[Non-Intubated Video-assisted Thoracoscopic Surgery (niVATS)]. / Minimalinvasive Lungenchirurgie unter Spontanatmung (niVATS).

Non-intubated minimally invasive lung surgery garnered renewed interest during the past decade and many centers across the country successfully implemented the technique for minor procedures like pleurodesis or wedge resection. Anatomical lung resection under spontaneous breathing still is considered as challenging, and as existing data to support it is conflicting and confusing, the approach remains limited to few dedicated outfits. We seek to present the historical perspective, critically report potential advantages and limitations of the technique and hand out a guideline that might prove to be helpful in building up a dedicated program.

Evaluating VATS versus Open Surgery for Non-Small Cell Lung Cancer: A 5-year Retrospective Study.

BACKGROUND AND OBJECTIVES: The efficacy and safety of video-assisted thoracoscopic surgery (VATS) versus open thoracotomy in the treatment of non-small cell lung cancer (NSCLC) were evaluated with a focus on mediastinal lymph node dissection, postoperative recovery, and longterm outcomes including survival rates and disease-free intervals. Materials and Methods: This retrospective study analyzed data from 228 NSCLC patients treated at the Institute of Oncology Bucharest from 2016 to 2022. Both VATS and open surgical approaches were compared, with variables including demographic data, comorbidities, surgical outcomes, and postoperative complications meticulously recorded. Statistical significance was assessed using chi-square and independent samples t-tests. Results: Among the findings, VATS demonstrated significantly better two-year progression-free survival rates for patients in early stages (Stages 1-3) of NSCLC compared to open surgery, with p-values 0.01 and 0.001, respectively. In contrast, no significant difference was observed in Stage 4. Furthermore, VATS resulted in shorter operative times (mean 299 vs. 347 minutes, p 0.001), less estimated blood loss (98.68 mL vs. 160.88 mL, p 0.001), reduced chest tube duration (5.78 days vs. 12.17 days, p 0.001), and decreased hospital stays (12.0 days vs. 27.7 days, p 0.001). Conclusions: VATS is associated with improved long-term disease-free survival for early-stage NSCLC and more favorable short-term surgical outcomes, highlighting its advantages over open thoracotomy. Despite its benefits, VATS did not significantly reduce postoperative complications compared to open surgery.

Thoracoscopic wedge resection of the upper lobe of the left lung achieved by a new approach of laryngeal mask general anesthesia with preservation of spontaneous breathing: A case report.

INTRODUCTION: General laryngeal mask anesthesia with the preservation of spontaneous breathing has accelerated the advancement of the enhanced recovery after surgery concept in thoracoscopic surgery. However, the need for increased doses of anesthetic drugs to reduce laryngeal mask airway (LMA) stimulation poses challenges due to the increased risk of hypotension, respiratory depression, susceptibility to hypoxemia, and carbon dioxide retention, particularly in the lateral position. PATIENT CONCERNS: During the perioperative period, reducing the dose of anesthetic drugs while simultaneously improving LMA tolerance and preventing circulatory and respiratory depression poses a challenge. DIAGNOSES: The patient was diagnosed with a nodule in the upper lobe of the left lung. INTERVENTIONS: In this case, we chose remimazolam sedation, which mildly inhibits circulatory respiration, and used mucosal surface anesthesia in the pharynx. This approach improved the patient's tolerance to LMA, reduced the dose of anesthetic drugs, and facilitated the successful thoracoscopic wedge resection of the upper lobe of the left lung with preservation of spontaneous respiration. OUTCOMES: During 2 weeks follow-up, the patient recovered satisfactorily and did not report any discomfort. CONCLUSION: We used pharyngeal mucosal surface anesthesia and thoracic paravertebral nerve block in combination with remimazolam sedation to provide precise analgesia, moderate sedation, and successful LMA general anesthesia with preservation of spontaneous respiration in patients undergoing thoracoscopic pulmonary wedge resection.

Surgically resected sarcomatoid carcinoma of the lung: a nationwide retrospective study in 2010.

