Interfissural Fixation of the Right Middle Lobe after Video-Assisted Thoracic Surgery Right Upper Lobectomy: Bronchial Anatomical Changes and Efficacy in Preventing Torsion.

Background: Torsion of the right middle lobe following right upper lobectomy is a rare but potentially fatal complication. To prevent this, fixation of the right middle lobe has been suggested. This study was performed to examine the impact of right middle lobe fixation on postoperative outcomes and bronchial changes. Methods: We enrolled patients who underwent curative-intent video-assisted thoracic surgery (VATS) right upper lobectomy for lung cancer from 2019 to 2022. Participants were grouped based on whether they did or did not receive right middle lobe fixation. Bronchial angles were measured using preoperative and postoperative chest computed tomography images, and postoperative outcomes and bronchial changes were compared between the 2 groups. Results: The study included a total of 50 patients, with 17 (34%) undergoing right middle lobe fixation. All procedures were performed using VATS. No significant differences between groups were observed in preoperative characteristics or postoperative outcomes. After surgery, both groups exhibited a significant increase in the right bronchus intermedius angle and a significant decrease in the branch angle. The postoperative right bronchus intermedius angle was significantly larger in the group without right middle lobe fixation compared to the group with fixation (47.38°±10.98° vs. 39.41°±9.21°, p=0.014). Three cases of atelectasis occurred in the group that did not undergo fixation while no cases were observed in the fixation group; however, this difference was not statistically significant. Conclusion: Fixation of the right middle lobe reduced postoperative angulation of the right bronchus intermedius, which may help prevent postoperative atelectasis.

Early Clinical Outcomes of Thoracoscopic Major Pulmonary Resection and Thymectomy Using Novel Articulating Endoscopic Forceps.

Background: Video-assisted thoracoscopic surgery (VATS) is recognized as a safe and effective treatment modality for early-stage lung cancer and anterior mediastinal masses. Recently, novel articulating instruments have been developed and introduced to endoscopic surgery. Here, we share our early experiences with VATS major pulmonary resection and thymectomy performed using ArtiSential articulating instruments. Methods: At the Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 500 patients underwent VATS pulmonary resection between July 2020 and April 2023, while 43 patients underwent VATS thymectomy between January 2020 and April 2023. After exclusion, 224 patients were enrolled for VATS major pulmonary resection, and 38 were enrolled for VATS thymectomy. ArtiSential forceps were utilized in 35 of the 224 patients undergoing pulmonary resection and in 12 of the 38 individuals undergoing thymectomy. Early clinical outcomes were retrospectively analyzed. Results: No significant differences were observed in sex, age, surgical approach, operation time, histological diagnosis, or additional procedures between the patients who underwent surgery using novel articulating instruments and the group treated with conventional endoscopic instruments for both VATS major pulmonary resection and thymectomy. However, the use of the novel articulating endoscopic forceps was associated with a significantly larger number of dissected lymph nodes (p=0.028) and lower estimated blood loss (p=0.009) in VATS major pulmonary resection. Conclusion: Major pulmonary resection and thymectomy via VATS using ArtiSential forceps were found to be safe and effective, with early clinical outcomes comparable to established methods. Further research into long-term clinical outcomes and cost-effectiveness is warranted.

Transaortic removal of a large primary sarcoma from the left ventricle assisted by strategic partial resection and endoscopic guidance: a case report.

BACKGROUND: Surgical resection remains the mainstay of treatment for cardiac sarcoma, a rare but lethal disease. Achieving complete removal of a large-sized left ventricular sarcoma remains a challenge even with various surgical approaches that have been employed. CASE PRESENTATION: We present a case of a 74-year-old woman with shortness of breath who underwent surgical removal of a primary cardiac sarcoma, measuring 6 × 3.5 × 3 cm, attached to the septum of the left ventricle and caused sub-aortic valve obstruction. Transaortic approach was chosen and the access to this entire huge mass was enabled by using interim partial resection which created a space for further dissection and subsequent deeper endoscopic views. The further dissection was finally able to be advanced on the apex, and the residual mass was completely resected with gross tumor-free margins. CONCLUSION: Interim partial resection and endoscopic guidance can highly facilitate the transaortic removal of even large left ventricular sarcomas.

