Papel de la cirugía torácica en la cirugía de paratiroides / Role of thoracic surgery in parathyroid surgery

INTRODUCCIÓN Y OBJETIVO: La prevalencia de paratiroides ectópicas oscila entre el 6.3 % y el 26 % en pacientes intervenidos por hiperparatiroidismo y la exploración mediastínica es necesaria en alrededor del 1-2 % de los pacientes con paratiroides ectópica. El objetivo del presente artículo es describir las particularidades del tratamiento quirúrgico de las paratiroides mediastínicas. SÍNTESIS: La localización preoperatoria de paratiroides ectópicas es fundamental para asegurar el éxito de la intervención; la gamma-grafía de doble fase con 99mTc-metoxi-isobutil-isonitrilo (99mTc-MIBI) se considera la técnica gold estándar para su localización. La navegación intraoperatoria radioguiada con sonda gamma y la monitorización intraoperatoria de la PTH son útiles para reducir el tiempo quirúrgico y evitar re-exploraciones innecesarias. Los abordajes mínimamente invasivos (VATS o cirugía robótica) para la exploración y extirpación de lesiones presentes en mediastino ofrecen ventajas sobre los abordajes abiertos convencionales como son la magnificación y mejor visión de las estructuras y la maniobrabilidad. CONCLUSIONES: El éxito de la extirpación quirúrgica de las paratiroides ectópicas se basa en la adecuada localización preoperatoria. La navegación radioguiada con sonda gamma y la monitorización de la PTH intraoperatorias son útiles para asegurar la adecuada resección de la paratiroides. Los abordajes mínimamente invasivos (VATS o cirugía robótica) han reducido la necesidad de esternotomía o toracotomía

Introduction and objective: The prevalence of ectopic parathyroids ranges from 6.3 % to 26 % in patients undergoing surgery due to hyperparathyroidism and mediastinal exploration is necessary in about 1-2 % of patients with ectopic parathyroid. The objective of this article is to describe the particularities of surgical treatment of mediastinal parathyroids. SYNTHESIS: Preoperative localization of ectopic parathyroids is essential to ensure the success of the intervention; dual phase scintigraphy with 99mTc-methoxy-isobutyl-isonitrile (99mTc-MIBI) is considered the gold standard technique for its location. Intraoperative radioguided navigation with a gamma probe and intraoperative monitoring of PTH are useful for reducing surgical time and avoiding unnecessary re-examinations. Minimally invasive approaches (VATS or robotic surgery) for the exploration and removal of mediastinal lesions offer advantages over conventional open approaches such as magnification and better vision of structures and maneuverability. CONCLUSIONS: The success of surgical removal of ectopic parathyroids is based on the appropriate preoperative location. Radio-guided navigation with gamma probe and intraoperative PTH monitoring are useful to ensure adequate parathyroid resection. Minimally invasive approaches (VATS or robotic surgery) have reduced the need for sternotomy or thoracotomy

The Evolution of Surgical Management for Children and Young Adults With Spontaneous Pneumothorax.

BACKGROUND: Few studies have analyzed pediatric spontaneous pneumothorax (SPTX) nationally. We sought to better define this patient population and explore the evolution of surgical management. METHODS: Patients (10-20 y old) with an International Classification of Diseases, Ninth Revision diagnosis of SPTX were identified within the Kids' Inpatient Database for the years 2006, 2009, and 2012. Diagnoses and procedures were analyzed by International Classification of Diseases, Ninth Revision codes. National estimates were obtained using case weighting. RESULTS: There were 11,792 pediatric SPTX hospitalizations, and patients were predominantly male (84.0%), non-Hispanic white (69.0%), with a mean age of 17.2 y (95% confidence interval, 17.2-17.3). Overall, 52.5% underwent tube thoracostomy as the primary intervention, and more than one-third had a major surgical procedure (34.9%). From 2006 to 2012, there was an increase in bleb excisions from 81.1% to 86.9% and an increase in mechanical pleurodesis from 64.2% to 69.0%. There was a significant change from a predominantly open thoracotomy approach in 2006 (76.1%) to a video-assisted thoracoscopic approach in 2012 (89.3%). CONCLUSIONS: Pediatric admission for SPTX results in tube thoracostomy in more than half of the cases and surgery in approximately one-third of the cases. Surgical intervention has changed to a more minimally invasive approach during the last decade, and counseling to patients and their families should reflect these updated management strategies. LEVEL OF EVIDENCE: III.

