Multicentre retrospective analysis on pulmonary metastasectomy: an European perspective.

OBJECTIVES: To assess the current practice of pulmonary metastasectomy at 15 European Centres. Short- and long-term outcomes were analysed. METHODS: Retrospective analysis on patients ≥18 years who underwent curative-intent pulmonary metastasectomy (January 2010 to December 2018). Data were collected on a purpose-built database (REDCap). Exclusion criteria were: previous lung/extrapulmonary metastasectomy, pneumonectomy, non-curative intent and evidence of extrapulmonary recurrence at the time of lung surgery. RESULTS: A total of 1647 patients [mean age 59.5 (standard deviation; SD = 13.1) years; 56.8% males] were included. The most common primary tumour was colorectal adenocarcinoma. The mean disease-free interval was 3.4 (SD = 3.9) years. Relevant comorbidities were observed in 53.8% patients, with a higher prevalence of metabolic disorders (32.3%). Video-assisted thoracic surgery was the chosen approach in 54.9% cases. Wedge resections were the most common operation (67.1%). Lymph node dissection was carried out in 41.4% cases. The median number of resected lesions was 1 (interquartile range 25-75% = 1-2), ranging from 1 to 57. The mean size of the metastases was 18.2 (SD = 14.1) mm, with a mean negative resection margin of 8.9 (SD = 9.4) mm. A R0 resection of all lung metastases was achieved in 95.7% cases. Thirty-day postoperative morbidity was 14.5%, with the most frequent complication being respiratory failure (5.6%). Thirty-day mortality was 0.4%. Five-year overall survival and recurrence-free survival were 62.0% and 29.6%, respectively. CONCLUSIONS: Pulmonary metastasectomy is a low-risk procedure that provides satisfactory oncological outcomes and patient survival. Further research should aim at clarifying the many controversial aspects of its daily clinical practice.

Energy devices versus electrocoagulation in video-assisted thoracoscopic lobectomy: a propensity-match cohort study.

BACKGROUND: The aim of the study was to compare the effect on perioperative outcome of intraoperative use of different devices for tissue dissection (electrocoagulation [EC] or energy devices [ED]) in patients who underwent video-assisted thoracoscopic surgery (VATS) lobectomy for lung cancer. METHODS: We retrospectively reviewed 191 consecutive patients who underwent VATS lobectomy, divided into two cohorts: ED (117 patients), and EC (74 patients); after propensity score matching, 148 patients were extracted, 74 for each cohort. The primary endpoints considered were complication rate and 30-day mortality rate. The secondary endpoints considered were length of stay (LOS) and the number of lymph nodes harvested. RESULTS: The complication rate did not differ between the two cohorts (16.22% EC group, 19.66% ED group, P=0.549), before and after propensity matching (16.22% for both EC and ED group, P=1.000). The 30-day mortality rate was 1 in the overall population. Median LOS was 5 days for both groups, before and after propensity match, with the same interquartile range, (IQR: 4-8). ED group had a significantly higher median number of lymph nodes harvested (ED median: 18, IQR: 12-24; EC median: 10, IQR: 5-19; P=0.0002). The difference was confirmed after the propensity score matching (ED median: 17, IQR: 13-23; EC median: 10, IQR: 5-19; P=0.0008). CONCLUSIONS: ED dissection during VATS lobectomy did not lead to different complication rates, mortality rates, and LOS compared to EC tissue dissection. ED use led to a significantly higher number of intraoperative lymph nodes harvested compared to EC use.

VATS phrenic nerve harvesting for brachial plexus neurotization: literature review and our experience.

