A Machine Learning Approach for Postoperative Outcome Prediction: Surgical Data Science Application in a Thoracic Surgery Setting.

BACKGROUND: The use of innovative methodologies, such as Surgical Data Science (SDS), based on artificial intelligence (AI) could prove to be useful for extracting knowledge from clinical data overcoming limitations inherent in medical registries analysis. The aim of the study is to verify if the application of an AI analysis to our database could develop a model able to predict cardiopulmonary complications in patients submitted to lung resection. METHODS: We retrospectively analyzed data of patients submitted to lobectomy, bilobectomy, segmentectomy and pneumonectomy (January 2006-December 2018). Fifty preoperative characteristics were used for predicting the occurrence of cardiopulmonary complications. The prediction model was developed by training and testing a machine learning (ML) algorithm (XGBOOST) able to deal with registries characterized by missing data. We calculated the receiver operating characteristic curve, true positive rate (TPR), positive predictive value (PPV) and accuracy of the model. RESULTS: We analyzed 1360 patients (lobectomy: 80.7%, segmentectomy: 11.9%, bilobectomy 3.7%, pneumonectomy: 3.7%) and 23.3% of them experienced cardiopulmonary complications. XGBOOST algorithm generated a model able to predict complications with an area under the curve of 0.75, a TPR of 0.76, a PPV of 0.68. The model's accuracy was 0.70. The algorithm included all the variables in the model regardless of their completeness. CONCLUSIONS: Using SDS principles in thoracic surgery for the first time, we developed an ML model able to predict cardiopulmonary complications after lung resection based on 50 patient characteristics. The prediction was also possible even in the case of those patients for whom we had incomplete data. This model could improve the process of counseling and the perioperative management of lung resection candidates.

Computed tomography-guided microcoil placement for localizing small pulmonary nodules before uniportal video-assisted thoracoscopic resection.

PURPOSE: The increasing number of computed tomography (CT) performed allows the more frequent identification of small, solid pulmonary nodules or ground-glass opacities. Video-assisted thoracic surgery (VATS) represents the standard in most lung resections. However, since VATS limit is the digital palpation of the lung parenchyma, many techniques of nodule localization were developed. The aim of this study was to determine the feasibility and safety of CT-guided microcoil insertion followed by uniportal VATS wedge resection (WR). MATERIALS AND METHODS: Retrospective study in a single institution, including patients undergone CT-guided microcoil insertion prior to uniportal VATS resection between May 2015 and December 2018. The lesion was identified using fluoroscopy. RESULTS: Forty-six consecutive patients were enrolled (22 male and 24 female). On CT: 5 cases of GGO, 2 cases of semisolid nodules, 39 cases of solid nodules. The median pathologic tumor size was 1.21 cm. Neither conversion to thoracotomy nor microcoil dislodgement was recorded. All patients underwent uniportal VATS WR (9/46 underwent completion lobectomy after frozen section). WR median time was 105 min (range 50-150 min). No patients required intraoperative re-resection for positive margins. After radiological procedure, 1 case of hematoma and 2 cases of pneumothorax were recorded. Four complications occurred in the postoperative period. The mean duration of chest drain and length of stay were 2.9 and 4.6 days, respectively. CONCLUSIONS: CT-guided microcoil insertion followed by uniportal VATS resection was a safe and feasible procedure having a minimal associated complications rate and offering surgeons the ease of localization of small intrapulmonary nodules.

Endovascular Treatment of Blunt Thoracic Aortic Injury by Fractured Rib.

We treated an 89-year-old patient affected by a descending thoracic aorta lesion due to a rib fracture with a penetrating costal stump. An urgent combined thoracic and endovascular surgical approach was performed, removing the rib fragment and positioning an aortic endoprosthesis simultaneously. Postoperative angio-computed tomography scan demonstrated the correct position of the endoprosthesis without any leakage or periaortic hemorrhage.

Extralobar Pulmonary Sequestration Presenting with Recurring Massive Pleural Effusion in a Young Woman: A Challenging Case.

We report a case of extralobar pulmonary sequestration (ELS) in a young woman, presenting with right recurring massive pleural effusion. The patient initially underwent a diagnostic Video Assisted Thoracic Surgery (VATS) for a suspected diffuse malignancy. After the aspiration of the pleural effusion we observed a highly vascularised cystic mass, with its origin from the right lower lobe. As we tried to retract the right lower lobe, the mass broke with massive bleeding requiring emergency right lateral thoracotomy. The mass was succesfully excised, resembling an extra-lobar pulmonary sequestration. The patient was discharged on post-operative day 5.