The Incidence of Brain-Dead Donors Based on Screening and Management Led by Intensivists.

BACKGROUND This study aimed to compare the incidence of brain-dead (BD) donors and potential brain-dead (PBD) donors before vs after the introduction of intensivists. MATERIAL AND METHODS This longitudinal retrospective study was performed between January 2012 and December 2020 at Seoul Metropolitan Government-Seoul National University Boramae Medical Center. Four dedicated intensivists were introduced in January 2016. The periods before and after introduction of the intensivists were defined as the pre-introduction period (2012-2015) and post-introduction period (2016-2020), respectively. RESULTS During the study period, there were 2872 discharges in the Intensive Care Unit, of which there were a total of 113 PBD (3.93%) and 36 BD (1.25%) donors. The number of PBD and BD donors increased in the post-introduction period compared in the pre-introduction period (PBD, 47.84 vs 27.14 per 1000 discharges; BD, 13.59 vs 11.03 per 1000 discharges). Poisson regression analysis showed the annual incidence rate of PBD donors significantly increased post-introduction (PBD, 27.53% vs 48.11%, P=0.044), while those of BD donors were similar between the 2 groups (BD, 11.41% vs 13.9%; P=0.743). The annual incidence rate of the total number of organ donations, multi-organ donations (>3 organs), and donation of organs (heart, lung, and kidney) increased in the post-introduction period compared to that in the pre-introduction period. CONCLUSIONS Our findings suggest a beneficial role of a dedicated intensivist, not only in improving actual organ donation and discovering PBD donors, but also in affecting the yield of the heart and lung transplantation in actual organ donation compared to donors without a dedicated intensivist.

Continuous vagal intraoperative neuromonitoring during video-assisted thoracoscopic surgery for left lung cancer: its efficacy in preventing permanent vocal cord paralysis.

OBJECTIVES: We investigated the safety and efficacy of continuous intraoperative neuromonitoring (CIONM) during video-assisted thoracoscopic lobectomy for left lung cancer in preventing recurrent laryngeal nerve injury. METHODS: From August 2015 to March 2020, 22 patients with left lung cancer without CIONM (unmonitored) and 20 patients with left lung cancer with CIONM underwent thoracoscopic lobectomy with complete mediastinal lymph node dissection including 4L dissection. Clinical outcomes from these 2 groups were compared. RESULTS: The incidence of 4L metastasis was 7.14% (3 patients). There was no significant difference in the total number of dissected 4L lymph nodes between the 2 groups (3.23 ± 2.2 in the unmonitored group, 3.95 ± 2.0 in the CIONM group). CIONM was successful in all of the cases. There was no significant difference in the incidence of postoperative vocal cord palsy (22.7% in the unmonitored group, 20% in the CIONM group, P = 1.000). All of the 5 patients (100%) had permanent vocal cord palsy in the unmonitored group. Although statistically insignificant, 75% (3 patients) had total recovery of the vocal cord function, with only 1 patient remaining in permanent vocal cord palsy in the CIONM group. CONCLUSIONS: CIONM was safe and efficient. CIONM might be helpful to avoid permanent vocal cord palsy by immediately warning the surgeon about impending nerve injury, so the surgeon can stop delivering further injury to the recurrent laryngeal nerve.

Comparable Clinical Outcome Using Small or Large Gross Tumor Volume-to-Clinical Target Volume Margin Expansion in Neoadjuvant Chemoradiotherapy for Esophageal Squamous Cell Carcinoma.

