Video-assisted thoracoscopic surgery versus open lobectomy for primary non-small-cell lung cancer: a propensity-matched analysis of outcome from the European Society of Thoracic Surgeon database.

OBJECTIVES: Video-assisted thoracoscopic anatomical resections are increasingly used in Europe to manage primary lung cancer. The purpose of this study was to compare the outcome following thoracoscopic versus open lobectomy in case-matched groups of patients from the European Society of Thoracic Surgeon (ESTS) database. METHODS: All patients having lobectomy as the primary procedure via thoracoscopy [video-assisted thoracoscopic surgery (VATS)-L)] or thoracotomy (TH-L) were identified in the ESTS database (January 2007 to December 2013). A propensity score was constructed using several patients' baseline characteristics. The matching using the propensity score was responsible for the minimization of selection bias. A propensity score-matched analysis was performed to compare the incidence of postoperative major complications (according to the ESTS database definitions) and mortality at hospital discharge between the matched groups. After exclusions, 28 771 patients were identified: 26 050 having thoracotomy and 2721 having thoracoscopy. Propensity score yielded two well-matched groups of 2721 patients. Numeric variables were compared by Student's t-tests and categorical variables were compared by McNemar's tests. RESULTS: Compared with TH-L, VATS-L was associated with a lower incidence of total complications [n = 792 (29.1%) vs 863 (31.7%), P = 0.0357], major cardiopulmonary complications [n = 316 (15.9%) vs 435 (19.6%), P = 0.0094], atelectasis requiring bronchoscopy [n = 65 (2.4%) vs 150 (5.5%), P < 0.0001], initial ventilation >48 h [n = 18 (0.7%) vs 38 (1.4%), P = 0.0075] and wound infection [n = 6 (0.2%) vs 17 (0.6%), P = 0.0218]. There was no difference in the incidence of postoperative atrial fibrillation between the two groups (P = 0.14). Postoperative hospital stay was 2 days shorter in the VATS-L patients (mean: 7.8 vs 9.8 days; P = 0.0003). In terms of outcome at hospital discharge, there were 27 deaths in the VATS-L group (1%) versus 50 in the TH-L group (1.9%, P = 0.0201). CONCLUSIONS: Data from the ESTS database confirmed that lobectomy performed through VATS is associated with a lower incidence of complications compared with thoracotomy.

Treatment of malignant tracheoesophageal fistula.

This article addresses the treatment of malignant enterorespiratory fistulas, especially malignant tracheoesophageal fistula (mTEF). mTEF typically occurs after radiochemotherapy for advanced esophageal cancer. Life expectancy is measured in months after successful treatment, and in days to weeks with a persistent fistula. To stop repeated episodes of aspiration and septic pneumonia, single or double stenting of the esophagus and trachea with self-expandable coated stents is the established palliative treatment. The indications, techniques, and pitfalls of esophageal and tracheal stenting are described. Surgical interventions are justified only in very select cases, so this article focuses on interventional rather than surgical treatment.

Combined videothoracoscopic and videomediastinoscopic approach improves radicality of minimally invasive mediastinal lymphadenectomy for early stage lung carcinoma.

OBJECTIVES: To assess the feasibility and radicality of a combined thoracoscopic and mediastinoscopic approach to mediastinal lymphadenectomy compared to thoracoscopy only for minimally invasive management of early stage lung carcinoma. METHODS: Prospective observational study of patients undergoing anatomical thoracoscopic lung resection for lung carcinoma in our department in 2007. Mediastinal lymphadenectomy was performed either thoracoscopically (VATS group) or by a combination of video-assisted mediastinoscopic lymphadenectomy (VAMLA) and thoracoscopy (VAMLA+VATS group). Inclusion criteria for the study were: stage Ia on CT scan, no central tumor at bronchoscopy, and no contraindications against lobectomy or segmentectomy. RESULTS: Eighteen VAMLA+VATS and fourteen VATS patients were studied. For histology, pTNM stage, type of resection, semiquantitative assessment of the fissure and vascular dissection plane, conversions, blood loss, operation time, adverse events and drainage time, no differences between the two groups were observed. In the VATS group, there was a slight preponderance of women, and right-sided tumors. In the VAMLA+VATS group, both the number of dissected mediastinal lymph node stations (mean, 6.4 stations vs 3.6 stations) and the weight of the mediastinal specimen (median, 11.2 groups vs 5.5 groups), were significantly higher than in the VATS group (p<0.05). CONCLUSIONS: A combined approach by VATS and VAMLA improves radicality of minimally invasive mediastinal lymphadenectomy without increase in operation time, morbidity, and drainage time.