Giant Cervico-mediastinal Well-differentiated Liposarcoma.

Liposarcomas are rare entities and those located in the neck and mediastinum are exceptional. We report the case of a 58 year-old Caucasian male who presented with dysphonia, mild dysphagia to solids, dyspnoea at exertion and cough due to a giant mass of the neck originating from the deep cervical space at C6 vertebral level spreading into the posterior mediastinum. The lesion, that was associated with a right vocal cord palsy, caused severe lateral displacement of the trachea and oesophagus. The case has been managed by complete surgical resection through a combined cervical and thoracic approach associated with a tracheostomy due to the risk of bilateral recurrent nerve dysfunction at the end of the intervention. The tumour was diagnosed as a encapsulated low-grade liposarcoma. Six months after surgery the tracheostomy was closed. At 24 months clinical and radiological follow-up the patient is doing well and disease free.

Uniportal Video-Assisted Thoracoscopic Surgery Completion Lobectomy Long after Wedge Resection or Segmentectomy in the Same Lobe: A Bicenter Study.

BACKGROUND: Completion lobectomy (CL) following a prior resection in the same lobe may be complicated by severe pleural or hilar adhesions. The role of uniportal video-assisted thoracoscopic surgery (U-VATS) has never been evaluated in this setting. METHODS: Data were collected from two Italian centers. Between 2015 and 2022, 122 patients (60 men and 62 women, median age 67.7 ± 8.913) underwent U-VATS CL at least 4 weeks after previous lung surgery. RESULTS: Twenty-eight (22.9%) patients were affected by chronic obstructive pulmonary disease (COPD) and twenty-five (20.4%) were active smokers. Among the cohort, the initial surgery was performed using U-VATS in 103 (84.4%) patients, triportal-VATS in 8 (6.6%), and thoracotomy in 11 (9.0%). Anatomical segmentectomy was the initial surgery in 46 (37.7%) patients, while hilar lymphadenectomy was performed in 16 (13.1%) cases. CL was performed on 110 (90.2%) patients, segmentectomy on 10 (8.2%), and completion pneumonectomy on 2 (1.6%). Upon reoperation, moderate pleural adhesions were observed in 38 (31.1%) patients, with 2 (1.6%) exhibiting strong adhesions. Moderate hilar adhesions were found in 18 (14.8%) patients and strong adhesions in 11 (9.0%). The median operative time was 203.93 ± 74.4 min. In four (3.3%) patients, PA taping was performed. One patient experienced intraoperative bleeding that did not require conversion to thoracotomy. Conversion to thoracotomy was necessary in three (2.5%) patients. The median postoperative drainage stay and postoperative hospital stay were 5.67 ± 4.44 and 5.52 ± 2.66 days, respectively. Postoperative complications occurred in 34 (27.9%) patients. Thirty-day mortality was null. Histology was the only factor found to negatively influence intraoperative outcomes (p = 0.000). Factors identified as negatively impacting postoperative outcomes at univariate analyses were male sex (p = 0.003), age > 60 years (p = 0.003), COPD (p = 0.014), previous thoracotomy (p = 0.000), previous S2 segmentectomy (p = 0.001), previous S8 segmentectomy (p = 0.008), and interval between operations > 5 weeks (p= 0.005). In multivariate analysis, only COPD confirmed its role as an independent risk factor for postoperative complications (HR: 5.12, 95% CI (1.07-24.50), p = 0.04). CONCLUSIONS: U-VATS CL seems feasible and safe after wedge resection and anatomical segmentectomy.

Impact of enhanced pathway of care in uniportal video-assisted thoracoscopic surgery.