BACKGROUND: Sarcomatoid carcinoma of the lung is a rare histological type of non-small cell lung cancer with a poor prognosis. We aimed to investigate the clinicopathological characteristics and prognostic factors of surgically resected sarcomatoid carcinoma of the lung. METHODS: We retrospectively reviewed 14999 patients who underwent surgical resection for non-small cell lung cancer accumulated by the Japanese Joint Committee of Lung Cancer Registry in 2010. Clinicopathological characteristics and survival were compared between the sarcomatoid carcinoma and other non-small cell cancer groups. The prognostic factors in the sarcomatoid carcinoma group were identified using a multivariate Cox proportional hazard model. RESULTS: Patients with sarcomatoid carcinoma comprised 1.4% of all patients. The sarcomatoid carcinoma group demonstrated a more aggressive pathology with presentation at more advanced stages, requiring more frequent extensive surgical resections. The sarcomatoid carcinoma group had remarkably poorer overall and recurrence-free survival than the other non-small cell lung cancer group. Adjuvant chemotherapy was associated with improved survival for pathological stage II-III sarcomatoid carcinoma cases rather than for pathological stage I disease. In the multivariate analysis, larger tumor size, lymphatic permeation, and no adjuvant chemotherapy were associated with the sarcomatoid carcinoma group's overall and recurrence-free survival. CONCLUSIONS: Surgically resected sarcomatoid carcinoma of the lung has a higher aggressive and metastatic potential and a worse prognosis than other non-small cell lung cancers. Adjuvant chemotherapy, which was associated with enhanced survival in patients with pathological stage II-III of the disease, could be considered for treating patients with pathological stage II-III sarcomatoid carcinoma of the lung.

A robotic left S6 and S1/2c segmentectomy using the lung-inverted approach.

In pulmonary segmentectomy, the dominant pulmonary arteries are traditionally divided at the fissure. However, this approach sometimes leads to inadvertent injury to the pulmonary artery and prolonged air leak when the fissure is fused. To overcome these problems, by taking advantage of the good visualization provided by robotic surgery, we have adopted the lung-inverted approach without fissure dissection for segmentectomy. We have successfully performed a robotic left S6 and S1+2c segmentectomy using the lung-inverted approach. In addition to a good postoperative course, the console time was 57 minutes, which was considered relatively short. This approach may have contributed to the short operating time because it did not require repeated rotation of the lung. A clear understanding of the anatomy was required to perform this approach properly, because each branch of the pulmonary vessels and bronchi was treated inverted at the hilum. A preoperative 3-dimensional computed tomography broncho-angiographic scan was considered useful because it allowed us to recognize the relative positions of the dominant pulmonary vessels, the bronchi and other structures that were preserved.

Unplanned Perioperative Reoperation Following Pulmonary Resection in Lung Cancer Patients: A Report of a Single-Center Experience.

BACKGROUND: Pulmonary resection is an important part of comprehensive treatment of lung cancer. Despite the progress in recent thoracic surgery, reoperation is occasionally inevitable for managing severe perioperative complications. This study aimed to investigate the incidence and causes of perioperative reoperation in lung cancer patients. METHODS: We retrospectively collected patients who underwent reoperation following pulmonary resection from January 2010 to February 2021 in China-Japan Friendship Hospital. RESULTS: Among the 5032 lung cancer patients who received primary pulmonary resection in our institute, 37 patients underwent perioperative reoperation with the rate being 0.74%. Lobectomy was the most frequently executed procedure (56.8%). The mean duration of the primary surgery was 143.6 ± 65.1 min. About half of the cases received secondary surgery within 24 h of the primary surgery, whereas only one case underwent secondary surgery 30 days after the primary surgery (due to chylous leakage). The major causes of the reoperation were bleeding (73.0%), chylous leakage (13.5%), lobar torsion (5.4%), air leakage (2.7%), atelectasis (2.9%), and cardiac herniation (2.7%). CONCLUSION: The most prevalent reasons for unplanned reoperation following pulmonary resection in lung cancer patients include bleeding, chylous leakage, and lobar torsion. The strict control of the surgical indications and standardization of surgical procedures are fundamental to reduce unplanned secondary operations after pulmonary resections. Timely identification of the need to secondary surgery is also important to ensure patients' safety.

Sleeve lobectomy versus pneumonectomy following neoadjuvant therapy in patients with non-small cell lung cancer.

