Learning curve for complex segmentectomy via uniportal video-assisted thoracoscopic surgery for the treatment of early-stage lung cancer.

Background: Recently, segmentectomy has emerged as a viable treatment option for early-stage lung cancer. Segmentectomy can be divided into simple segmentectomy and complex segmentectomy. While simple segmentectomy is a relatively straightforward surgical procedure, complex segmentectomy poses a considerable challenge because of its intricate anatomical variations and the need for a complex surgical approach. The introduction of uniportal video-assisted thoracoscopic surgery (VATS) further complicates matters. This study aimed to assess whether thoracic surgeons, who have previously conducted only uniportal VATS lobectomy and simple segmentectomy, could effectively navigate the learning curve when undertaking their first complex segmentectomy procedure. Methods: A single surgeon with experience limited to uniportal VATS lobectomy and simple segmentectomy began performing uniportal VATS complex segmentectomy in 2019, completing 167 cases of complex segmentectomy during the same period and performing 70 cases of simple segmentectomy. We analyzed the learning curve by comparing the surgical outcomes and operative time curves between simple segmentectomy and complex segmentectomy. Results: The complex segmentectomy group exhibited similarities with the simple segmentectomy group in terms of patient and tumor characteristics, operative outcomes, and postoperative outcomes, with the exception of the complex segmentectomy group showing slightly reduced chest tube drainage and shorter hospital stays. The operative times and time curve patterns showed no significant difference between the two groups, indicating a potential lack of a distinct learning curve for complex segmentectomy. Conclusions: Complex segmentectomy via uniportal VATS, when performed by surgeons proficient in simple segmentectomy and lobectomy techniques, has comparable outcomes and potentially eliminates the need for an extensive learning curve. This approach expands the options for treating early-stage non-small-cell lung cancer (NSCLC), allowing for tailored patient care. Further studies are needed to assess long-term outcomes.

Uniportal video-assisted thoracoscopic fissureless right upper lobe anterior segmentectomy for inflammatory myofibroblastic tumor: A case report.

BACKGROUND: Inflammatory myofibroblastic tumors (IMTs) are exceptionally rare neoplasms with intermediate malignant potential. Surgery is the accepted treatment option, aiming for complete resection with clear margins. CASE SUMMARY: A 39-year-old woman presented with a growing solitary pulmonary nodule measuring 2.0 cm in the right upper lobe (RUL) of the lung. The patient under-went a RUL anterior segmentectomy using uniportal video-assisted thoracoscopy. A preliminary tissue diagnosis indicated malignancy; however, it was later revised to an IMTs. Due to the absence of a minor fissure between the right upper and middle lobes, an alternative resection approach was necessary. Therefore, we utilized indocyanine green injection to aid in delineating the intersegmental plane. Following an uneventful recovery, the patient was discharged on the third postoperative day. Thereafter, annual chest tomography scans were scheduled to monitor for potential local recurrence. CONCLUSION: This case underscores the challenges in diagnosing and managing IMTs, showing the importance of accurate pathologic assessments and tailored surgical strategies.

Parallel Venovenous and Venoarterial Extracorporeal Membrane Oxygenation for Respiratory Failure and Cardiac Dysfunction in a Patient with Coronavirus Disease 2019: A Case Report.

Venovenous (VV) extracorporeal membrane oxygenation (ECMO) is a lifesaving technique for patients experiencing respiratory failure. When VV ECMO fails to provide adequate support despite optimal settings, alternative strategies may be employed. One option is to add another venous cannula to increase venous drainage, while another is to insert an additional arterial return cannula to assist cardiac function. Alternatively, a separate ECMO circuit can be implemented to function in parallel with the existing circuit. We present a case in which the parallel ECMO method was used in a 63-year-old man with respiratory failure due to coronavirus disease 2019, combined with cardiac dysfunction. We installed an additional venoarterial ECMO circuit alongside the existing VV ECMO circuit and successfully weaned the patient from both types of ECMO. In this report, we share our experience and discuss this method.

Intractable chylous leak after radical esophagectomy treated with radiotherapy.