Enhanced Recovery After Surgery (E.R.A.S.) is a multimodal, evidence-based and patient-centered pathway designed to minimize surgical stress, enhancing recovery and improving perioperative outcomes. However, considering that the potential clinical implication of E.R.A.S. on patients undergoing video-assisted thoracic surgery (V.A.T.S.) has not properly defined, we proposed to implement our minimally invasive program with a specific clinical pathway able to enhance recovery after lung resection. Aim of this study was to assess the impact of this integrated program of Enhanced Pathway of Care (E.P.C.) in Uniportal V.A.T.S. patients undergoing lung resection, in terms of efficiency and safety. We conducted a retrospective, observational study enrolling patients undergoing uniportal V.A.T.S. resections from January 2015 to May 2020. Two groups were created: pre-E.P.C. and E.P.C. Propensity score matching analysis was performed to evaluate length of stay (LOS), postoperative cardiopulmonary complications (CPC) and readmission rate (READM). We analyzed 1167 patients (E.P.C. group: 182; pre-E.P.C. group: 985). E.P.C. group has a mean LOS shorter compared to pre-E.P.C. group (3.13 vs 4.19 days, p < 0.0001) without increasing on CPC (E.P.C. 12% vs pre-E.P.C. 11%, p = 0.74) and READM rate (E.P.C. 1.6% vs pre-E.P.C. 4.9%, p = 0.07). In particular, the LOS was shortened in the E.P.C. patients submitted to lobectomy, segmentectomy and wedge resection. Moreover, the three subgroups had similar CPC and READM rates for E.P.C. and control patients. In conclusion, this study demonstrated the benefits and safety of E.P.C. program showing a reduction of LOS for patients undergoing uniportal V.A.T.S. resection.

Uniportal video-assisted thoracoscopic left superior segmentectomy.

Obtaining adequate margins when performing lung cancer resection is crucially important. Therefore, during thoracoscopic segmentectomy, where the direct palpation of the tumor is not always possible, it is mandatory to accurately identify the intersegmental plane in order to achieve a satisfactory oncological and surgical result. In this video tutorial, we demonstrate a uniportal video-assisted thoracoscopic (VATS) superior segmentectomy of the left lower lobe, adopting two different techniques for identifying the intersegmental plane: the inflation-deflation method and selective resected segmental inflation, and we present the pros and cons of each. With the inflation/deflation technique, which is the most common maneuver used, we inflated the whole lung after occlusion of the target segmental bronchus, inducing collapse of the superior segment and inflation of the remaining lobe. However, this inexpensive and easy method often makes identification of the intersegmental plane unreliable because of the collateral ventilation. Moreover, because of the expansion of inflated segments, it limits thoracic working space during the VATS procedure. In contrast, selective resected segmental inflation guarantees an optimal surgical space even during a VATS procedure. In this case, we directly inflated the segmental bronchus of the superior segment through a butterfly needle in order to selectively expand only the selected segment. The careful demarcation of the intersegmental plane is mandatory in order to obtain adequate margins and achieve a high success rate for thoracoscopic segmentectomy. Although a one-size-fits-all method is not feasible, we strongly recommend  making every effort for identifying it as best as possible; indeed, its inadequate demarcation may be the main cause of unsatisfactory surgical and oncological results in terms of locoregional recurrence and long-term survival.

Uniportal video-assisted thoracoscopic thymectomy: the glove-port with carbon dioxide insufflation.

BACKGROUND: Since 2004, uniportal video-assisted thoracic surgery (VATS) approach was progressively widespread and also applied in the treatment of thymoma, with promising results. We report the first series of patients who undergone uniportal VATS thymectomy using a homemade glove-port with carbon dioxide (CO2) insufflation. The aim of this article is to analyze the safety and feasibility to perform an extended thymectomy (ET). METHODS: A prospective, single-centre, short-term observational study including patients with mediastinal tumours undergoing scheduled uniportal VATS resection using a glove-port with CO2. Operations were performed through a single incision of 3.5 cm at the fifth intercostal space, right or left anterior axillary line. A 5 mm-30° camera and working instruments were employed through a glove-port with CO2. RESULTS: Thirty-eight patients (20 men; mean age 61.6 years) underwent ET between September 2016 and October 2019. Thirteen patients had a history of Myasthenia Gravis (MG) with thymoma and 8 had incidental findings of thymoma. Additionally, 8 mediastinal cysts and 9 thymic hyperplasia were included. Mean diameter of the tumor was 5.1 cm (range, 1.6-14 cm) and mean operation time was 143 minutes. Mean postoperative drainage duration and hospital stay were 2.3 and 4.3 days, respectively. Mean blood loss was 41 mL. There was no occurrence of surgical morbidity or mortality. During the follow-up period (1-36 months), no recurrence was noted. CONCLUSIONS: Our results suggest that uniportal VATS thymectomy through glove-port and CO2 is safe and feasible procedure, even with large thymomas. Furthermore, the glove-port system represents a valid, cheap and widely available alternative to the commercial devices usually adopted in thoracic surgery.