Ten-Year Trends of Clinicopathologic Features and Surgical Treatment of Lung Cancer in China.

BACKGROUND: Lung cancer has changed significantly during the past 2 decades in its epidemiology and treatment. This retrospective analysis used data from 7 major areas of China over 10 years to evaluate clinicopathologic and surgical treatment trends of lung cancer in China during the past decade. METHODS: Data from 7184 patients with primary lung cancer who were treated between 2005 and 2014 in 8 provinces of China were retrospectively collected. Their clinicopathologic features and surgical treatment information were recorded. Simple linear regression models and the Cochrane-Armitage trend test were used to assess temporal trends. RESULTS: The proportion of female patients (from 57.4% to 59.6%; P < .001) and nonsmoking patients (from 37.1% to 48.9%; P < .001) and of patients with a family history of malignant tumors (from 7.0% to 11.5%; P < .001) increased significantly. The percentage of adenocarcinomas increased significantly (from 36.4% to 53.5%; P < .001), with a decrease in squamous cell carcinomas (from 45.4% to 34.4%; P < .001). After 2008, the application of minimally invasive surgery significantly increased in China (from 2.4% in 2008 to 34.4% in 2014; P < .001), with a decline in the rate of conversion to open operation (from 14.3% in 2008 to 4.8% in 2014; P = .146) and an increase in the proportion of systematic mediastinal lymph node dissection (from 50.0% in 2008 to 84.1% in 2014; P = .001). CONCLUSIONS: This study investigated recent 10-year trends in the clinicopathologic features and surgical treatment of lung cancer in China and found significant important changes. These findings provide valuable information and evidence for the future control of the disease in China.

[Advances in the Study of the Effects of Video-assisted Thoracoscopic Segmentectomy 
on Pulmonary Function].

The National Comprehensive Cancer Network (NCCN) clinical practice guideline of non-small cell lung cancer (NSCLC) in 2018 points out that anatomic pulmonary resection is a preferred option for early stage NSCLC. With the development of video-assisted thoracoscopy, minimally invasive thoracic surgery represented by thoracoscopy has been widely used in clinical practice. Video-assisted thoracoscopic segmentectomy has become one of the treatment options for early stage NSCLC. Clinical studies have found that sublobar resection can achieve similar results and preserve more pulmonary function in the treatment of early stage NSCLC compared with lobectomy, but the changes of pulmonary function after segmentectomy are still controversial. This article focuses on the research progress of pulmonary function changes in NSCLC patients after video-assisted thoracoscopic segmentectomy.
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National trends and perioperative outcomes of robotic resection of thymic tumours in the United States: a propensity matching comparison with open and video-assisted thoracoscopic approaches†.

