Outside the Cage Subcostal RATS Lobectomy: Technical Aspects and Results of the First Series of a Novel Approach to Pulmonary Lobectomy.

OBJECTIVE: The goal of minimally invasive surgery is to reduce trauma to patients and improve their postoperative outcomes. In this context, the utilization of robot-assisted thoracic surgery (RATS) in the treatment of lung cancer has increased worldwide. The feasibility of single-incision major pulmonary resections by RATS was recently reported, with the objective of minimizing the surgical trauma of the traditional multiportal RATS approach. However, both techniques require intercostal incisions, potentially causing immediate and chronic pain resulting from intercostal nerve injury. To reduce postoperative pain resulting from intercostal approaches, we developed a nonintercostal, outside the thoracic cage (OTC) approach for RATS lobectomy, avoiding intercostal instrumentation. This report aims to describe the results of the first reported series of OTC subcostal RATS lobectomies. METHODS: Retrospective analysis of a series of the first consecutive patients operated on using the novel OTC subcostal RATS lobectomy technique. RESULTS: Between August and December 2022, a total of 10 consecutive cases were analyzed. The median age was 63 (55 to 84) years, the mean body mass index was 29 (24 to 45) kg/m2, and the median American Society of Anesthesiologists score was III (II to IV). No serious adverse events were observed, and there was no conversion of the surgical technique. The mean operative time was 132.6 (98 to 223) min. The median length of stay was 2 days. No pain-related complications, readmissions, or 30-day mortality were observed. CONCLUSIONS: This series demonstrates that OTC RATS lobectomy is feasible and safe. A phase I clinical trial is currently underway to prospectively assess the safety of the technique as well as its clinical relevance.

Clinicodemographic characteristics and prognostic role of myasthenia gravis in thymoma: Experience from a Saudi population.

OBJECTIVES: The objectives of the study were to determine the clinicodemographic characteristics and the prognostic role of myasthenia gravis (MG) in thymoma. METHODS: The records of patients who underwent surgical resection of thymoma at King Faisal Specialist Hospital and Research Center in the past 23 years were reviewed. Seventy thymoma patients were finally included and were then categorized based on MG status into the MG group (39 patients) and the non-MG group (31 patients). Collected data included patients' demographic characteristics, tumor characteristics, and postoperative clinical outcomes. All analyses were conducted using SPSS. The comparison between both groups was tested using the Student t-test and Chi-square test for continuous and categorical variables, respectively. A P = 0.05 or less indicated statistical significance. RESULTS: Patients' age ranged from 11 to 76 years, and female predominance was observed (55.7%). Compared to the non-MG group, no difference in patients' gender was observed (P = 0.058); however, MG patients had a younger age (39.30 vs. 48.77, P = 0.0095). No difference was noted between both groups based on the World Health Organization classification (P = 0.398), but MG patients tended to present with less-advanced tumors based on the TNM classification (P = 0.039) and lower stage based on the MASAOKA staging system (P = 0.017). No significant change in tumor size (P = 0.077), resectability (P = 0.507), and adjuvant therapy (P = 0.075) were observed. MG was not significantly associated with postoperative complications, morbidity, or mortality. However, it exhibited a prognostic protective role in terms of lower recurrence (2.56% vs. 35.48%, P = 0.0001) and longer survival duration (18.62 vs. 10.21 years, P < 0.001) as compared to non-MG patients. CONCLUSIONS: MG occurrence in thymoma patients is more likely to occur at a younger age, higher TNM classification, and advanced MASAOKA stage. Although no significant association was noted between MG and complications and mortality, MG exhibited a protective role in thymoma by providing a lower recurrence rate and longer survival duration.

Pulmonary metastasis of head and neck cancer: surgical removal outcomes from a tertiary care center.

PURPOSE: There has been no clear data on the effectiveness of pulmonary metastasectomy on several original cancers, including head and neck. We aim to collect data about the metastasectomies performed in our center for eligible patients and elaborate more on predictors and prognosis. METHODS: A retrospective analysis of 56 patients who underwent metastasectomy from head and neck cancers at our facility between January 2000 and January 2016 (16 years). Statistical analysis was performed based on gender, disease-free interval (DFI), location of the original tumor, and histological subtypes to assess their effect and relevance to the prognosis and disease recurrence. RESULTS: Twenty-nine males and 27 females had lung metastasis from head and neck. The primary lesions of the lung metastasis were more often found in the thyroid (34%), followed by nasopharynx (32%). As for histology, the most common one was papillary cancer (34%), followed by squamous cell carcinomas (29%). The DFI was more than 2 years in 32 patients (57%). The survival rates were 79.5% at 3 years and 71.7% at 5 years. In the univariate analysis, histology was the only independent prognostic factor (p = 0.05). On the other hand, age (p = 0.6), DFI (p = 0.24), and site of the primary tumor (p = .06) showed no effect on the prognosis of head and neck cancers metastasizing to the lungs. CONCLUSION: Pulmonary metastasectomy for lesions originating from head and neck provides good long-term survival. Histological subtype was the only statistically significant prognostic factor.

Surgical treatment of pulmonary metastasis: report from a tertiary care center.

Objective This retrospective analysis aimed to determine the factors influencing prognosis in adult patients who presented to our thoracic surgery service with lung metastases and were eligible for pulmonary metastasectomy. Methods We retrospectively reviewed the data of 296 patients who underwent resection of 575 lung metastases from January 2000 to January 2016. Univariate and multivariate analyses were performed based on age, sex, histology of the primary tumor, disease-free interval, number and size of metastases. Results Sixty-eight (22.97%) patients developed lung metastases from bone sarcoma, 68 (22.97%) from soft-tissue sarcoma, 56 (18.9%) from head and neck cancers, 46 (15.5%) from colorectal cancer, and 58 (19.6%) from other epithelial tumors. The mean size of the lung nodules was 2.48 cm. Open surgical resection was performed in 217 (73.3%) patients. After a mean follow-up of 43 months, 120 (40.7%) patients had died or were lost to follow-up. Univariate analysis confirmed that patients with bone cancer, soft tissue sarcoma, or colorectal carcinoma had a worse prognosis ( p = 0.0003). Moreover, those with a disease-free interval >24 months had a better 5-year survival ( p = 0.0001). The number and size of metastases, age, and sex had no effect on prognosis. The actuarial survival after complete metastasectomy was 71.6% (95% confidence interval: 66-75) at 2 years and 59.3% (95% confidence interval: 56-64) at 5 years. Conclusions Pulmonary metastasectomy provides good long-term survival. The type of primary tumor and disease-free interval are independent prognostic factors for survival.

Missed pulmonary metastasis.

OBJECTIVE: To assess the rate of detection of pulmonary nodules on preoperative computed tomography, based on intraoperative palpation of non-imaged pulmonary nodules, in patients who underwent thoracotomy for metastasectomy with bimanual lung palpation. METHODS: A retrospective study carried out on all cases of pulmonary metastasectomy performed in King Faisal Specialist Hospital and Research Center over a 10-year period (2001-2011). The number of nodules detected on preoperative computed tomography by a radiologist was compared with the number of nodules identified on pathology. Resected pulmonary nodules were classified to benign or malignant. Secondary outcomes were operative approach and primary malignancy. RESULTS: 215 metastasectomies were performed by thoracotomy. The incidence of nodules that were not imaged preoperatively was 36% (41% of mesenchymal tumors, 28% of epithelial tumors). CONCLUSION: Metastasectomy by an open approach, which affords bimanual palpation of the entire lung, discovered ipsilateral non-imaged malignant pulmonary metastases in 36% of cases (41% of mesenchymal tumors).