The purpose of this study was to evaluate the feasibility of small primary gross tumor volume (GTV)-to-clinical target volume (CTV) margin expansion in neoadjuvant chemoradiation for esophageal squamous cell carcinoma. Medical records of 139 patients with locally advanced esophageal squamous cell carcinoma who underwent neoadjuvant chemoradiation and radical esophagectomy were retrospectively reviewed. Patients treated with longitudinal primary GTV-to-CTV margin expansion of 2 cm and no additional expansion of the CTV through the esophagus were classified into a small margin (SM) group (37 patients). The remaining 102 patients were classified as a large margin (LM) group. Patterns of recurrence including local and out-field regional recurrence rates were compared between the two groups. Clinical outcomes including rates of local control, regional control, failure-free survival, and overall survival were also compared. More patients in the SM group underwent paclitaxel + carboplatin, Mckeown esophagectomy, and intensity-modulated radiation therapy than in the LM group. With a median follow-up of 25.6 months, there was no significant difference in the crude rate of local recurrence (10.8% vs. 6.9%, P=0.694), out-field regional recurrence (27.0% vs. 19.6%, P=0.480), or out-field regional recurrence without in-field recurrence (10.8% vs. 12.7%, P=0.988) between the two groups. There was no significant difference in failure-free survival (5-year, 34.4% vs. 30.6%, P=0.652) or overall survival (44.1% vs. 38.5%, P=1.000), either. Esophageal fistula was not reported in the SM group (0.0% vs. 7.9%, P=0.176). In conclusion, a radiation field with 2 cm of longitudinal primary GTV-to-CTV was feasible in the neoadjuvant setting for esophageal squamous cell carcinoma treatment.

Randomized Trial of Poloxamer 407-Based Ropivacaine Hydrogel After Thoracoscopic Pulmonary Resection.

BACKGROUND: We conducted a comparative study to evaluate the efficacy of poloxamer 407-based ropivacaine hydrogel at the wound site (Gel) and continuous thoracic paravertebral block using On-Q PainBuster (On-Q; B. Braun Medical) for postoperative pain after thoracoscopic pulmonary resection. METHODS: This prospective, randomized, noninferiority study included 89 patients randomized to the Gel group (poloxamer 407-based 0.75% ropivacaine, 22.5 mg) or the On-Q group (0.2% ropivacaine, 4 mg/h for 48 hours). The primary outcome measure was total fentanyl consumption, and secondary outcome measures were the need for rescue analgesia and pain intensity using the numeric rating scale (NRS). RESULTS: There was no significant difference in total fentanyl consumption between the Gel group and the On-Q group (1504.29 ± 315.72 µg vs 1560.32 ± 274.81 µg, P = .374). Pain intensity using the NRS between the Gel group and the On-Q group demonstrated no statistical differences at 6 hours (3.56 vs 3.55, P = .958), 24 hours (3.21 vs 3.00, P = .25), 48 hours (2.75 vs 2.49, P = .233), and 72 hours (2.39 vs 2.33, P = .811), and there was no significant difference in the frequency of analgesic rescue medication use (3.70 vs 3.33, P = .417). CONCLUSIONS: We confirm the noninferiority of Gel compared with On-Q for acute postoperative pain after thoracoscopic pulmonary resection. Considering a technical simplicity and low systemic toxicity of the local injection of Gel, this analgesic modality may be worthy of further research and is thus considered to have potential as a viable alternative to On-Q for regional analgesia.

Video-assisted thoracic surgery sleeve resection and bronchoplasty using 3D imaging system: its safety and efficacy.