Lymph node metastases in a pedicled pericardial fat pad flap.

Routine use of pedicled thymus or pericardial fat pad flap for prophylactic bronchial stump coverage in neoadjuvant treated non-small cell lung cancer (NSCLC) is challenged by the observation of synchronous lymph node metastases to the flap. As a consequence, we suggest local muscle flaps, and histological examination of the pericardial fat pad.

Mediastinoscopic ultrasonography.

OBJECTIVES: Pretherapeutic T4 staging of centrally located lung cancer is crucial for the treatment strategy, but non-invasive imaging techniques are of low accuracy. We have developed the new imaging technique of intraoperative mediastinoscopic ultrasound (MUS) to predict technical resectability in tumors staged cT4 based on computed tomographic scanning. METHODS: Intraoperatively, a sterilizable fingertip ultrasound probe is introduced and guided through the video mediastinoscope with a modified grasper during staging mediastinoscopy. The position of the probe in front of the tracheobronchial tree and in direct contact with the vena cava and pulmonary artery reduces air interference. We reviewed the results for 24 patients with tumors staged cT4 between July 2002 and January 2006. For 18, the prediction of MUS concerning resectability could be compared with intraoperative findings at the time of thoracotomy. RESULTS: MUS visualizes all central vessels and their relation to the tumor with high accuracy. The pulmonary artery and pulmonary veins are displayed not only in their central parts but also in their interlobar branches. Of the 24 patients, 18 proceeded to thoracotomy after conclusive MUS and had tumors proved to be technically resectable in accordance with prediction by MUS. Comparison of cT (computed tomographic scan), cT (MUS) and pT revealed that T stages defined by MUS accurately predict pathologic T stages. CONCLUSION: MUS allows investigators to assess infiltration of the great vessels and the mediastinum, especially in right-sided tumors. MUS will supplement endoscopic ultrasound-guided fine needle aspiration for the right upper mediastinum in staging of centrally located tumors.

Video-assisted mediastinoscopic lymphadenectomy (VAMLA).

BACKGROUND: The development of a two-bladed spreadable videomediastinoscope in 1992 allowed increased exposure and bimanual dissection of mediastinal structures. Concurrent with technical progress in mediastinoscopy, neoadjuvant treatment of stage III lung cancer was introduced, and accuracy of pretreatment mediastinal staging became a topic at issue. In this setting, development of a videomediastinoscopic technique for complete mediastinal lymphadenectomy was the obvious thing to do. METHODS: Video-assisted mediastinoscopic lymphadenectomy (VAMLA) dissection is guided by anatomical landmarks, very similar to open lymphadenectomy. It includes en bloc resection of the right and central compartments and dissection and lymphadenectomy of the left-sided compartments. In a preliminary case-control study of 40 patients, VAMLA technique was standardized and evaluated against open lymphadenectomy. A second study investigated 130 patients with resectable lung cancer and radiographically normal mediastinum who underwent VAMLA and consecutive lung resection with mediastinal reexploration. RESULTS: VAMLA harvested significantly more nodes than open lymphadenectomy. With a mean duration of 54 minutes and a complication rate of 4.6%, VAMLA appeared applicable to clinical routine. We noted a sensitivity of 93.8%, a specificity of 100%, and a false-negative rate of 0.9%. CONCLUSIONS: In our experience, VAMLA is a feasible method of mediastinal staging. Its accuracy and radicality can equal open lymphadenectomy. However, VAMLA is minimally invasive and therefore pretherapeutically available. Its advantages might be of interest with neoadjuvant strategies, trials, involved field radiation, video-assisted thoroscopic lobectomy, and left-sided tumors.

Video-assisted mediastinoscopic lymphadenectomy.

Systematic mediastinal lymphadenectomy is usually done at thoracotomy together with lung resection. It is a prerequisite for accurate nodal staging and has an impact on survival. With the introduction of neoadjuvant therapy for stage III lung carcinoma, mediastinal staging before therapy became more important. Video-assisted mediastinoscopic lymphadenectomy (VAMLA) is a minimally invasive technique of systematic mediastinal dissection that equals radicality of open lymphadenectomy, and can be carried out before neoadjuvant treatment and independently from tumour resection. The VAMLA dissection technique follows the anatomical mediastinal structures, and includes the stations 7, 4R+L, 2R+L, and 3. Compared to open dissection, VAMLA harvested significantly more nodes. Dissection rates of 96%, 92%, 100% and 100% for the stations 2R, 4R, 7 and 4L were reported. In routine clinical use, the mean duration was 54 min, the complication rate was 4.6%. Accuracy data in 130 patients with radiologically normal mediastinum were: sensitivity 93.8%, specificity 100%, false negative rate 0.9%. VAMLA is an extremely accurate staging tool as well as definitive mediastinal surgery. Thus, VAMLA is valuable if neoadjuvant therapy is considered for minor mediastinal involvement, to avoid re-mediastinoscopies after induction treatment, to define the exact involved radiation field in functionally unresectable patients, for highly accurate pre-therapy staging in trials, and to improve mediastinal dissection with VATS lobectomy and left-sided tumours.