OBJECTIVES: Despite the recent increased rate of adoption of robotic approaches for the resection of thymic tumours, their use is still limited to large-volume academic centres. To date, a large-scale analysis of the robotic approach has not been performed. We assessed the recent trends and outcomes of robotic thymectomies in the United States compared to those of open and video-assisted thoracoscopic surgical (VATS) approaches. METHODS: The National Cancer Database was queried for patients who underwent resection for thymic tumours (2010-2014). Predictors of using the robotic approach were estimated by logistic regression analysis. Propensity matching analysis (robotic versus open and robotic versus VATS) was done (1:1-caliper 0.05), controlling for age, gender, comorbidity index, induction treatment, tumour size and tumour extension. RESULTS: A total of 2558 thymectomies were performed (robotic = 300, VATS = 280, open = 1978). The use of a robotic approach increased from 6% (2010) to 14% (2014). The number of hospitals performing at least 1 robotic thymectomy increased from 22 (2010) to 52 (2014). Independent predictors influencing the choice of a robotic approach included an academic research/integrated cancer programme [odds ratio (OR) 1.66, confidence interval (CI) 1.22-2.27], later year of diagnosis (2014; OR 2.23, CI 1.31-3.80) and a patient's race (Asian) (OR 1.68, CI 1.05-2.69). A robotic approach was less likely to be utilized in midwestern hospitals (OR 0.65, CI 0.42-0.99), in larger tumours (cm) (OR 0.85, CI 0.80-0.90), with invasion of adjacent organs (OR 0.55, CI 0.37-0.82), thymic carcinoma (OR 0.62, CI 0.40-0.97) and following induction chemotherapy (OR 0.22, CI 0.08-0.61). In a propensity-matched analysis, there were no differences in the incidence of positive margins, nodal dissection, 30-day readmission rates and 30-/90-day mortality rates between the groups. However, a robotic approach was associated with fewer conversions compared to VATS, with a trend towards a shorter length of stay compared to an open approach. There were no differences in the 5-year overall survival rate between the matched groups (robotic 93% vs VATS 94%; P = 0.571; robotic 91% vs open 80%; P = 0.094). CONCLUSIONS: Over a 4-year study period, there was a significant increase in robotic utilization for thymectomies and an increase in the number of hospitals performing the procedure. In a matched analysis, a robotic approach was comparable to a VATS or an open approach. Current trends demonstrate increased robotic utilization for small thymomas with excellent perioperative results.

Do the surgical results in the National Lung Screening Trial reflect modern thoracic surgical practice?

INTRODUCTION: Surgical data from the National Lung Screening Trial (NLST) has yet to be closely examined. We sought to analyze surgical procedures and complications from the NLST to determine their relevance to modern surgical practice. METHODS: The NLST database was queried for patients who underwent surgical resection for confirmed lung cancer, specifically evaluating postoperative complications. Numerical variables were compared using the Mann-Whitney U test. Categorical variables were compared using the χ2 test. Logistic regression uni- and multivariable analysis of independent risk factors of postoperative complications was performed. RESULTS: At operation, 80% of patients (n = 821) had lobectomy, 4.1% (n = 42) had pneumonectomy, and 16.1% (n = 166) had sublobar resection, among whom 69% (n = 114) had wedge resection. Only 29.6% (n = 305) of the cohort had a thoracoscopic resection. Although the overall rate of surgical patients with any complication was 31% (n = 318), only 15.5% of patients (n = 160) had major complications, most commonly prolonged air leaks (n = 67, 6.5%). Respiratory failure (n = 28, 2.7%), prolonged ventilation (n = 9, 0.9%), myocardial infarction or cardiac arrest (n = 7, 0.7%), and stroke (n = 2, 0.2%) were rare events. Overall 30-day mortality in patients undergoing resection was 1.7% (n = 18). On multivariable analysis, greater smoking pack history (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.001-1.01) and pulmonary comorbidities (OR, 1.34; 95% CI, 0.98-1.82) were significant or approached significance for an association with complications/death, whereas sublobar resection (OR, 0.59; 95% CI, 0.38-0.94) and video-assisted thoracoscopic surgery approach (OR, 0.76; 95% CI, 0.56-1.04) were significant or approached significance for an association with decreased rates of complications/death. CONCLUSIONS: Operative mortality and postoperative morbidity were very low in patients undergoing resection for screen-detected lung cancer. Increased use of sublobar resection and minimally invasive surgical approaches may be associated with fewer complications.

Systematic mediastinal lymph node dissection outcomes and conversion rates of uniportal video-assisted thoracoscopic lobectomy for lung cancer.