OBJECTIVES: Neoadjuvant therapy has gained widespread acceptance as the standard modality for locally advanced non-small cell lung cancer. However, the clinical benefit of sleeve lobectomy (SL) or pneumonectomy (PN) following neoadjuvant therapy remains controversial. METHODS: The clinical and pathological characteristics of non-small cell lung cancer patients who underwent SL or PN after neoadjuvant therapy at a high-volume single centre between December 2019 and March 2023 were retrospectively collected. The SL group was matched 4:1 with the PN group by propensity score matching. The surgical outcomes were systematically collected and analysed. RESULTS: During a 5-year study period, the majority of patients (175 of 215, 81.4%) underwent the SL procedure, while 40 patients (18.6%) underwent PN. Following propensity score matching, the SL group exhibited lower postoperative arrythmia (4.8% vs 26.9%, P < 0.001), lower 30-day mortality (1.0% vs 7.7%, P = 0.046) and a shorter length of postoperative hospital stay (6.0 days vs 10.0 days, P < 0.001), compared with the PN group. In addition, no significant difference was observed between the two groups in terms of disease-free survival or overall survival (P = 0.977 and P = 0.913, respectively). CONCLUSIONS: SL stands as a safe and feasible option for patients with centrally located non-small-cell lung cancer who have undergone neoadjuvant therapy, in comparison to PN. This finding suggests that SL remains the preferable choice when feasible in the context of the widespread utilization of neoadjuvant therapy.

[Comparison of the efficacy of robot assisted and thoracoscopic assisted thoracic surgery in non-small cell lung cancer].

Objective: To compare the safety and short-term efficacy of robotic-assisted thoracic surgery(RATS) and video-assisted thoracoscopic surgery(VATS) in patients with non-small cell lung cancer (NSCLC). Methods: A retrospective analysis of the clinical data of 2 058 NSCLC patients who underwent RATS and VATS from January 2021 to December 2022 in Xiangya Hospital of Central South University was conducted, including 1 006 males and 1 052 females, with the age of (57.3±9.9) years. According to the surgical approach, the patients were divided into RATS group (n=1 190) and VATS group (n=868). The nearest neighbor matching method was used to perform 1∶1 propensity score matching (PSM). A comparison was made about the intraoperative conditions and postoperative complication rates between the RATS and VATS groups before and after PSM. Furthermore, after PSM, a stratified analysis was conducted based on surgical approach, separately comparing the intraoperative conditions and postoperative complication rates between the VATS and RATS groups among patients who underwent lobectomy and segmentectomy, respectively. Results: After PSM, a total of 1 692 patients were included, with 846 patients in both the VATS and RATS groups. After stratification based on surgical approach, there were 503 patients in the RATS group and 548 patients in the VATS group for lobectomy, and 338 patients in the RATS group and 298 patients in the VATS group for segmentectomy. Before PSM, statistically significant differences were observed between the RATS and VATS groups in terms of intraoperative conversion to open thoracotomy, number of lymph node dissection/sampling stations, extubation time, total length of hospital stay, and total hospitalization costs (all P<0.001). After PSM, compared with the VATS group, the RATS group had a lower intraoperative conversion rate to open surgery [1.2% (10/846) vs 5.1% (43/846)], less intraoperative blood loss [(73.6±77.4) ml vs (112.6±239.3) ml], a greater number of sampled/dissected lymph node stations [(4.8±2.0) vs (3.7±1.8)], a shorter duration of drainage tube placement [(3.6±2.7) d vs (4.1±2.5) d], and a higher postoperative drainage volume [(273.9±183.0) ml vs (256.5±168.7) ml] (all P<0.001). There was no statistically significant difference in the incidence of postoperative complications between the two groups (P=0.108). The results of the surgical stratification analysis showed statistically significant differences between the two groups in terms of intraoperative blood loss, number of lymph node dissection/sampling stations, extubation time, and total hospitalization costs for both lobectomy and segmentectomy surgeries (all P<0.001). In lobectomy surgeries, the RATS group had a lower rate of intraoperative conversion to open thoracotomy than that of VATS group [1.6% (8/503) vs 7.7% (42/548), P<0.001]. In segmentectomy surgeries, the RATS group had more postoperative drainage volume than that of VATS group [(249.8±151.5) ml vs (218.7±132.9) ml, P=0.023]. There was no statistically significant difference in the incidence of surgical complications between the two groups for both lobectomy and segmentectomy surgeries (both P>0.05). Conclusion: In the surgical management of NSCLC, RATS offers more advantages over VATS in reducing conversion rates to open surgery, minimizing perioperative adverse events, and facilitating faster patient recovery postoperatively.

