Intraoperative marking of pulmonary nodules in a hybrid operating room: electromagnetic navigation bronchoscopy versus percutaneous marking.

Background: Intraoperative identification of subsolid or small pulmonary nodules during minimally invasive procedures is challenging. Recent localization techniques show varying success and complications. Hybrid operating rooms (HORs), equipped with radiological tools, facilitate intraoperative imaging. This study compares the accuracy and safety of marking pulmonary nodules using electromagnetic navigation bronchoscopy (ENB) combined with Cone Beam Computed Tomography (CBCT) vs. CBCT-guided percutaneous marking (PM). Methods: This retrospective cohort study included patients with pulmonary nodules scheduled for minimally invasive resection in a HOR. Marking techniques included ENB assisted by CBCT and PM guided by CBCT. The study compared the success rate, procedure time, intraoperative complications and radiation dose of both techniques. Results: A total of 104 patients with 114 nodules were included (October 2021-July 2024). Thirty nodules were marked using ENB, and 84 with PM. One case used both techniques due to ENB failure. No differences among groups were found in nodule characteristics. Success rates were similar (93.3% in ENB group vs. 91.7% in PM group, p = 1). Marking took significantly longer time in the ENB group (median 40 min) compared to PM group (25 min, p = 0.007). Five (6%) patients in the PM group experienced intraoperative complications compared to none in the ENB (p = 0.323). Radiation dose was significantly higher in the ENB group (p = 0.002). Conclusions: ENB assisted by CBCT is a safe and effective technique, with success rates comparable to CBCT-guided PM, though it may result in longer procedural times and higher radiation doses.

Early outcomes of robotic versus video-thoracoscopic anatomical segmentectomy: a propensity score-matched real-world study.

OBJECTIVES: Minimally invasive anatomic segmentectomy for the resection of pulmonary nodules has significantly increased in the last years. Nevertheless, there is limited evidence on the safety and feasibility of robotic segmentectomy compared to video-assisted thoracic surgery. This study aimed to compare the real-world early outcomes of robotic and video-thoracoscopic in anatomic segmentectomy. METHODS: Single centre cohort study including all consecutive patients undergoing segmentectomy by either robotic or video-thoracoscopic from June 2018 to November 2023. Propensity score case matching analysis generated two matched groups undergoing robotic or video-thoracoscopic segmentectomy. Short-term outcomes were analysed and compared between groups. RESULTS: 204 patients (75 robotic and 129 video-thoracoscopic patients) were included. After matching, 146 patients (73 cases in each group) were compared. One 30-day death was observed in the robotic group (P = 1). Two conversions to thoracotomy occurred in the robotic, and none in the video-thoracoscopic group (P = 0.5). Surgical time was longer in the robotic group (P = 0.091). There were no significant differences between robotic and video-thoracoscopic groups in postoperative complications (13.7% vs 15.1%, P = 1), cardiopulmonary complications (6.8% vs 6.8%, P = 1), major complications (4.1% vs 4.1%, P = 1), prolonged air leak (4.1% vs 5.5%, P = 1), arrythmia (1.4% vs 0%, P = 1) and reoperation (2.7% vs 2.7%, P = 1). Median length of stay was 3 days (IQR, 2-3 days) in the robotic group vs 3 days (IQR, 2.5-4 days) in the video-thoracoscopic group (P = 0.212). CONCLUSIONS: Robotic segmentectomy is a safe and feasible alternative to video-thoracoscopy, as no significant differences in early postoperative outcomes were found between the two techniques.

The robotic surgery learning curve of a surgeon experienced in video-assisted thoracoscopic surgery compared with his own video-assisted thoracoscopic surgery learning curve for anatomical lung resections.

OBJECTIVES: Robotic surgery, although it shares some technical features with video-assisted thoracoscopic surgery (VATS), offers some advantages, such as ergonomic design and a 3-dimensional view. Thus, the learning curve for robotic lung resection could be expected to be shorter than that of VATS for surgeons who are proficient in VATS. The goal of this study was to analyse the robotic learning curve of a VATS experienced surgeon and to compare it to his own VATS learning curve for anatomical lung resections. METHODS: We conducted a retrospective observational study based on the prospectively recorded data of the first 150 anatomical lung resections performed with VATS (75 cases) and with the robotic (75 cases) approach by the same surgeon in our centre. Learning curves were analysed using the cumulative sum method to assess the trends for total operating time and surgical failure (intraoperative complications, conversion, technical postoperative complications and reintervention) across case sequences. Subsequently, using adequate statistical tests, we compared the postoperative outcomes in both groups. RESULTS: The median operating time was similar for both approaches (P = 0.401). Surgical failure rate was higher for the robotic cases (21.3% vs 12%; P = 0.125). Based on cumulative sum analyses, operating time decreased starting with case 34 in the VATS group and with case 32 in the robotic cohort. Surgical failure tended to decline starting with case 28 in the VATS group and with case 32 in the robotic group. Perioperative results were similar in both groups. CONCLUSIONS: When we compared robotic and VATS learning curves for anatomical lung resection, we did not find any differences. Postoperative outcomes were also similar with both approaches.