Postoperative chylous leak after esophagectomy is a rare but potentially life-threatening complication that results in hypovolemia, electrolyte imbalance, malnutrition, and immunologic deficiency. However, the management of postoperative chylous leak remains controversial. Following a diagnosis of esophageal cancer, a 64-year-old man was treated by video-assisted thoracoscopic esophagectomy, laparoscopic gastric tube formation, prophylactically thoracic duct ligation, and reconstruction with esophagogastrostomy at the neck level. Massive postoperative drainage from the thorax and abdomen did not initially meet the diagnostic criteria for chylothorax, which was ultimately diagnosed 3 weeks after the operation. Despite various treatments including total parenteral nutrition, octreotide and midodrine, reoperation (thoracic duct ligation and mechanical pleurodesis), and thoracic duct embolization, the chylous leak persisted. Finally, low-dose radiation therapy was administered with a daily dose of 2 Gy and completed at a total dose of 14 Gy. After this, the amount of pleural effusion gradually decreased over 2 weeks, and the last drainage tube was removed. The patient was alive and well at 60 months postoperatively. Herein, we describe a patient with intractable chylous leak after esophagectomy, which persisted despite conservative treatment, thoracic duct ligation, and embolization, but was finally successfully treated with radiotherapy.

A comparison of the short-term outcomes of simple and complex segmentectomy via uniportal video-assisted thoracoscopic surgery.

Background: Performing complex segmentectomy via uniportal video-assisted thoracoscopic surgery (VATS) is a more demanding and intricate procedure than simple segmentectomy or lobectomy. Thus, the aim of our study is to evaluate the safety and feasibility of uniportal VATS complex segmentectomy compared to uniportal VATS simple segmentectomy by investigating surgical outcomes of patients undergoing those procedures. Methods: We conducted a review of medical records for all patients who underwent uniportal VATS segmentectomy for lung cancer from May 2019 to February 2023. The characteristics of the patients and tumors, as well as the operative and postoperative outcomes, were compared between the group of patients who underwent simple segmentectomy and the group who underwent complex segmentectomy. Results: Among 199 patients, 67 underwent simple segmentectomy through uniportal VATS, while 132 patients received complex segmentectomy through the same technique. There were no significant differences between the two groups regarding patient and tumor characteristics, operative outcomes, and postoperative outcomes, except for the surgical margin distances. Uniportal VATS complex segmentectomy resulted in shorter duration of postoperative stay (6 vs. 7 days, P=0.0116) but a closer surgical margin distance (20 vs. 22 mm, P=0.0175). Conclusions: Our study supports the use of uniportal VATS complex segmentectomy as a safe and feasible treatment option compared to uniportal VATS simple segmentectomy for patients with clinical stage 1A non-small-cell lung cancer (NSCLC). However, it is important to note that a short resection margin is probable in complex segmentectomy cases. Therefore, the location of the tumor should be thoroughly evaluated when performing uniportal VATS complex segmentectomy.

Large mesenchymal cystic and chondroid pulmonary hamartoma mimicking lung cancer: Case report.

Pulmonary hamartoma is the most commonly resected benign neoplasm of lung. The mesenchymal cystic subtype is a rare and often bilaterally occurring variant composed of multiple cysts and nodules. Herein, we present an asymptomatic 70-year-old woman with a large and mostly cystic growth of right hilar region. Computed tomography of the chest and fluorodeoxyglucose positron emission tomography/computed tomography imaging traced its origins to right middle lobe. Overall features suggested primary lung cancer or perhaps other cystic lung disease.Because transbronchial lung biopsy failed to establish a histologic diagnosis, right middle lobectomy was undertaken by video-assisted thoracoscopic surgery. The gross surgical specimen harbored a single and sizeable (8.0 × 4.0 cm) cystic lesion containing multiple yellow-white nodules. A diagnosis of mesenchymal cystic and chondroid hamartoma was ultimately rendered. This particular case is noteworthy, given the initial clinical resemblance to primary lung cancer.

Left anterior descending artery dissection with retrograde aortic dissection during percutaneous coronary intervention: a case report.