The role of 3-dimensional reconstruction imaging in bronchopulmonary sequestration.

Bronchopulmonary sequestration is a congenital abnormality characterized by non-functioning lung tissue, abnormal connection with the tracheobronchial tree and anomalous systemic arterial supply. Although considered a rare phenomenon presenting early in life, sequestration may also present with recurrent chest infections in late adulthood. Additionally, bronchopulmonary sequestration may rarely be incidentally encountered during thoracic surgery. Several subtypes exist including intralobar, extralobar and hybrid bronchopulmonary sequestration (congenital pulmonary artery malformation). Surgical resection is curative and serves as the treatment of choice for symptomatic patients. Radiological imaging prior to surgery is essential in these patients because the arterial supply may be anatomically complex, and aberrant artery branches are common. Utilization of virtual 3-dimensional remodelling and computed tomography reconstruction imaging can not only establish a diagnosis of bronchopulmonary sequestration but can also optimize preoperative planning. This approach will ultimately prove useful in anticipating surgically challenging steps and avoiding unnecessary intraoperative complications. We present a video tutorial on the role of 3-dimensional reconstruction imaging in bronchopulmonary sequestration and a step-by-step guide for performing a right robotic-assisted surgical resection of an S2 hybrid bronchopulmonary sequestrated segment. This case is followed by a second case of intralobar bronchopulmonary sequestration encountered incidentally during thoracic surgery.

Effect of Anatomical Pulmonary Segmentectomy and Lobectomy under Uniportal Video-Assisted Thoracoscopic Surgery on Cardiopulmonary Function and Serum Tumor Markers in Patients with Early-Stage Non-Small Cell Lung Cancer.

AIM: In patients with early non-small cell lung cancer (NSCLC), single-port thoracoscopic anatomical segmentectomy is the primary therapeutic approach. However, the recovery of lung function is slow after operation. Conversely, anatomical segmental pneumonectomy, which excises a smaller volume of lung tissue, may facilitate more rapid functional recovery. This study aims to elucidate the comparative efficacy of these two surgical interventions by analyzing postoperative changes in cardiopulmonary function parameters and serum tumor markers. METHODS: A retrospective analysis was conducted on 120 patients with NSCLC between October 2020 and October 2023. The cohort was classified into two groups based on the surgical intervention: the pulmonary segmentectomy group (n = 57), which underwent uniportal video-assisted thoracoscopic anatomical pulmonary segmentectomy, and the lobectomy group (n = 63), which received uniportal video-assisted thoracoscopic anatomical lobectomy. Surgical parameters and perioperative stress indicators were recorded for both groups of patients. Additionally, cardiopulmonary function indicators and serum biomarker levels of the patients before and 3 months after operation were compared. RESULTS: The operation time of the segmentectomy group was longer than that of the lobectomy group, the intraoperative blood loss was higher, and the postoperative hospital stay, chest drainage volume and drainage tube indwelling time were shorter (p < 0.001). After treatment, forced expiratory volume in one second (FEV1), forced vital capacity (FVC), FEV1/FVC and maximal voluntary ventilation (MVV) in the segmentectomy group were higher than those in the lobectomy group (p < 0.001). After treatment, stroke volume (SV) and left ventricular ejection fraction (LVEF) in the segmentectomy group were higher than those in the lobectomy group (p < 0.001). There were no significant differences in carbohydrate antigen 50 (CA50), carcinoembryonic antigen (CEA) and cytokeratin 19 fragment antigen 21-1 (CYFRA21-1) levels between the two groups after treatment (p > 0.05). The levels of Epinephrine (E), Noradrenaline (NE) and Cortisol (Cor) in the segmentectomy group were lower than those in the lobectomy group at one day after operation (p < 0.001). CONCLUSIONS: Compared to uniportal video-assisted thoracoscopic anatomical lobectomy, anatomical pulmonary segmentectomy for the treatment of NSCLC is more effective in reducing surgical-induced damage to cardiopulmonary function and can lower perioperative oxidative stress response. However, both surgical approaches exhibit minimal impact on serum tumor marker levels.