Similar outcomes after newly implemented rats approach compared to standard vats for anatomical lung resection. A propensity-score matched analysis.

INTRODUCTION: Outcomes after the introduction of surgical innovations can be impaired by learning periods. The aim of this study is to compare the short-term outcomes of a recently implemented RATS approach to a standard VATS program for anatomical lung resections. METHODS: Retrospective review of consecutive patients undergoing pulmonary anatomical resection through a minimally invasive approach since RATS approach was applied in our department (June 01, 2018, to November 30, 2019). Propensity score matching was performed according to patients' age, gender, ppoFEV1, cardiac comorbidity, type of malignancy, and type of resection. Outcome evaluation includes: overall morbidity, significant complications (cardiac arrhythmia, pneumonia, prolonged air leak, and reoperation), 30-day mortality, and length of hospital stay. Data were compared by two-sided chi-square or Fisher's exact test for categorical and Mann-Whitney U test for continuous variables. RESULTS: A total of 273 patients (206 VATS, 67 RATS) were included in the study. After propensity score matching, data of 132 patients were analyzed. The thirty-days mortality was nil. Overall morbidity (RATS: 22.4%, VATS: 29.2%; p=0.369), major complications (RATS: 9% vs VATS: 9.2%; p=0.956) and the rates of specific major complications (cardiac arrhythmia RATS: 4.5%, VATS: 4.6%, p=1; pneumonia RATS:0%, VATS:4.6%, p=0.117; prolonged air leak RATS: 7.5%; VATS: 4.6%, p=0.718) and reoperation (RATS: 3%, VATS: 1.5%, p=1) were comparable between both groups. The median length of stay was 3 days in both groups (p=0.101). CONCLUSIONS: A RATS program for anatomical lung resection can be implemented safely by experienced VATS surgeons without increasing morbidity rates.

"Obesity paradox" has not an impact on minimally invasive anatomical lung resection.

INTRODUCTION: The paradoxical benefit of obesity, the 'obesity paradox', has been analyzed in lung surgical populations with contradictory results. Our goal was assessing the relationship of body mass index (BMI) to acute outcomes after minimally invasive major pulmonary resections. METHODS: Retrospective review of consecutive patients who underwent pulmonary anatomical resection through a minimally invasive approach for the period 2014-2019. Patients were grouped as underweight, normal, overweight and obese type I, II and III. Adjusted odds ratios regarding postoperative complications (overall, respiratory, cardiovascular and surgical morbidity) were produced with their exact 95% confidence intervals. All tests were considered statistically significant at p<0.05. RESULTS: Among 722 patients included in the study, 37.7% had a normal BMI and 61.8% were overweight or obese patients. When compared with that of normal BMI patients, adjusted pulmonary complications were significantly higher in obese type I patients (2.6% vs 10.6%, OR: 4.53 [95%CI: 1.86-12.11]) and obese type II-III (2.6% vs 10%, OR: 6.09 [95%CI: 1.38-26.89]). No significant differences were found regarding overall, cardiovascular or surgical complications among groups. CONCLUSIONS: Obesity has not favourable effects on early outcomes in patients undergoing minimally invasive anatomical lung resections, since the risk of respiratory complications in patients with BMI≥30kg/m2 and BMI≥35kg/m2 is 4.5 and 6 times higher than that of patients with normal BMI.

[Review and update of the prognostic factors in lung metastasis surgery]. / Revisión y actualización de los factores pronósticos en la cirugía de las metástasis pulmonares.