INTRODUCTION: Brachial plexus traumatic lesions often lead to severe upper extremity deficits that dramatically compromise quality of life of mostly young patients. Optimal treatment aims to restore elbow flexion transferring various donor nerves. Phrenic nerve (PN) is a powerful source of transferable axons and, despite supraclavicular sectioning being the most used technique, it can be harvested through video-assisted thoracoscopic surgery (VATS). EVIDENCE ACQUISITION: About PN harvesting, less than 20 articles were found in Literature. Most of them are clinical case-reports or case-series or expert opinions. Most of these studies are from China and East Asia and very rarely from Europe; none from Italy. Therefore, we present our experience in PN VATS harvesting in two patients, first cases reported in Italy. EVIDENCE SYNTHESIS: Few papers explore risks and benefits of PN as a donor site for brachial plexus reconstruction. There is no clear consensus in the literature whether a traditional approach or minimally invasive surgery is advisable to harvest PN for neurotization. Currently there's no clear indication nor a definitive contraindication about routine use of PN for surgical treatment of BPTLs, it's mostly a matter of choosing the best donor nerve for every single patient. This choice depends on the patient's characteristics, type of traumatic lesion, time from the traumatic event and on the center's experience. The only real concern about using PN as a donor is the potential loss of pulmonary function. In our center two patients with complete brachial plexus avulsion underwent PN transfer via VATS in 2021. Usually, recovery of muscle function depends on time between injury and surgical repair. A commonly accepted recommendation is to perform surgery within six months from the traumatic lesion12. In our experience, the time between trauma and surgery was five months for patient A and six months for patient B. Even if some authors13 consider previous thoracic trauma with rib fractures a major contraindication for homolateral PN harvesting, we believe that the presence of pleural adhesions should not exclude a patient from surgery. No intra or postoperative complications were observed. Both patients were discharged on IV postoperative day. An intense rehabilitation program within three months after surgery is mandatory and regular follow-up is needed to monitor any improvement. No respiratory symptoms or discomfort is recorded up to now. CONCLUSIONS: Nerve transfer is a safe and reliable surgical reconstructive procedure and phrenic nerve, due to its pure motor nature, is a very good donor for brachial plexus injuries14. VATS is a valid procedure to guarantee a much longer nerve, avoiding any graft use, and doesn't seem to determine significant pulmonary function loss. Previous thoracic trauma, rib fractures and pneumothorax are commonly considered contraindications for VATS harvesting. However, a major trauma leading to BPTL often implies homolateral thoracic trauma with or without rib fracture or pneumothorax. This could be a reasonable justification to reconsider those contraindications and extend the potential cohort of patients that could benefit from this technique.

Lung Biopsy With a Non-intubated VATS Approach in an Obese Population: Indications and Results.

Background: According to the international guidelines, patients affected by interstitial lung disease with unusual clinical presentation and radiological findings that are not classic for usual interstitial pneumonia end up meeting criteria for surgical lung biopsy, preferably performed with video-assisted thoracic surgery. The growing appeal of non-intubated thoracic surgery has shown the benefits in several different procedures, but the strict selection criteria of candidates are often considered a limitation to this approach. Although several authors define obesity as a contraindication for non-intubated thoracoscopic surgery, the assessment of obesity as a dominant risk factor represents a topic of debate when minor tubeless procedures such as lung biopsy are considered. Our study aims to investigate the impact of obesity on morbidity and mortality in non-intubated lung biopsy patients with interstitial lung disease, analyzing the efficacy and safeness of this procedure. Materials and Methods: The study group of 40 obese patients consecutively collected from 202 patients who underwent non-intubated lung biopsy was compared with overweight and normal-weight patients, according to their body mass index. Post-operative complications were identified as the primary endpoint. The other outcomes explored were the early 30-day mortality rate and intraoperative complications, length of surgery, post-operative hospitalization, patient's pain feedback, and diagnostic yield. Results: The overall median age of the patients was 67.4 years (60, 73.5). No 30-day mortality or significant differences in terms of post-operative complications (P = 0.93) were noted between the groups. The length of the surgery was moderately longer in the group of obese patients (P = 0.02). The post-operative pain rating scale was comparable among the three groups (P = 0.45), as well as the post-operative length of stay (P = 0.96). The diagnosis was achieved in 99% of patients without significant difference between groups (P = 0.38). Conclusion: Our analysis showed the safety and efficacy of surgical lung biopsy with a non-intubated approach in patients affected by lung interstitiopathy. In the context of perioperative risk stratification, obesity would not seem to affect the morbidity compared to normal-weight and overweight patients undergoing this kind of diagnostic surgical procedure.