Clinical Effects of Enhanced Recovery after Surgery in Perioperative Period Patients with Video-Assisted Thoracoscopic Lobectomy.

AIM: Enhanced recovery after surgery (ERAS) guidelines provide significant benefits for patients after surgery. Care bundles combine various evidence-based treatments and care measures for managing refractory clinical diseases. Therefore, we aimed to evaluate the ERAS measures and care bundles to reduce post-operative complications associated with video-assisted thoracic surgery (VATS) lobectomy and promote patients' recovery. METHODS: As a retrospective study, this study included 120 non-small cell lung carcinoma patients, who were divided into a control group and an observation group according to the post-operative care methods of the patients in the medical record system. Among them, sixty patients, admitted from January 2018 to January 2019, were included in the control group, and 60 patients, admitted from January 2022 to January 2023, were included in the observation group. The control group received routine care (non-ERAS group), and the observation group followed the bundles of care strategy based on ERAS guidelines (ERAS group). Data collected included baseline characteristics, clinical parameters, and post-operative parameters of patients in the ERAS and non-ERAS groups. The clinical data of all patients came from the hospital medical record system. RESULTS: There were no significant differences in gender, age, tumor node metastasis (TNM) stages, smoking, and drinking between the ERAS and non-ERAS groups (p > 0.05). Similarly, no significant differences were observed in Cardiac Ejection fraction (≥50%), forced expiratory volume in 1 sec % (FEV1%) forced vital capacity (FVC), Lymphocyte, Neutrophils (%), and Tumor diameter between the ERAS and non-ERAS groups (p > 0.05). In contrast, significant differences were found in FVC, FEV1%, diffusing capacity of the lungs for carbon monoxide single breath (DLCO SB), Albumin, C-reactive protein, Leukocyte, Monocytes, Lymphocyte (%), Hemoglobin, and Neutrophils between the ERAS and non-ERAS groups (p < 0.05). Furthermore, Receiver Operating Characteristic (ROC) analysis indicated that Leukocytes, DLCO, C-reactive protein (CRP), FEV1%, Monocytes, Lymphocytes (%), Neutrophils (%), and Body Mass Index (BMI) were essential predictors of ERAS. Using cutoff values of Leukocytes >12.5, FEV1% >112.9, Monocytes >16.8 (109/L), and Neutrophils >11.6, patients undergoing VATS lobectomy were more likely to experience a quick recover. When ERAS measures integrated bundles of care, the extubation time can reduced to less than 5.5 days, the visual analogue scale (VAS) score to less than 3.5, and the post-operative hospital stay to less than 10.5 days. CONCLUSIONS: ERAS management measures based on bundles of care can significantly improve the prognosis of patients undergoing VATS lobectomy, reduce post-operative complications, and accelerate safe rehabilitation. Furthermore, they can greatly shorten hospital stays, lower overall healthcare costs, and alleviate social and family burdens. These significant differences may be related to factors such as Leukocytes, FEV1%, Monocytes, and Neutrophils.

Effects of Thoracoscopic Right Upper Lobe Apical Segmentectomy on Exercise Capacity and Quality of Life in Early-Stage NSCLC Patients.