Retrograde catheter-induced coronary artery dissection during percutaneous coronary intervention is an exceedingly rare occurrence, and the likelihood of it extending into the aorta is even more uncommon. Typically, surgical treatment involves aortic root replacement combined with coronary artery bypass grafting. However, in this particular case, a meticulous approach was employed. By carefully guiding wires into the true lumens and placing stents in the proximal left main and left anterior descending arteries, the immediate complications were averted by obstructing the retrograde flow in the false lumen. Subsequently, an off-pump coronary artery bypass was performed using the left internal mammary artery to the left anterior descending artery, without the need to manipulate the aorta. This approach resulted in a short operation time and the absence of any other complications.

Uniportal video-assisted thoracoscopic anatomical resection of the right anterior pulmonary segment in a 10-year-old child with congenital pulmonary airway malformation.

Congenital pulmonary airway malformation (CPAM) is a very rare phenomenon subject to malignant transformation that requires surgical resection. In an asymptomatic 10-year-old girl, we identified a single cystic and consolidated lesion on computed tomography. This incidental finding was confined to anterior segment of lung in right upper lobe (RUL). Uniportal video-assisted thoracoscopic surgery (VATS) served to successfully achieve anterior segmentectomy, without chest tube placement. The surgical specimen confirmed features of CPAM, also showing acute and chronic inflammation with abscess formation. Once the surgical mainstay for such lesions, open lobectomy is now under challenge by thoracoscopic technique, port-reduction methods, and a lung-preserving strategy. Herein, we have shown uniportal VATS anatomical resection of right anterior pulmonary segment to be a viable option for a 10-year-old child with CPAM confined to a single lung segment.

Use of thoracoscopy for thoracic sympathetic nerve block in primary hyperhidrosis.

Thoracic sympathetic nerve block (TSNB) has been widely used in the treatment of neuropathic pain. To reduce block failure rates, TSNB is assisted with several modalities including fluoroscopy, computed tomography, and ultrasonography. The present study describes our experience assessing the usefulness of thoracoscopy in TSNB for predicting compensatory hyperhidrosis before sympathectomy in primary hyperhidrosis. From September 2013 to October 2021, TSNB was performed under local anesthesia using a 2-mm thoracoscope in 302 patients with severe primary hyperhidrosis. Among the 302 patients, 294 were included for analysis. The target level of TSNB was T3 in almost all patients. The mean procedure time was 21 min. Following TSNB, the mean temperature of the left and right palms significantly changed from 31.5 to 35.3 °C and from 31.5 to 34.8 °C, respectively. With TSNB, primary hyperhidrosis was relieved in all patients. Pneumothorax occurred in six patients, in which no chest tube insertion was required. One patient developed hemothorax and was discharged the next day after small-bore catheter drainage. Transient ptosis developed in 10 patients and improved within a day in all patients. Our experiences showed that thoracoscopic TSNB is accurate, safe, and feasible to block the thoracic sympathetic nerve in patients with severe primary hyperhidrosis.

Uniportal video-assisted thoracoscopic surgery without drainage-tube placement for pulmonary wedge resection: a single-center retrospective study.

BACKGROUND: Uniportal video-assisted thoracoscopic surgery without drainage-tube placement has been demonstrated to be safe and feasible for select situations. The purpose of this study is to assess the demographic, baseline, and intraoperative characteristics of patients who developed residual pneumothorax after thoracic surgery without drainage-tube placement. METHODS: We reviewed the records of all patients who underwent pulmonary wedge resection via uniportal video-assisted thoracoscopic surgery without drainage-tube placement between May 2019 and May 2022. The decision to omit chest-tube drainage was originally made on a case-by-case basis, using internal criteria. Postoperative chest radiography was performed on the day of surgery, on postoperative day 1, at the first outpatient visit, and at 1 month after surgery. RESULTS: A total of 134 patients met the selection criteria; 23 (17.2%) had residual pneumothorax on chest radiography on postoperative day 1, and 5 (3.7%) had residual pneumothorax at the first outpatient visit. Only 1 patient (0.7%) had residual pneumothorax on chest radiography at 1 month after surgery; this patient did not require chest-tube insertion or any other intervention. The presence of partial pleural adhesions independently increased the risk for postoperative residual pneumothorax on chest radiography, whereas older patient age reduced the risk. CONCLUSIONS: Uniportal video-assisted thoracoscopic surgery for pulmonary wedge resection without drainage-tube placement is both safe and feasible for carefully selected patients. Most patients with residual pneumothorax in our study experienced spontaneous resolution, and none required reintervention.