INTRODUCTION: Since the International Registry of Lung Metastases established the factors that determine survival after performing lung metastasectomy in 1997, numerous studies have attempted to determine these prognostic factors of survival. Our objective has been to analyse the mortality, survival and disease-free survival lung metastasis surgery by studying the different variables that determine them. PATIENTS AND METHOD: All patients subjected to surgery for lung metastasectomy between 1998 and 2008 were included in this study. The Kaplan-Meier and log-rank tests were performed, as well as a Cox regression using multivariate analysis. RESULTS: A total of 178 lung metastases were removed in 146 patients during this period. The mean age was 62.22 years (median 63 years) and 64.6% were males. There were 2 cases (1.1%) of mortality and the incidence of complications was 5.02% (9 cases). The overall survival was 67.75 months with a 3 and 5 year survival of 67.4% and 52.4%, respectively. The variables that showed statistical significance in the multivariate analysis were: age disease free interval, number of nodules and size of nodules. The "state of the margins" variable was almost significant (P=.054). DISCUSSION: To have only one metastasis and it is less than 1cm, a long disease free interval, and a resection with free margins, are the most favourable prognostic factors after resection of lung metastasis.

"Obesity paradox" has not an impact on minimally invasive anatomical lung resection.

INTRODUCTION: The paradoxical benefit of obesity, the 'obesity paradox', has been analyzed in lung surgical populations with contradictory results. Our goal was assessing the relationship of body mass index (BMI) to acute outcomes after minimally invasive major pulmonary resections. METHODS: Retrospective review of consecutive patients who underwent pulmonary anatomical resection through a minimally invasive approach for the period 2014-2019. Patients were grouped as underweight, normal, overweight and obese type I, II and III. Adjusted odds ratios regarding postoperative complications (overall, respiratory, cardiovascular and surgical morbidity) were produced with their exact 95% confidence intervals. All tests were considered statistically significant at p<0.05. RESULTS: Among 722 patients included in the study, 37.7% had a normal BMI and 61.8% were overweight or obese patients. When compared with that of normal BMI patients, adjusted pulmonary complications were significantly higher in obese type I patients (2.6% vs 10.6%, OR: 4.53 [95%CI: 1.86-12.11]) and obese type II-III (2.6% vs 10%, OR: 6.09 [95%CI: 1.38-26.89]). No significant differences were found regarding overall, cardiovascular or surgical complications among groups. CONCLUSIONS: Obesity has not favourable effects on early outcomes in patients undergoing minimally invasive anatomical lung resections, since the risk of respiratory complications in patients with BMI≥30kg/m2 and BMI≥35kg/m2 is 4.5 and 6 times higher than that of patients with normal BMI.

Similar outcomes after newly implemented rats approach compared to standard vats for anatomical lung resection. A propensity-score matched analysis.

INTRODUCTION: Outcomes after the introduction of surgical innovations can be impaired by learning periods. The aim of this study is to compare the short-term outcomes of a recently implemented RATS approach to a standard VATS program for anatomical lung resections. METHODS: Retrospective review of consecutive patients undergoing pulmonary anatomical resection through a minimally invasive approach since RATS approach was applied in our department (June 01, 2018, to November 30, 2019). Propensity score matching was performed according to patients' age, gender, ppoFEV1, cardiac comorbidity, type of malignancy, and type of resection. Outcome evaluation includes: overall morbidity, significant complications (cardiac arrhythmia, pneumonia, prolonged air leak, and reoperation), 30-day mortality, and length of hospital stay. Data were compared by two-sided chi-square or Fisher's exact test for categorical and Mann-Whitney U test for continuous variables. RESULTS: A total of 273 patients (206 VATS, 67 RATS) were included in the study. After propensity score matching, data of 132 patients were analyzed. The thirty-days mortality was nil. Overall morbidity (RATS: 22.4%, VATS: 29.2%; p=0.369), major complications (RATS: 9% vs VATS: 9.2%; p=0.956) and the rates of specific major complications (cardiac arrhythmia RATS: 4.5%, VATS: 4.6%, p=1; pneumonia RATS:0%, VATS:4.6%, p=0.117; prolonged air leak RATS: 7.5%; VATS: 4.6%, p=0.718) and reoperation (RATS: 3%, VATS: 1.5%, p=1) were comparable between both groups. The median length of stay was 3 days in both groups (p=0.101). CONCLUSIONS: A RATS program for anatomical lung resection can be implemented safely by experienced VATS surgeons without increasing morbidity rates.

Early exercise pulmonary diffusing capacity of carbon monoxide after anatomical lung resection: a word of caution for fast-track programmes.