BACKGROUND: Video-assisted thoracic surgery sleeve resection with bronchial anastomosis or bronchoplasty is a technically demanding procedure. Three-dimensional endoscopic surgery has been reported to be helpful in decreasing operation time and improving spatial perception with less surgical errors, but there have been rare reports about relatively difficult thoracoscopic procedures utilizing 3D thoracoscope. We performed this study to evaluate early clinical outcomes of thoracoscopic sleeve resection and bronchoplasty utilizing 3D thoracoscope. METHODS: Data from a total of 36 patients who underwent thoracoscopic sleeve lobectomy or bronchoplasty at our institution from December 2015 to October 2017 were retrospectively reviewed. Three-port approach with one utility incision was used with a 10 mm, 30° three-dimensional thoracoscope. Twenty-three patients (81%) were male, and mean age was 65.9 ± 9.4 years. Fourteen patients (38.9%) underwent sleeve resection with bronchial anastomosis, 22 (61.1%) underwent wedge or simple bronchoplasty, and one patient received concomitant PA procedure. Bronchial anastomosis sites were not covered with viable tissue flaps. RESULTS: There was no (0%) suture needle injury from spatial misperception during bronchoplasty or sleeve anastomosis. There was no (0%) operative mortality. The pathologic report revealed squamous cell carcinoma (63.9%), adenocarcinoma (19.4%), carcinoid (6.9%), adenosquamous carcinoma (3.4%), and sarcomatoid carcinoma (2.8%). One (2.8%) late mortality was due to systemic recurrence of sarcomatoid carcinoma. There was no (0.0%) anastomotic failure. The mean number of dissected lymph nodes were 27.4 ± 13.2, and mean operation time was 216.8 ± 60.0 min. Median postoperative 24-h drain amount was 315 mL. Median chest tube days and hospital days were 4 and 6, respectively. Two patients (5.6%) had complications greater than Clavien-Dindo grade II-one case of ARDS, and the other case of a delayed bronchopleural fistula. CONCLUSIONS: Thoracoscopic sleeve resection and bronchoplasty utilizing HD 3D thoracoscope is a safe and effective procedure with excellent early clinical outcomes. Further investigation for long-term outcomes will be needed.

Is Hypertrophic or Keloid Wound Scar a Risk Factor for Stricture at Esophagogastric Anastomosis Site after Esophageal Cancer Operation?

Background/Aims: Anastomotic stricture at the esophagus and the conduit anastomosis site after the surgical resection of esophageal cancer is relatively common. This study examined whether a hypertrophic scar or keloid formation at a surgical wound is related to an anastomotic stricture. Methods: From March 2007 to July 2017, 59 patients underwent curative surgery for esophageal cancer. In 38 patients, end-to-end anastomosis (EEA) of the esophagus and the conduit was performed using EEA 25 mm. A hypertrophic wound scar was defined when the width of the midline laparotomy wound scar exceeded 2 mm. The relationship between the hypertrophic scar and stricture and the other risk factors for anastomotic stricture in these 38 patients was analyzed. Results: Of the 38 patients, eight patients (21.1%) had an anastomotic stricture, and a hypertrophic skin scar was observed in 14 patients (36.8%). Univariate analysis revealed lower BMI and hypertrophic scars as risk factors (p=0.032, p=0.001 respectively). Multivariate analysis revealed a hypertrophic scar as an independent risk factor for an anastomotic stricture (p=0.010, OR=27.06, 95% CI 2.19-334.40). Conclusions: Hypertrophic wound scars can be a risk factor for anastomotic stricture after surgery for esophageal cancer. An earlier prediction of anastomotic stricture by detecting hypertrophic wound healing in patients undergoing esophagectomy may improve the patients' quality of life and surgical outcomes by earlier treatments.

Video-Assisted Thoracic Surgery Intrathoracic Anastomosis Technique.

The extracorporeal anastomosis technique for video-assisted thoracoscopic surgery (VATS) intrathoracic esophagogastric anastomosis is a convenient, easy technique to use in VATS esophagectomy. The surgeon can assess the viability and the status of the gastric conduit, and the introduction of a circular stapler can be easily done under direct vision extracorporeally, enabling easy and simple VATS intrathoracic anastomosis between the esophagus and the gastric conduit.