BACKGROUND: To evaluate the systematic mediastinal lymph node (LN) dissection outcomes and conversion rates of uniportal video-assisted thoracoscopic surgery (UVATS). METHODS: Patients with non-small-cell lung cancer who underwent video-assisted thoracoscopic surgery (VATS) and systematic mediastinal LN dissection between January 2015 and January 2017 were retrospectively reviewed. We categorized the patients into two groups according to the different surgical approaches. Patients' clinical data were collected and compared. The index of estimated benefit from LN dissection was used to evaluate the therapeutic value of LN dissection for each station. RESULTS: A total of 453 patients underwent VATS, including 197 patients in the UVATS group and 256 patients in the triportal VATS (TVATS) group. There were no significant differences in the 1-, 2- and 3-year survival rates of these two groups (P > 0.05). There were no statistically significant differences in the operative time, numbers and stations of LNs, numbers and stations of N2 LNs, conversion rate or postoperative complications. The UVATS group had less intraoperative blood loss, a shorter duration of hospital stay, less chest tube drainage and a shorter duration of chest tube drainage than the TVATS group (P < 0.05). The conversion rates in the UVATS and TVATS groups were 5.1% and 4.3%, respectively, and the difference was not significant. The same degree of LN sampling was achieved in both groups. CONCLUSION: UVATS permits the same degree of LN sampling as TVATS without a difference in the conversion rate.

Serial Observation of Blood Alcohol Concentration post Ethanol Pleurodesis (SOBER) Study: A Prospective Observational Study.

OBJECTIVES: To measure the blood alcohol concentration levels in patients after chemical pleurodesis with ethanol sclerosant via video-assisted thoracoscopic surgery. DESIGN: Prospective observational study. SETTING: Single tertiary university hospital. PARTICIPANTS: Eight patients undergoing chemical pleurodesis with ethanol sclerosant for management of recurrent pneumothoraces or pleural effusions. INTERVENTIONS: After ethics board approval, written informed consent was obtained from 8 patients undergoing chemical pleurodesis with ethanol sclerosant for management of recurrent pneumothoraces or pleural effusions. Five patients received a dose of 100 mL of 70% ethanol/1% iodine, and 3 patients received 30 mL. Blood alcohol concentration measurement was obtained at 30, 60, 90, and 120 minutes after the ethanol was instilled in the interpleural space. The postoperative quality of recovery scale was conducted preoperatively and then at 30 and 60 minutes postoperatively and on postoperative days 1 and 3. MEASUREMENTS AND MAIN RESULTS: The highest observed blood alcohol concentration was recorded at 30 minutes post-instillation of ethanol in all patients. The blood alcohol concentration peak for 75% of patients (6/8) was >0.05 g/dL at 30 minutes post-instillation of ethanol, and for 4 patients (50%), this remained >0.05 g/dL at 60 minutes. The median area under curve of ethanol absorbed was 5.66 g/dL/min (3.24-7.29). CONCLUSIONS: Significant systemic absorption of ethanol can occur after instillation of ethanol sclerosant, which potentially may affect the quality of recovery in patients. Postoperative management of these patients may need to be specifically tailored to take into account these observations.

Thirty-Day Unplanned Reintubation Following Pleurodesis: A Retrospective National Registry Analysis.

OBJECTIVE: To examine risk factors associated with 30-day unplanned reintubation after pleurodesis. DESIGN: A retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program surgical outcomes registry. SETTING: United States hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. PARTICIPANTS: The study comprised 2,358 patients who underwent video-assisted thorascopic surgery for pleurodesis from 2007 to 2016. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The final sample included 2,358 cases, of which 93 (3.9%) required 30-day unplanned reintubation. Cases with 30-day unplanned reintubation, compared to those without, had higher unadjusted rates of American Society of Anesthesiologists physical status (ASA PS) score ≥4 (54.8% v 27.2%), preoperative dyspnea (71% v 57%), congestive heart failure (14% v 5.4%), functional dependence (28% v 10.3%), and diabetes mellitus (29% v 17.8%) (all p < 0.05). Patients with 30-day reintubation experienced higher unadjusted rates of 30-day outcomes including mortality (50.5% v 10.1%), pneumonia (28% v 4.9%), ventilator dependence (50.5% v 10.1%), sepsis (7.5% v 1.9%), myocardial infarction (5.4% v 0.1%), cardiac arrest (18.3% v 0.6%), transfusion (14% v 4.5%), and reoperation (15.1% v 3.2%) (all p < 0.05). The odds of 30-day unplanned reintubation were increased significantly on multivariable analysis for patients with ASA PS score ≥4, functional dependence, disseminated cancer, renal dialysis, and weight loss (all p < 0.05). CONCLUSION: Given the dearth of population-based studies addressing risk factors of reintubation after pleurodesis, this study suggests further review of preoperative optimization, which is required to improve patient outcomes and safety.