OBJECTIVES: In healthy individuals, increasing pulmonary blood flow during exercise also increases the % of the diffusing capacity of the lungs for carbon monoxide (DLCO%), but its evolution after lung resection is unknown. In this study, our goal was to measure changes in exercise DLCO% during the first 3 days after anatomical lung resection. METHODS: We performed a prospective observational study on consecutive patients with non-small-cell lung cancer scheduled for anatomical resection, except pneumonectomy, during a 6-month period. Patients underwent measurement of the DLCO% by a single-breath technique adjusted by the concentration of haemoglobin-before and after standardized exercise the day before and 3 consecutive days after surgery. The delta (Δ) variation (basal versus exercise) was calculated. The number of functioning resected segments was calculated by bronchoscopy. Postoperative pain and pleural air leak were estimated using a visual analogue scale and graduated conventional pleural drainage systems, respectively, and their influence on ΔDLCO each postoperative day was evaluated by linear regression analysis. RESULTS: Fifty-seven patients were included. The visual analogue scale of pain and pleural air leaks were not correlated to Δ values (model R2: 0.0048). The evolution of Δ values during 3 postoperative days showed a progressive recovery of values, but on the third day, DLCO% capacity during exercise was still impaired (P < 0.01), especially in patients who underwent a resection of more than 3 functioning segments. CONCLUSIONS: Physiological increase in DLCO% during exercise is still impaired on the third postoperative day in patients undergoing resection of more than 3 functioning pulmonary segments. This fact should be considered before discharging those patients after anatomical lung resection.

Extracción segura de cuerpo extraño intrapulmonar después de traumatismo torácico penetrante: control vascular y sutura primaria es el tratamiento de elección / Safe extraction of an intrapulmonary foreign body after a penetrating thoracic trauma: vascular control and primary suture is the treatment of choice

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Revisión y actualización de los factores pronósticos en la cirugía de las metástasis pulmonares / Review and update of the prognostic factors in lung metastasis surgery

Introducción Desde que en 1997 el Registro Internacional de Metástasis Pulmonares estableció los factores que condicionan la supervivencia tras realizar metastasectomía pulmonar, numerosos trabajos han tratado de determinar las variables que condicionan dicha supervivencia. Nuestro objetivo principal es analizar la mortalidad, la supervivencia y la supervivencia libre de enfermedad de la cirugía de las metástasis pulmonares, estudiando las diferentes variables que puedan condicionarlas. Pacientes y método Se ha incluido en este estudio a todos los pacientes intervenidos de metastasectomía pulmonar entre 1998 y 2008. Se ha realizado análisis de supervivencia de Kaplan-Meier y log-rank test y análisis multivariable mediante regresión de Cox. Resultados En este periodo se han realizado 178 metastasectomías a 146 pacientes. La edad media era 62,22 (mediana, 63) años y el 64,6% eran varones. La mortalidad ha sido del 1,1% (2 casos) y la incidencia de complicaciones, del 5,02% (9 casos). La supervivencia total media ha sido de 67,75 meses y la supervivencia a los 3 y 5 años, del 67,4 y el 52,4% respectivamente. Las variables que han mostrado significación estadística en el análisis univariable son edad, intervalo libre de enfermedad, número de nódulos y tamaño de nódulos. La variable estado de los bordes está próxima a la significación (p=0,054).ConclusionesPresentar sólo una metástasis y que sea < 1cm, un intervalo libre de enfermedad largo y resección con bordes libres son los factores pronósticos más favorables tras una resección de metástasis pulmonar (AU)

Introduction: Since the International Registry of Lung Metastases established the factors that determine survival after performing lung metastasectomy in 1997, numerous studies have attempted to determine these prognostic factors of survival. Our objective has been to analyse the mortality, survival and disease-free survival lung metastasis surgery by studying the different variables that determine them. Patients and method: All patients subjected to surgery for lung metastasectomy between 1998 and 2008 were included in this study. The Kaplan-Meier and log-rank tests were performed, as well as a Cox regression using multivariate analysis. Results: A total of 178 lung metastases were removed in 146 patients during this period. The mean age was 62.22 years (median 63 years) and 64.6% were males. There were 2 cases (1.1%)of mortality and the incidence of complications was 5.02% (9 cases). The overall survival was67.75 months with a 3 and 5 year survival of 67.4% and 52.4%, respectively. The variables that showed statistical significance in the multivariate analysis were: age disease free interval, number of nodules and size of nodules. The ‘‘state of the margins’’ variable was almost significant (P = .054). Discussion: To have only one metastasis and it is less than 1 cm, a long disease free interval, and a resection with free margins, are the most favourable prognostic factors after resection of lung metastasis (AU)