AIM: Thoracoscopic lobectomy (TL) is an effective surgical approach for resecting tumor lesions in patients with early non-small cell lung cancer (NSCLC). However, TL may result in damage to normal lung tissue, potentially impacting prognosis. Thoracoscopic right upper lobe apical segmentectomy (TS) has been proposed as an alternative to improve surgical outcomes, but its impact on exercise capacity and quality of life remains unclear. This study aimed to investigate the effect of TS on exercise capacity and quality of life in patients with early-stage NSCLC. METHODS: A retrospective analysis was conducted on the clinical data of 120 patients with early-stage NSCLC who underwent surgical treatment in Shangyu People's Hospital of Shaoxing between August 2020 and August 2023. The patients were divided into two groups based on the surgical approach: the TL group (n = 66) and the TS group (n = 54). The primary objective was to compare surgery-related indicators and the overall incidence of complications between the TS group and the TL group. Additionally, changes in forced vital capacity (FVC), forced expiratory volume in one second (FEV1), maximum ventilatory volume (MVV), 6-minute walking distance (6MWD), and European Organization for Research and Treatment of Cancer quality of life (EORTC QLQ-C30) scores were evaluated before and after operation. RESULTS: The TS group showed significantly reduced intraoperative blood loss, chest drainage, and hospital stay compared to the TL group (p < 0.05). However, there was no significant difference in the operation time and the number of lymph node dissections between the two groups after operation (p > 0.05). FVC, FEV1, MVV, and 6MWD values of the two groups were significantly lower than those before operation (p < 0.05). However, FVC, FEV1, MVV, and 6MWD in the TS group were significantly higher than those in the TL group (p < 0.05). The scores of roles, emotion, cognition, social function, and total health status in the two groups after operation were significantly higher than those before operation, and the scores of physical functions, shortness of breath, diarrhea, fatigue, pain, cough and insomnia were significantly lower than those before operation (p < 0.05). Compared to the TL group, the TS group showed higher scores of physical, social function dimensions, and total health status, as well as lower scores of fatigues, shortness of breath, insomnia, and pain (p < 0.05). CONCLUSIONS: TS treatment has less surgical trauma and a lower risk of complications for patients with early-stage NSCLC, which is beneficial for promoting postoperative recovery, reducing lung function damage and improving the quality of life of patients.

The Use of Bronchial Rheoplasty in Emphysema Patients Previously Treated with Endoscopic Lung Volume Reduction: A Case Series.

Endoscopic lung volume reduction (ELVR) is an established treatment option for patients with severe emphysema. Not all patients are candidates for this type of intervention, and in the context of significant airway secretions, they may be excluded from treatment. Bronchial Rheoplasty (BR) was developed to treat mucus hypersecretion by delivering nonthermal pulsed electric fields to the airway epithelium and submucosa. The literature to date demonstrates that patients treated with BR in clinical studies have a reduction in airway goblet cell hyperplasia as well as substantive clinical improvement in the setting of chronic bronchitis (CB). In this case series, we present four patients treated at three different institutions who had previously undergone ELVR with beneficial outcome. However, over time, these patients subsequently developed worsening clinical issues, including complaints of increased and thickened mucus, along with exacerbations in the setting of a loss of some ELVR-associated benefits. These patients then underwent exploratory treatment with BR with the intent of reducing their secretion burden and potentially restoring the efficacy associated with the initial placement of the airway valves. All BR procedures were well tolerated, and three of the four patients showed substantial improvement in their symptom burden. Airway examinations during the second of the two BR procedures also revealed what appeared to be less airway mucosal inflammation and a decrease in the quantity of airway secretions. Therefore, treatment with BR may have the potential to improve and restore the initial benefits associated with ELVR, thus enhancing long-term outcomes. Further clinical studies with sufficient follow-up are warranted to assess this in a larger cohort of patients, and to determine whether treatment with BR prior to ELVR may make more patients eligible for this treatment through reduction in their secretions and/or symptoms.

Single-stage Open Lobectomy and Modified Ravitch Procedure in an Infant with Coexisting Severe Pectus Excavatum and Congenital Cystic Adenomatous Malformation.

ABSTRACT: Coexisting congenital cystic adenomatous malformation of the lungs and severe pectus excavatum (PE) is an uncommon presentation that poses significant management challenges. Conventionally managed in a staged manner, there are increasing reports of superior outcomes with single-staged concurrent repair with minimally invasive techniques (video-assisted thoracoscopic surgery [VATS] and minimally invasive repair of PE [MIRPE]). The outcome of a single-stage open repair for both anomalies has not been previously reported to the best of our search. We report the successful single-stage management of a 9-month-old infant with both anomalies who had an open lobectomy and modified Ravitch procedure. We aim to report the feasibility and safety of a single-stage concurrent repair of both conditions using open techniques, as VATS and MIRPE are not readily available in our environment.

A robotic fissureless right upper lobectomy using a posterior approach.