[Pulmonary intralobar sequestration in adults: Evolution of surgical treatment]. / Séquestrations pulmonaires intralobaires de l'adulte : évolution du traitement chirurgical.

BACKGROUND: Until now, the traditional procedure to treat intralobar pulmonary sequestration (ILS) in adults has been a lobectomy performed by open thoracotomy. We have reviewed our data to observe if the surgical management of these lesions has evolved over the last years. METHODS: We retrospectively reviewed the records of the patients who were operated for an ILS either by posterolateral thoracotomy (PLT group), or by thoracoscopy (TS group) between 2000 and 2016. RESULTS: Eighteen patients were operated for a SIL during this period. Prior to 2011, all resections were performed by thoracotomy (n=6) and after 2011 the surgical approach was either a thoracotomy (n=5) or a thoracoscopy (n=7). There was one conversion because of dense pleural adhesions and this patient was integrated in the PLT group for further analysis. ILS were more frequently encountered on the left side (n=12, 66.6 %) than on the right one (n=6, 33.3 %) and exclusively in the lower lobes. All patients of the PLT group underwent a lobectomy. In the TS group, 5 patients underwent a sublobar resection (2 segmentectomiesS9+10, 1 basilar segmentectomy and 2 atypical resections). There was no mortality. In the PLT group, 5 patients (45 %) had complications versus one patient (14 %) in the TS group. The mean hospital stay was 7.4 days in the PLT group versus 5.4 days in the TS group. CONCLUSIONS: These data confirm that ILS can be safely treated by a sublobar resection that should be performed, whenever possible, thoracoscopically.

Approach to pneumothorax surgery: a national survey of current UK practice.

BACKGROUND: Pneumothorax is a common condition with various management options. We aimed to determine the current surgical practice in the United Kingdom. METHOD: An online questionnaire regarding surgical strategy was sent to all consultants who were members of the Society for Cardiothoracic Surgery (80 thoracic). RESULTS: Fifty-six consultants, mainly thoracic, responded to the survey. Video-assisted thoracoscopic surgery was unanimously the preferred approach, the majority (59%) using 3 ports. Regarding the timing of surgery, 53 (95%) surgeons would intervene at first presentation with persistent air leak and/or lung collapse, 41 (73%) for a first bilateral pneumothorax, 22 (39%) only for recurrent pneumothorax, and 18 (32%) for the first computed tomography evidence of bullae. Apical bullectomy + pleurectomy was the preferred technique for 26 (46%) surgeons, and apical bullectomy + apical pleurectomy + pleural abrasion was the choice for 13 (23%). Some surgeons were concerned about talc and avoid it. The majority (70%) used a single apical drain with or without 24-48 h suction. Regarding chest radiography, the response was variable but 48% performed immediate postoperative and/or daily chest radiographs. Currently, most surgeons (59%) use digital drains and feel it monitors air leaks better. The perceived chronic pain (1%-3%) and recurrence rates (0%-3%) were stated by 59% and 86%, respectively. CONCLUSION: There is variability in the surgical management of pneumothorax among surgeons across the UK, but they all use video-assisted thoracoscopic surgery as the intervention of choice for pneumothorax surgery, and there is a shift towards early surgical intervention.

Association between perioperative cholesterol level and analgesia after video-assisted thoracoscopic surgery.

