS group (mean age, 30) averaged 5.4 anterior levels and 11 posterior levels fused. The thoracotomy group (mean age, 32) averaged 5.8 anterior levels and 12 posterior levels fused. Estimated blood loss was nearly identical for the posterior procedures in both groups, whereas the anterior blood loss was significantly higher in the thoracotomy group as compared with the VATS group (541 cc vs. 288 cc). Operative time did not differ significantly between the two cohorts. Percent curve correction immediately postoperative (52% correction VATS; 51% correction thoracotomy) as well as at the 2-year follow-up (50% VATS and 54% thoracotomy) was nearly identical. There was no difference in postoperative ODI (p=.6) or SRS scores (p=.5) between groups. Complications were frequent but not significantly different between the two groups (p=.3). CONCLUSION: VATS is equally effective as thoracotomy with respect to fusion rate, major curve correction, and functional outcome scores. Although a decrease in operative blood loss was seen in the VATS patients, this was not clinically significant.

Comparison of acute phase reaction and postoperative stress in pigs undergoing video-assisted thoracoscopic versus thoracotomy pneumonectomy.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has been used for many thoracic diseases as an alternate approach to thoracotomy. The aim of this study was to compare the surgical outcome of pneumonectomy using VATS with that using thoracotomy pneumonectomy in pigs. Fourteen pigs were equally divided into two groups; one group underwent VATS and the other group underwent transthoracic pneumonectomy. We monitored pre-, intra-, and post-operative physiologic parameters, along with blood cell count, serum C-reactive protein (CRP), serum amyloid A (SAA), interleukin-6 (IL-6) and cortisol. The differences between the two approaches were analyzed. RESULTS: Mean surgical time in the VATS group (160.6 ± 16.2 min) was significantly longer than that in the thoracotomy group (123.7 ± 13.2 min). In both groups, CRP and IL-6 concentrations were significantly increased at postoperative 4 h, and then gradually decreased to preoperative levels. CRP and IL-6 at postoperative day 1 were significant lower in the VATS group compared with the thoracotomy group. SAA was significantly increased at postoperative days 1 and 3 in both groups compared with preoperative levels. Cortisol was significantly increased immediately after surgery in both groups compared with preoperative levels, and was significantly higher in the thoracotomy group than the VATS group at postoperative 4 h and 1 day. CONCLUSIONS: There was no difference between the two groups in physiologic parameters and blood cell count. However, the results indicate that VATS resulted in a smaller incision, less acute-phase reaction, less stress and less pain compared with thoracotomy pneumonectomy.

Establishing Benchmarks for Resuscitation of Traumatic Circulatory Arrest: Success-to-Rescue and Survival among 1,708 Patients.

BACKGROUND: Attempts are made with emergency department thoracotomy (EDT) to salvage trauma patients who present to the hospital in extremis. The EDT allows for relief of cardiac tamponade, internal cardiac massage, and proximal hemorrhage control. Minimally invasive techniques, such as endovascular hemorrhage control (EHC) are available, but their noninferiority to EDT remains unproven. Before adopting EHC, it is important to evaluate the current outcomes of EDT. We hypothesized that EDT survival has improved during the last 4 decades, and outcomes stratified by pre-hospital CPR and injury patterns will provide benchmarks for success-to-rescue and survival outcomes for patients in extremis. STUDY DESIGN: Consecutive trauma patients undergoing EDT from 1975 to 2014 were prospectively observed as part of quality improvement. Predicted probabilities of survival were adjusted for pre-hospital CPR, mechanism of injury, injury pattern, patient demographics, and time period of EDT using logistic regression. Success-to-rescue was defined as return of spontaneous circulation with blood pressure permissive for transfer to the operating room. RESULTS: There were 1,708 EDTs included, with an overall 419 (24%) success-to-rescue patients and 106 survivors (6%), and 1,394 (79%) of these patients had pre-hospital CPR and 900 (54%) had penetrating wounds. The most common injury patterns were chest (29%), multisystem with head (27%), and multisystem without head (21%). Penetrating injury was associated with higher survival than blunt trauma (9% vs 3% p < 0.001). Success-to-rescue increased from 22% in 1975 to 1979 to 35% over the final 5 years (p < 0.001); survival increased from 5% to 14% (p < 0.001). CONCLUSIONS: Outcomes of EDT have improved over the past 40 years. In the last 5 years, STR was 35% and overall survival was 14%. These prospective observational data provide benchmarks to define the role of EHC as an alternative approach for patients arriving in extremis.

Hybrid surgical approach of video-assisted minithoracotomy for lung cancer: significance of direct visualization on quality of surgery.