The fissureless technique in a lobectomy is considered useful to avoid postoperative prolonged air leak when a fissure is fused because it is not dissected. In particular, this technique has been used most frequently in right upper lobectomies because the dense fissure was most frequently found between the right upper and middle lobes. We believe that the surgical steps in this technique should be modified depending on the surgical approach, although the concept that the hilar structures, including the pulmonary vessels and bronchi, are each transected prior to division of a dense fissure is the same. We demonstrate a robotic right upper lobectomy with an explanation of the nuances of its performance. The operating time was 135 minutes with a blood loss of 50 ml. The patient's postoperative course was uneventful. We removed the chest tube on postoperative day 1, and the patient was discharged on postoperative day 3. The final pathology report was pT1bN0M0, stage 1A2, squamous cell carcinoma. These good perioperative results indicate the feasibility of this technique.

Robotic intrapericardial bilobectomy with stapler on the atrium and pericardial reconstruction.

Few intrapericardial robotic lung resection cases have been reported in the literature because of the perceived complexity of the procedure, with most surgeons embarking on an open resection via a thoracotomy. We present the case of a right middle and lower lobe tumour involving the pericardium and the origin of the right middle lobe vein. An intrapericardial lower bilobectomy was performed, with pericardial resection, pre-pericardial fat resection and mesh reconstruction. The vascular stapler for the right middle lobe vein was fired on the atrium. The resection was completed via a retrograde and fissureless approach, dividing the bronchus intermedius first, because it was impossible to open the fissure, leaving the division of the pulmonary artery until last. The case was performed solely robotically, with no complications and excellent postoperative recovery. Robotic resection can be performed successfully when pericardial lung tumours are involved.

Thoracoscopic S1 segmentectomy, right upper lobe: alternative posterior approach.

Minimally invasive pulmonary segmentectomy allows adequate oncological treatment in selected cases while preserving lung parenchyma and minimizing perioperative morbidity and length of hospital stay. Although several variations of minimally invasive pulmonary segmentectomy have been described, a fully thoracoscopic multiport approach that allows direct access to the segmental structures, is straightforward and is versatile enough to allow adaptation in case of unexpected intraoperative findings (such as conversion to lobectomy in the case of positive margins) is preferable. The S1 (apical) segment of the right upper lobe has some unique features that may make a conventional anterior approach challenging. The presence of multiple vascular structures bearing complex anatomical relationships and the requirement for preserving these structures may make identification of and access to the apical artery, and subsequent access to the segmental bronchus, challenging. In contradistinction, a posterior approach may obviate some of these challenges by allowing direct access to the segmental bronchus. Once the bronchus is divided, the apical artery is in direct alignment with the operating instruments, without encroachment from other troublesome vascular structures. This situation, however, remains contingent on individual anatomy, which may vary.

The pulmonary-vascular-stump filling defect on CT post lung tumor resection: a predictor of cancer progression.

BACKGROUND: To explore the pulmonary-vascular-stump filling-defect on CT and investigate its association with cancer progression. METHODS: Records in our institutional database from 2018 to 2022 were retrospectively analyzed to identify filling-defects in the pulmonary-vascular-stump after lung cancer resection and collect imaging and clinical data of patients. RESULTS: Among the 1714 patients analyzed, 95 cases of filling-defects in the vascular stump after lung cancer resection were identified. After excluding lost-to-follow-up cases, a total of 77 cases were included in the final study. Morphologically, the filling-defects were dichotomized as 46 convex-shape and 31 concave-shape cases. Concave defects exhibited a higher incidence of increase compared to convex defects (51.7% v. 9.4%, P = 0.001). Among 61 filling defects in the pulmonary arterial stump, four (6.5%) increasing concave defects showed the nuclide concentration on PET and extravascular extension. The progression-free survival (PFS) time differed significantly among the concave, convex, and non-filling-defect groups (log-rank P < 0.0001), with concave defects having the shortest survival time. Multivariate Cox proportional hazards analysis indicated that the shape of filling-defects independently predicted PFS in early onset on CT (HR: 0.46; 95% CI: 0.39-1.99; P = 0.04). In follow-ups, the growth of filling-effects was an independent predictor of PFS (HR: 0.26; 95% CI: 0.11-0.65; P = 0.004). CONCLUSIONS: Certain filling-defects in the pulmonary-arterial-stump post lung tumor resection exhibit malignant growth. In the early onset of filling-defects on CT, the concave-shape independently predicted cancer-progression, while during the subsequent follow-up, the growth of filling-defects could be used independently to forecast cancer-progression.