Novel double-stapling technique for distal oesophageal resection and oesophago-jejunal anastomosis.

AIM: The restoration of the digestive tract by performing an esophago-jejunal anastomosis (EJA) is a crucial step of the total gastric and distal esophagus surgical resection for esophago-gastric junction (EGJ) cancer. We have already ideated and tested on a cadaver model an innovative technique which could be useful to minimize the risk of complications related to the phase of securing the anvil of the circular stapler prior to perform the EJA. This surgical technique was derived from the well-known "double-stapling Knight and Griffen" one that was described for the rectal resection. We used the following described technique in 20 patients with EGJ cancer and it is efficient, reliable, safe, easy to learn and easy to perform. MATERIALS AND METHODS: From August 2014 to May 2015, 20 patients (14 male and 6 female) underwent surgery for esophagogastric junction cancer: In all patients a distal esophageal resection and total gastrectomy was performed. Through the trans-hiatal access, the free margins of the esophageal stump were suspended and the anvil of a circular stapler on a new dedicated and registered support bar was inserted into the lumen. Subsequently, the linear suturing stapler is closed over the bar and then fired to suture the distal stump of the esophagus; after the confirmation of a negative margin, the bar is retracted and the push-rod of the anvil is pulled out through the linear suture. Finally, the anastomosis is performed with the classic technique by using a circular stapler. RESULTS: No postoperative mortality occurred; postoperative course has been uneventful for 18 patients. One patient developed anastomotic fistula that has been treated conservatively with endoscopic prothesis, removed after 20 days. One patient developed in 3 POD myocardial infarction Mean Hospital stay has been 14 days (range 7-20 days). CONCLUSIONS: The aim of our new procedure is the insertion the anvil of a common circular stapler without handsewn securing; this is to reduce the technical difficulties related to the hand-sewn securing into a deep and narrow anatomic location, typical of the trans-hiatal approach. KEY WORDS: Anastomosis, Oesophago-gastric junction cancer, Stapler, Trans-hiatal.

Persistent lung expansion after pleural talc poudrage in non-surgically resected malignant pleural mesothelioma.

BACKGROUND: To investigate the prognostic effect of persistent lung expansion after pleural talcage and other variables in non-surgically resected malignant pleural mesothelioma (MPM) patients. METHODS: All consecutive patients submitted to video-assisted thoracoscopic (VAT) pleurodesis by talc poudrage for MPM between 2006 and 2011 were studied. The following parameters were prospectively recorded: age; sex; smoking history; asbestos exposure; C-reactive protein (CRP) levels; platelet (PLT) count; Eastern Cooperative Oncology Group performance status (ECOG PS); histologic subtype; clinical stage (cStage); chemotherapy; pleural fluid volume; and persistence of lung expansion at 3 months follow-up. Survival was assessed in June 2013. RESULTS: A total of 172 patients were considered; 146 of 172 patients demonstrated a complete lung expansion at discharge, whereas only 85 of 172 patients had persistent expanded lung on the affected side at the 3-month follow-up chest x-ray. Median survival was 11.5 months (95% confidence interval [CI], 10% to 14%) and 2-year disease-specific survival was 13% (95% CI, 7% to 24%) for the entire cohort. Multivariate analysis showed that non-epithelioid histology (hazard ratio [HR], 2.81; 95% CI, 1.82% to 5.09%), pleural fluid recurrence (HR 2.54; 95% CI, 1.73% to 4.40%), cStage greater than II (HR 2.36; 95% CI, 1.50% to 4.32%), ECOG PS greater than 1 (HR 2.19; 95% CI, 1.26% to 4.23%), CRP greater than 5 mg/L (HR 2.01; 95% CI, 1.18% to 4.12%), and PLT count greater than 400,000 (HR 1.76; 95% CI 1.14% to 3.92%) were independent predictors of poor prognosis. CONCLUSIONS: Persistent lung expansion after pleural talc poudrage and absence of fluid recurrence is demonstrated to be a stronger factor in predicting survival rather than clinical stage and other clinical variables in not surgically resected MPM patients.

Metastasis to subsegmental and segmental lymph nodes in patients resected for non-small cell lung cancer: prognostic impact.