BACKGROUND: Cholesterol plays an important role in the action of opioid analgesics, but its association with postoperative pain has not been clarified. Our study examined the association of pre- and postoperative total serum cholesterol (TSC), and change between the pre- and postoperative TSC levels with postoperative pain outcomes in patients with non-small cell lung cancer (NSCLC) who underwent video-assisted thoracoscopic surgery (VATS) lobectomy. METHODS: We retrospectively reviewed medical records of patients with NSCLC who underwent VATS lobectomy at the Seoul National University Bundang Hospital in South Korea. We sought to determine the association between preoperative TSC, TSC on postoperative day (POD) 0-1, and pre- and postoperative changes in TSC by comparing numeric rating scale (NRS) scores on POD 0, 1, and 2 and total morphine equivalent consumption on POD 0-2. Multivariate linear regression analyses were used, and P < 0.05 was considered statistically significant. RESULTS: A total of 1,720 patients with NSCLC who underwent VATS lobectomy were included in the analysis. The change in TSC, preoperative TSC, and postoperative TSC showed no associations with morphine equivalent consumption on POD 0-2 (P > 0.05). In addition, the changes in TSC, preoperative TSC, and postoperative TSC were not associated with postoperative NRS pain score on POD 0, 1, and 2 (P > 0.05). CONCLUSIONS: Our results indicated that no significant association was observed between pre- and postoperative TSC level and postoperative pain outcome after VATS lobectomy of the lung.

Evaluation of the Determinants of Satisfaction With Postoperative Pain Control After Thoracoscopic Surgery: A Single-Center, Survey-Based Study.

BACKGROUND: The need to measure, compare, and improve the quality of pain management is important to patients, payers, and health care providers. Pain after thoracic surgery can be severe, and thoracoscopic approaches have not had the favorable impact on pain as anticipated. The aim of this study was to evaluate the determinants of patient satisfaction with acute pain management and the effectiveness of pain control after video-assisted thoracoscopic surgery using a modified version of the Revised American Pain Society Patient Outcome Questionnaire. METHODS: We performed a single-center, prospective, survey-based study of 300 patients who had undergone elective video-assisted thoracoscopic surgery. Patients were enrolled and completed the survey on postoperative day 1 or 2. The primary outcome variable was patient-reported satisfaction with acute postoperative pain treatment measured on a 1-4 scale. The relationship between the items on the survey and patient satisfaction was analyzed to determine the factors significantly associated with satisfaction. RESULTS: Fifty-one percent of the patients had the highest satisfaction level with pain treatment, and 4% of the patients had the lowest satisfaction level. The mean reported acceptable pain level was 3.8 ± 1.9 (numeric rating scale [NRS], 0-10). The average pain intensity score at the time of the survey was 2.8 ± 2.1 (NRS, 0-10). The median for the most pain in the prior 24 hours was 7 (NRS, 0-10; interquartile range, 5-9). Five items from the survey were significantly associated with the satisfaction level. The predictor with the highest associated odds ratio (OR) with satisfaction was the ability to participate in pain management decisions (OR, 1.45; P < .0001). Another positively associated predictor was receiving helpful information about pain treatment options (OR, 1.31; P = .002). Negatively associated predictors of patient satisfaction included level of pain intensity at time of survey (OR, 0.76; P = .002), lowest pain score in the prior 24 hours (OR, 0.70; P = .0006), and having pain interfere with sleep in the postoperative period (OR, 0.72; P = .037). CONCLUSIONS: Our findings highlight several factors associated with patient satisfaction with acute postoperative pain management. Interventions focused on achieving acceptable pain levels for the majority of the time, ensuring that patients are able to get sleep, providing patients with helpful information about their pain treatment, and, most importantly, allowing patients to participate in decisions about their pain management may improve patient satisfaction with postoperative pain management.

Trends in Hospital Treatment of Empyema in Children in the United States.