Robotic lobectomy for lung cancer: initial experience of a single institution in Korea.

BACKGROUND: Robotic surgery is known to have several advantages including magnified three-dimensional vision and angulation of the surgical instruments. To evaluate the feasibility and efficiency of robotic lobectomy in the treatment of lung cancer, we analyzed the outcomes of our initial experiences with robotic lobectomy at a single institution in Korea. METHODS: Eighty-seven patients with lung cancer underwent robotic lobectomy (robotic group: 34 patients) and video-assisted thoracic surgery (VATS) lobectomy (VATS group: 53 patients) between 2011 and 2016 at our hospital. The medical records of these patients were retrospectively analyzed. RESULTS: The operation times of the two groups were significantly different (robotic group, 293±74 min; VATS group, 201±62 min; P<0.01). Intraoperative blood loss occurred more in the robotic group than in the VATS group (robotic group, 403±197 mL; VATS group, 298±188 mL; P=0.018). The numbers of lymph nodes dissected in the two groups were significantly different (robotic group, 22±12; VATS group, 14±7; P<0.01). There was no intraoperative mortality in both groups. CONCLUSIONS: Despite the initial difficulties, robotic lobectomy for lung cancer was a safe and feasible procedure with no operative mortality. If operation time and intraoperative blood loss improve as the learning curve progresses, robotic surgery may overcome the limitations of VATS in lung cancer surgery.

Prognostic Factors of Pathological N1 Non-small Cell Lung Cancer After Curative Resection Without Adjuvant Chemotherapy.

BACKGROUND: The aim of this study was to evaluate the outcomes of patients with pathological N1 non-small cell lung cancer who did not receive adjuvant chemotherapy. We attempted to identify those patients for whom adjuvant chemotherapy would be indispensable. METHODS: Among 132 patients who were diagnosed with pathological N1 lung cancer at a single institution from January 2010 to December 2016 were 32 patients who did not receive adjuvant treatment after curative surgical resection. The surgical and oncological outcomes of these patients were analyzed. Candidate factors for predicting recurrence were analyzed to identify patients at high risk of recurrence. RESULTS: The median follow-up time for all 32 patients was 1044 days. The 5-year recurrence-free survival (RFS) and disease-specific survival rates of the patients without adjuvant therapy were 50.3% and 77.6%, respectively. By multivariate analysis, tumors with a lepidic growth pattern [hazard ratio (HR) 0.119, p = 0.024] and extralobar lymph node metastasis (HR 6.848, p = 0.015) were significant factors predicting recurrence. The difference between the 5-year RFS rates of patients with tumors with or without a lepidic growth pattern was statistically significant (63.5% vs 40.0%, respectively; p = 0.050). The 5-year RFS rates of patients with intralobar lymph node metastasis versus those with extralobar lymph node metastasis were 63.3% and 18.8%, respectively (p = 0.002). CONCLUSIONS: Patients with tumors without a lepidic growth pattern or with extralobar lymph node metastasis who do not receive adjuvant chemotherapy have a high recurrence rate after surgery. Therefore, these patients should be encouraged to undergo adjuvant chemotherapy if their overall condition is not a contraindication for chemotherapy.

Nonintubated Uniportal Video-Assisted Thoracoscopic Surgery: A Single-Center Experience.

BACKGROUND: We report our surgical technique for nonintubated uniportal video-assisted thoracoscopic surgery (VATS) pulmonary resection and early postoperative outcomes at a single center. METHODS: Between January and July 2017, 40 consecutive patients underwent nonintubated uniportal VATS pulmonary resection. Multilevel intercostal nerve block was performed using local anesthesia in all patients, and an intrathoracic vagal blockade was performed in 35 patients (87.5%). RESULTS: Twenty-nine procedures (72.5%) were performed in patients with lung cancer (21 lobectomies, 6 segmentectomies, and 2 wedge resections), and 11 (27.5%) in patients with pulmonary metastases, benign lung disease, or pleural disease. The mean anesthesia time was 166.8 minutes, and the mean operative duration was 125.9 minutes. The mean postoperative chest tube duration was 3.2 days, and the mean hospital stay was 5.8 days. There were 3 conversions (7.5%) to intubation due to intraoperative hypoxemia and 1 conversion (2.5%) to multiportal VATS due to injury of the segmental artery. There were 7 complications (17.5%), including 3 cases of prolonged air leak, 2 cases of chylothorax, 1 case of pleural effusion, and 1 case of pneumonia. There was no in-hospital mortality. CONCLUSION: Nonintubated uniportal VATS appears to be a feasible and valid surgical option, depending on the surgeon's experience, for appropriately selected patients.