BACKGROUND: We investigated the prognostic significance of segmental and subsegmental (level 13 and 14) lymph nodes metastasis in patients with resected non-small cell lung cancer (NSCLC). METHODS: The pattern of lymph nodal metastasis was analyzed in 124 patients with pN1 NSCLC. Long-term outcomes were compared for 390 pN0, 124 pN1, and 82 pN2 consecutive patients submitted to planned pulmonary resection for NSCLC between 2000 and 2006. The pN1 status was stratified into 3 groups according to the highest level of lymph node involvement: level 10 (hilar); level 11+12 (lobar + interlobar); and level 13+14 (segmental + subsegmental). RESULTS: The 5-year overall survival (OS) rates for pN0, pN1, and pN2 patients were 93%, 66%, and 25%, respectively. The highest level of lymph node involvement was a significant prognostic indicator; the 5-year OS rate for level 13+14, level 11+12, level 10 pN1, and pN2 was 81%, 58%, 48%, and 25%, respectively. Significant differences were recorded in long-term outcome when pN0 and pN1 level 13+14, pN1 level 13+14, and pN1 level 11+12, pN1 level 11+12 and pN1 level 10 were compared (p < 0.05). The median number of examined level 13+14 lymph nodes was 2 (range 0 to 6) and 57% pN1 patients had metastasis at level 13+14 lymph nodes. CONCLUSIONS: The highest level of lymph node metastases may be used to stratify outcome of patients with pN1 disease. Routine examination of level 13+14 lymph nodes is to be recommended to correctly identify patients at risk of relapse and predict long-term prognosis.

Non-small cell lung cancer in surgically treated women.

AIM AND BACKGROUND: To determine whether female patients operated on for non-small cell lung cancer (NSCLC) have a survival advantage compared to male patients. METHODS AND STUDY DESIGN: We analyzed data from 1,426 prospectively collected patients submitted to lung resection for NSCLC between 1999 and 2008. RESULTS: Two groups, including 1,014 male and 412 female patients, were compared. Female patients were significantly younger, were more frequently asymptomatic, were less likely to be smokers, had better preoperative respiratory function, had a lower frequency of COPD, and were less commonly affected by cardiovascular comorbidity than men. Adenocarcinoma was more frequently present and early pathological stage (stage IA) more frequently detected in women at diagnosis. The operative mortality was significantly lower among women (1.6% vs 4.6%) (P = 0.012), and women underwent significantly more segmentectomies and fewer pneumonectomies (P = 0.001). The disease-related 5-year survival rate was significantly higher in women (66% vs 51%) (P = 0.0008). At univariate analysis the absence of symptoms at presentation, lower pathological stage, squamous cell type, and female gender were positive factors influencing long-term survival. At multivariate analysis low pathological stage, squamous cell type and female gender were confirmed as independent positive prognostic predictors. Women had a significant survival advantage irrespective of the histological subtype at pathological stage IA, IB, IIB and IIIA disease (P <0.05). CONCLUSIONS: Female gender was confirmed to be a particular subset amongst patients affected by NSCLC and exerted a positive effect on disease-related survival of patients submitted to surgical resection. This important effect of gender should be cautiously kept in mind in analyzing the results of current and future trials for lung cancer therapy.

Thymomaptysis: unusual presentation of invasive thymoma.

Symptomatic thymomas are characterized by non-specific thoracic symptoms or symptoms related to associated para-thymic syndromes. We report the case of a 56-year old Caucasian male who was affected by invasive (Masaoka IVA) WHO mixed AB-B2 thymoma after the elimination through the sputum of a fragment of tumour vegetating in the left upper lobar bronchus. The patient received multimodal treatment consisting of neoadjuvant cisplatinum-based polychemiotherapy, radical surgical resection ('en bloc' thymectomy, thymomectomy and pulmonary left upper lobe exeresis and pleural implants resection) and subsequent mediastinal radiation therapy. At 18-month follow-up, the patient is alive and disease-free.

Single thymic gland metastasis from resected non-small-cell lung cancer.

Primary thymic tumors are rare, but secondary ones are exceptionally uncommon. We report the case of a single metastasis within the thymic gland from a lung adenocarcinoma that had been completely resected 3 years before. There was high diagnostic doubt because the thymic lesion was not associated with the recurrence of the paraneoplastic syndrome or the increased CEA levels described at the moment of the treatment of the primary tumor. The lesion was diagnosed and treated at the same time by transcervical thymectomy. At the one-year follow-up, the patient is alive and disease-free.