OBJECTIVE: To evaluate trends in procedures used to treat children hospitalized in the US with empyema during a period that included the release of guidelines endorsing chest tube placement as an acceptable first-line alternative to video-assisted thoracoscopic surgery. STUDY DESIGN: We used National Inpatient Samples to describe empyema-related discharges of children ages 0-17 years during 2008-2014. We evaluated trends using inverse variance weighted linear regression and characterized treatment failure using multivariable logistic regression to identify factors associated with having more than 1 procedure. RESULTS: Empyema-related discharges declined from 3 in 100 000 children to 2 in 100 000 during 2008-2014 (P = .04, linear trend). There was no significant change in the proportion of discharges having 1 procedure (66.1% to 64.1%) or in the proportion having 2 or more procedures (22.1% to 21.6%). The proportion coded for video-assisted thoracoscopic surgery as the only procedure declined (41.4% to 36.2%; P = .03), and the proportions coded for 1 chest tube (14.6% to 20.9%; P = .04) and 2 chest tube procedures (0.9% to 3.5%; P < .01) both increased. The median length of stay for empyema-related discharges remained unchanged (9.3 days to 9.8 days; P = .053). Having more than 1 procedure was associated with continuous mechanical ventilation (adjusted OR, 2.7; 95% CI, 1.8-4.1) but not with age, sex, payer, chronic conditions, transfer admission, hospital size, or census region. CONCLUSIONS: The use of video-assisted thoracoscopic surgery to treat children in the US hospitalized with empyema seems to be decreasing without associated increases in length of stay or need for additional drainage procedures.

Video-assisted thoracoscopic surgery lobectomy for non-small cell lung cancer.

Since 1990s, video-assisted thoracoscopic surgery (VATS) lobectomy has become a standard procedure for early-stage non-small cell lung cancer. However, VATS lobectomies are less common, and no randomized controlled trial of VATS versus conventional open lobectomy for early-stage lung cancer has been performed in Japan. Furthermore, VATS lobectomy procedures are not standardized in Japan, and may vary by institution or by practitioner, which complicates their evaluation. Although VATS procedures (such as pneumonectomy, bronchoplasty, and chest wall resection) have been reportedly performed for patients with advanced disease, whether VATS could be a standard modality for advanced lung cancer is unclear from an oncological perspective. Until recently, VATS lobectomies commonly used three or four ports to conduct systemic lymph node dissection; however, VATS lobectomies with reduced port have been recently reported. This article reviews current trends in VATS lobectomy procedures.

Outcomes of video-assisted thoracoscopic surgery for transvenous lead extraction.

INTRODUCTION: To evaluate the outcomes of video-assisted thoracoscopic surgery (VATS) during transvenous lead extractions (TLEs). METHODS AND RESULTS: Ninety-one high-risk patients who underwent TLE in the operating room from January 1, 2015, to March 31, 2017, were included in the study. Of these, 9 patients underwent VATS during TLE. Their clinical characteristics, indications for lead extraction, and complications associated with TLE in the 9 patients who had VATS were compared with those for the 82 patients who did not have VATS. The mean (SD) age of the study patients was 61 (17) years (64.8% were male). The lead dwell time, number of leads extracted, and clinical comorbidities were similar between the 2 groups. Superior vena cava (SVC) tear occurred in 2 of the 9 patients in VATS group and in 1 of the 82 in the non-VATS group (22.2% vs. 1.2%, P = 0.03). Of the 2 patients in the VATS group who had SVC tears, in 1 the tear was visualized immediately and there was no hemodynamic compromise. In the other patient, the SVC tear was within the pericardium; the blood pressure recovered quickly after sternotomy and repair. Both patients had complete lead extraction and survived hospitalization. The patient in the non-VATS group who had an SVC tear had a successful repair but died of postoperative complications. CONCLUSIONS: Utilization of VATS to facilitate TLE is beneficial for early recognition of SVC tear and timely surgical repair in select high-risk patients.

Tailored management of stage IIIa non-small-cell lung cancer in the era of the 8th edition of the TNM classification for lung cancer.