A Rare Case of Tetralogy of Fallot Associated with Pulmonary Artery Sling.

Pulmonary artery sling is a rare congenital cardiac anomaly, in which the left pulmonary artery originates from the right pulmonary artery and courses leftward between the trachea and the esophagus. Tetralogy of Fallot associated with pulmonary artery sling is even rarer, and only a few cases have been reported in the literature. We present a case of tetralogy of Fallot associated with pulmonary artery sling that was repaired successfully.

Comparison of non-intubated versus intubated video-assisted thoracoscopic lobectomy for lung cancer.

BACKGROUND: Non-intubated, or awake, video-assisted thoracoscopic surgery has been implemented for non-anatomical lung resection and the results obtained were encouraging to consider the approach for anatomical pulmonary resection. This study was conducted to evaluate the perioperative outcomes of the non-intubated and intubated video-assisted thoracoscopic lobectomy in lung cancer in regards to feasibility and safety. METHODS: A retrospective analysis of 62 consecutive video-assisted thoracoscopic lobectomies (31 lobectomies as non-intubated, 31 lobectomies as intubated) performed in Seoul St. Mary's Hospital, The Catholic University of Korea between January and December 2016. RESULTS: Both groups share comparable clinical characteristics including the age, sex, BMI, FEV1, DLCO, smoking history, lung lobes procedure, histological type and pathological staging. There was no difference in the mean of postoperative hospitalization period (6.9 versus 7.6 days, P=0.578) and the total chest tube duration (5.6 versus 5.4 days, P=0.943) between non-intubated and intubated lobectomy respectively. Both groups had a comparable surgical outcome for the anesthesia duration, operative time, blood loss and postoperative complications. The operative time required for lobe-specific surgery was shorter in the non-intubated group except for the LLL (mean 121.7 minutes for non-intubated group versus 118.3 minutes for the intubated group). The only statistically significant surgical outcome was for the number of dissected lymph nodes between both groups (the mean number of nodes for the non-intubated group was 12.6 versus 18.0 nodes for the intubated group, P=0.003). One patient in the non-intubated group required conversion to single lung intubation and mini-thoracotomy because of bleeding with no conversion in the intubated group. No mortality encountered in either group. CONCLUSIONS: The perioperative surgical outcomes for the non-intubated video-assisted thoracoscopic lobectomy are comparable to the intubated technique. Non-intubated video-assisted thoracoscopic lobectomy is safe and is technically feasible. However, further prospective randomized studies are needed for a better comparison between non-intubated and intubated VATS lobectomy.

Changes in thoracic cavity dimensions of pectus excavatum patients following Nuss procedure.

BACKGROUND: Using a simple and intuitive method, we evaluated changes in the dimensions of the thoracic cavity of pectus excavatum (PE) patients following the Nuss procedure. METHODS: We performed a retrospective review of 141 patients who had undergone the Nuss procedure. The thoracic cavity was visualized using computed tomography (CT) scans and its dimensions determined by measuring the anteroposterior (AP) and transverse (T) diameters at three anatomical landmarks (the jugular notch, and manubriosternal and xiphisternal joints). The Wilcoxon signed-rank test was used to compare differences between preoperative and postoperative parameters. Kruskal-Wallis tests were performed to compare differences among groups in patient age, type of PE, and number of inserted bars. RESULTS: Of the 141 patients (115 men, 26 women), 87 had symmetric and 54 had asymmetric defects. The postoperative AP diameters at the manubriosternal and xiphisternal joints were significantly higher than their preoperative values, whereas the Haller indices and T diameters at the three anatomical landmarks were significantly lower than their preoperative values. In the multiple bars group, the postoperative AP diameters increased significantly compared with their preoperative values. In the multiple bars group, and in patients aged above 13 years, the postoperative T diameters at all three anatomical landmarks decreased significantly compared with their preoperative values. CONCLUSIONS: Correction of anterior depression of the sternum and compensatory narrowing of the chest width were observed in PE patients following the Nuss procedure. Further research will be necessary to determine the relationship between these observations and postoperative changes in chest volume.