STUDY OBJECTIVES: Controversy regarding the most suitable surgical approach for treating malignancies of the lung is a matter of continuous discussions. "Complete" video-assisted thoracic surgery (VATS) that is performed using only the vision of a monitor is generally limited to lung resections of minimal difficulty. With the great interest in minimally invasive techniques for treating various pathologies, we have widely applied an integrated surgical approach that combines muscle-sparing minithoracotomy (incision, 4 to 10 cm) and video assistance using mainly direct visualization of the lung resection, which we have called hybrid VATS. The aim of this study is to evaluate the usefulness of hybrid VATS. DESIGN: Retrospective single-center study. INTERVENTIONS: From January 1998 to October 2004, 405 of 678 lobectomies (60%) and 165 of 226 segmentectomies (73%) were performed for primary lung cancer using hybrid VATS. RESULTS: Bronchoplasty was performed in 93 of the 678 patients (14%) who underwent lobectomy and in 11 of the 226 patients (5%) who underwent segmentectomy. Hybrid VATS was utilized in 33% of sleeve lobectomy procedures and in 27% of sleeve segmentectomy procedures. The mean (+/- SD) surgical time using hybrid VATS was 164 +/- 48 min for lobectomy and 158 +/- 35 min for segmentectomy, and the mean blood loss was 166 +/- 120 and 109 +/- 80 mL, respectively. There was one operative mortality (0.2%) secondary to cardiogenic shock. Postoperative complications developed in 11% of patients with p-stage IA disease after undergoing hybrid VATS, in contrast to 19% of patients after undergoing open thoracotomy. The prognosis of patients treated by hybrid VATS was equivalent to that obtained with open thoracotomy. CONCLUSIONS: Minithoracotomy combined with video support that is performed predominantly via direct visualization is a secure, integrated, minimally invasive approach to performing major resection for lung cancer, including atypical procedures such as bronchoplasty. This hybrid VATS can be an acceptable and satisfactory option whenever the performance of complete VATS is considered to be challenging.

Surgical lung biopsy for diffuse pulmonary disease: experience of 196 patients.

OBJECTIVE: Surgical lung biopsy is considered the final method of diagnostic modality in patients with undiagnosed diffuse pulmonary disease. Nevertheless, the effect of surgical lung biopsy on the diagnosis, treatment, and outcome of the patient still remains controversial. This study reviewed the experiences of surgical lung biopsies in 196 consecutive patients during the past 7 years. METHODS: Surgical lung biopsy was performed after achievement of general anesthesia through video-assisted thoracoscopic surgery or a 7-cm minithoracotomy. Biopsy specimens were swabbed for aerobic and anaerobic bacterial, fungal, and mycobacterial cultures. The sections of specimens were routinely stained with hematoxylin and eosin, and acid-fast, Gomori methenamine silver, Gram stain, or other special stains were added if necessary. RESULTS: The pathologic diagnosis after surgical lung biopsy included infection (30.6%), interstitial pneumonia or fibrosis (21.9%), diffuse alveolar damage (17.3%), neoplasm (13.3%), autoimmune diseases (8.2%), and others (8.2%). After surgical lung biopsy, 165 (84.2%) patients had changes in their therapy, 124 (63.3%) patients had clinical improvement of their conditions, and 119 (60.7%) patients survived to hospital discharge. Comparison between immunocompromised and immunocompetent patients showed that diagnosis of infection was significantly higher ( P < .01) in the former group (41.2% vs 20.2%). In addition, there was no significant difference in the distribution of diagnosis and rate of change in therapy between the respiratory failure and nonrespiratory failure groups. However, the rates of response to therapy and patient survival were significantly lower in the respiratory failure group (51.2% and 41.5%) than in the nonrespiratory failure group (71.9% and 78.1%, P < .05). There was no surgical mortality directly related to the procedure. The surgical morbidity rate was 6.6%. CONCLUSION: Surgical lung biopsy is a safe and accurate diagnostic tool for diffuse pulmonary disease. For a large proportion of the patients, change of therapy and then clinical improvement can be achieved after surgical lung biopsy. Surgical lung biopsy should be considered earlier in patients with undiagnosed diffuse pulmonary disease, especially when the respiratory condition is deteriorating.

Cost-minimization analysis of alternative diagnostic approaches in a modeled patient with non-small cell lung cancer and subcarinal lymphadenopathy.

OBJECTIVE: To evaluate the costs of alternative diagnostic evaluations of enlarged subcarinal lymph nodes (SLNs) in modeled patients with non-small cell lung cancer (NSCLC). METHODS: A cost-minimization model was used to compare 5 diagnostic approaches in the evaluation of enlarged SLNs in modeled patients with NSCLC. Values for the test performance characteristics and prevalence of malignancy in patients with SLN were obtained from the medical literature. The target population was adult patients known or suspected to have NSCLC with SLNs with a short axis length of at least 10 mm on thoracic computed tomography (CT). RESULTS: The lowest-cost diagnostic work-up was by initial evaluation with endoscopic ultrasonography-guided fine-needle aspiration (EUS FNA) biopsy ($11,490 per patient) compared with mediastinoscopy (with biopsy) ($13,658), transbronchial FNA biopsy ($11,963), CT-guided FNA biopsy ($13,027), and positron emission tomography ($12,887). The results were sensitive to rate of SLN metastases and EUS FNA sensitivity. The EUS FNA biopsy remained least costly if the probability of SLN metastases exceeded 24% or EUS FNA sensitivity was higher than 76%. Primary mediastinoscopy was the most economical if not. CONCLUSIONS: Which testing strategy is least costly for SLN evaluation in a modeled patient with NSCLC may be determined by the pretest probability of nodal metastases. Use of EUS FNA biopsy minimizes the cost of diagnostic evaluation in most cases.