Stage IIIA is a very heterogeneous group encompassing locally advanced disease with T3 and T4 tumors without any nodal involvement and very small T1a primary tumors with unilateral mediastinal lymphatic disease. Tailored management defines interdisciplinary management requiring board decisions, which can sometimes be difficult particularly in stage IIIa non-small-cell lung cancer (NSCLC). Lobectomy still is standard of care even for stage I NSCLC, which increasingly is implemented using minimally invasive surgical technique. On the other hand even locally extended tumors are today safely resected with low morbidity and mortality. According to the 2015 guidelines of the European Society of Thoracic Surgeons any kind of anatomical lung resection for lung cancer with curative intent has to be accompanied by formal mediastinal lymph node dissection. The transcervical route for complete bilateral mediastinal lymphadenectomy offers improved completeness of resection without the need for single lung ventilation and ideally supports the concept of minimally invasive surgery.

Trends and Outcomes of Thoracoscopic Lobectomy or Segmentectomy: A National Surgical Quality Improvement Project Analysis.

Video-assisted thoracoscopic surgery may be associated with less morbidity than open lobectomy or segmentectomy, but some studies have questioned the benefit of thoracoscopic surgery. This study aimed to determine trends and factors associated with patient's likelihood of undergoing thoracoscopic lobectomy or segmentectomy and to compare outcomes with each approach. This retrospective study included adult patients undergoing pulmonary lobectomy or segmentectomy from the American College of Surgeons National Surgical Quality Improvement Project from 2007 to 2015 (n = 14,717). Logistic regression analysis was conducted to determine the association of patient demographics, clinical characteristics, and surgeon specialty with thoracoscopic lobectomy or segmentectomy. Propensity score matching was performed to evaluate outcomes for thoracoscopic and open lobectomy or segmentectomy. Use of thoracoscopic lobectomy or segmentectomy increased from 11.6% in 2007 to 60.6% in 2015 (P< 0.0001). Older patients, females, and Hispanics were more likely to undergo thoracoscopic lobectomy, whereas morbidly obese patients, patients with higher American Society of Anesthesiology class, and patients with 4-6 frailty conditions had a lower likelihood of receiving thoracoscopic lobectomy or segmentectomy. Thoracic surgeons had 57% (odds ratio 1.57, 95% confidence interval 1.36-1.81) higher odds of performing thoracoscopic surgery than other surgeons. Thoracoscopic lobectomy or segmentectomy reduced risk of 30-day mortality (1.0% vs 1.9%; odds ratio 0.51, 95% confidence interval 0.37-0.70) and resulted in shorter length of stay (4 days vs 6 days; Beta coefficient = -0.37, P < 0.0001), and fewer complications. The frequency of thoracoscopic lobectomy or segmentectomy has increased substantially over the last 10 years and now accounts for over half of lobectomies. Video-assisted thoracoscopic surgery showed better outcomes than open lobectomy or segmentectomy.

Is it appropriate to perform video-assisted thoracoscopic surgery for advanced lung cancer?

Video-assisted thoracoscopic surgery (VATS) has showed benefits in terms of pain, hospital stay and accomplishment of adjuvancy therapy versus open surgery in early stage of non-small-cell lung cancer. Over the last years, the indication of VATS technique has been expanded to advanced lung cancer. In this article, we discuss the definition of VATS and advanced lung cancer, and the safety and feasibility of VATS technique for the resection of advanced tumors.

Enhanced Recovery After Surgery (ERAS®) in thoracic surgical oncology.

Enhanced recovery after surgery (ERAS®) is a strategy that seeks to reduce patients' perioperative stress response, thereby reducing potential complications, decreasing hospital length of stay and enabling patients to return more quickly to their baseline functional status. The concept was introduced in the late 1990s and was first adopted for use with patients undergoing open colorectal surgery. Since that time, the concept of ERAS has spread to multiple surgical specialties. This article explores the key elements for patient care using an ERAS protocol applied to minimally invasive thoracic surgery.