Consolidation/Tumor Ratio on Chest Computed Tomography as Predictor of Postoperative Nodal Upstaging in Clinical T1N0 Lung Cancer.

BACKGROUND: In clinical T1N0 peripheral lung cancers, lymph node upstaging is occasionally encountered postoperatively. However, nodal upstaging is rare in lung cancers presenting as ground-glass opacities. The aim of this study was to determine if lymph node upstaging could be reliably extrapolated from parameters such the consolidation/tumor ratio of chest computed tomography. METHODS: We conducted a retrospective study of 486 patients treated for peripheral clinical T1N0 non-small cell lung cancer, each undergoing lobectomy with mediastinal lymph node dissection. We compared preoperative variables in the pathologic N0 and nodal upstaging groups, analyzing such variables to determine factors predictive of lymph node upstaging. RESULTS: Of the 486 patients studied, lymph node upstaging occurred in 42 (8.6%). In the upstaging group, the mean nodule diameter exceeded that of the pathologic N0 group (2.3 vs 1.9 cm, respectively; p < 0.001), and the mean consolidation/tumor ratio was larger in the upstaging group than the pN0 group (0.95 vs 0.68, respectively; p < 0.001). Nodule diameter and consolidation/tumor ratio emerged as significant predictive factors for lymph node upstaging after surgery in a multivariate analysis (hazard ratio [HR] 2.259, p = 0.039; HR 173.645, p = 0.001, respectively). CONCLUSIONS: Consolidation/tumor ratio and nodule diameter are significant predictive factors of postoperative lymph node upstaging. The higher the consolidation/tumor ratio and smaller the nodule diameter, the less likely the occurrence of postoperative lymph upstaging would be in clinical T1N0 peripheral non-small cell lung cancer.

Predictive factors for invasive adenocarcinoma in patients with clinical non-invasive or minimally invasive lung cancer.

BACKGROUND: Pure ground glass opacity (GGO) or part-solid GGO with small solid component (≤5 mm) are likely to be non-invasive or minimally invasive lung cancer. However, those lesions sometimes are diagnosed as invasive adenocarcinoma postoperatively. The aim of this study was to determine the predictors of invasive adenocarcinoma in clinical non- or minimally invasive lung cancer. METHODS: From January 2010 to December 2017, 203 patients were diagnosed as clinical adenocarcinoma in situ (AIS) or minimally invasive adenocarcinoma (MIA) identified on chest computed tomography (CT) and they underwent surgical resection. A retrospective study was performed to analyze the prediction of invasive adenocarcinoma in clinical non- or minimally invasive lung cancer. RESULTS: Of all clinical AIS or MIA patients, invasive adenocarcinoma was diagnosed in 55 patients (27.1%). In clinical AIS, invasive adenocarcinoma was diagnosed in 19 patients (17.9%) and 36 patients (37.1%) were diagnosed as invasive adenocarcinoma in clinical MIA (P=0.002). Tumor diameter and the presence of solid component were confirmed to be significant predictive factors for invasive adenocarcinoma in a multivariate analysis [hazard ratio (HR) 1.071, P=0.037; HR 2.573, P=0.005; respectively]. CONCLUSIONS: Large tumor size and the presence of solid component in clinical AIS or MIA are predictive factors for invasive adenocarcinoma. Therefore, early surgical intervention is recommended for those lesions.

A chest tube misplaced in the heart?

A 69-year-old patient with a malignant right pleural effusion experienced an inadvertent chest tube insertion through the hepatic vein, which ended up in the right ventricle. This rare complication occurred using a 14-Fr Thal-Quick chest tube (Seldinger method). The chest tube was successfully removed in a non-operative approach.