Lymphomas presenting as chest wall tumors.

Four cases of thoracic lymphoma mimicking chest wall tumors are presented. As resection is not the treatment of first choice in lymphomas, pretherapeutical evaluation of chest wall tumors should include a thoroughly staging and a biopsy for histopathological diagnosis. Chest wall destruction due to an anterior mediastinal mass, or a chest wall tumor associated with mediastinal lymph node enlargement, could be suspicious of thoracic lymphoma. Lymphoma with chest wall involvement mostly turns out to be Hodgkin's disease or large B-cell lymphoma. Stage and histopathological diagnosis have major impact on treatment and prognosis. Therapy is chemotherapy or chemo-radiation.

Systematic Video-Assisted Mediastinoscopic Lymphadenectomy (VAMLA).

Accurate mediastinal lymph node dissection during thoracotomy is mandatory for staging and for adjuvant therapy in lung cancer. Pre-therapeutic staging for neoadjuvant therapy or for video assisted thoracoscopic resection of lung cancer is achieved usually by CT-scan and mediastinoscopy. However, these methods do not reach the accuracy of open nodal dissection. Therefore we developed a technique of radical video-assisted mediastinoscopic lymphadenectomy (VAMLA). This study was designed to show that VAMLA is feasible and that radicality of lymphadenectomy is comparable to the open procedure.In a prospective study all VAMLA procedures were registered and followed up in a database. Specimens of VAMLA were analysed by a single pathologist. Lymph nodes were counted and compared to open lymphadenectomy. The weight of the dissected tissue was documented. In patients receiving tumour resection subsequently to VAMLA, radicality of the previous mediastinoscopic dissection was controlled during thoracotomy.37 patients underwent video-assisted mediastinoscopy from June 1999 to April 2000. Mean duration of anaesthesia was 84.6 (SD 35.8) minutes.In 7 patients radical lymphadenectomy was not intended because of bulky nodal disease or benign disease. The remaining 30 patients underwent complete systematic nodal dissection as VAMLA.18 patients received tumour resection subsequently (12 right- and 6 left-sided thoracotomies). These thoracotomies allowed open re-dissection of 12 paratracheal regions, 10 of which were found free of lymphatic tissue. In two patients, 1 and 2 left over paratracheal nodes were counted respectively. 10/18 re-dissected subcarinal regions were found to be radically dissected by VAMLA. In 6 patients one single node and in the remaining 2 cases 5 and 8 nodes were found, respectively. However these counts also included nodes from the ipsilateral main bronchus. None of these nodes was positive for tumour.Average weight of the tissue that was harvested by VAMLA was 10.1 g (2.2-23.7, SD 6.3). An average number of 20.5 (6-60, SD 12.5) nodes per patient were counted in the specimens. This is comparable to our historical data from open lymphadenectomy.One palsy of the recurrent nerve in a patient with extensive preparation of the nerve and resection of 11 left-sided enlarged nodes was the only severe complication in this series.VAMLA seems to accomplish mediastinal nodal dissection comparable to open lymphadenectomy and supports video assisted surgery for lung cancer. In neoadjuvant setting a correct mediastinal N-staging is achieved.

Radical video-assisted mediastinoscopic lymphadenectomy (VAMLA)--technique and first results.

Exact pretherapeutic lymph node staging of lung cancer is of special importance for selecting patients for neoadjuvant therapy or for video-assisted thoracoscopic resection. Staging is usually performed by computerized tomography scan and mediastinoscopy. However, these methods do not reach the accuracy of open nodal dissection. Therefore, we developed a technique of radical video-assisted mediastinoscopic lymphadenectomy (VAMLA). In a prospective study, all VAMLA procedures were documented. Lymph nodes were counted and compared to open lymphadenectomy. In 40/46 patients, radical paratracheal and subcarinal dissection was achieved by VAMLA. An average number of 20.7 (5-60, SD 11.1) nodes was gained. This is comparable to our data from open lymphadenectomy.