Robotic Assisted-Bronchoscopy With Cone-Beam CT ICG Dye Marking for Lung Nodule Localization: Experience Beyond USA.

Electromagnetic navigation bronchoscopy (ENB)-guided indocyanine green (ICG) fluorescence dye marking of subsolid, small and deep lung lesions facilitates subsequent minimally invasive lung resection surgeries. The novel robotic-assisted bronchoscopy (RAB) platform can improve the accuracy and yield of ENB biopsy, and the use of RAB has been extended to ICG dye marking. However, performing this procedure in the hybrid operating room guided by cone-beam CT (CBCT) with immediate proceed to lung surgery has not been well reported. We studied the safety, feasibility and clinical outcomes of 5 consecutive cases performed between December 2021 and March 2022. Navigation success was 100% while localization success using ICG was 80%. The benefits and pitfalls of robotic bronchoscopy procedures, and challenges of combining with hybrid operating room CBCT were discussed in detail. In conclusion, robotic-assisted bronchoscopy is a promising and useful tool for ICG fluorescence dye-marking, providing accurate navigation, superior maneuverability and improved ergonomics compared to conventional bronchoscopy-guided ENB procedures. Learning curve is reasonable, but meticulous system set up to incorporate the robotic system into existing CBCT platform may be required to ensure a smooth procedure.

Uniportal video-assisted thoracic surgery for major lung resection is associated with less immunochemokine disturbances than multiportal approach.

Multiportal video-assisted thoracic surgery (VATS) for major lung resection causes less immunochemokine production compared to thoracotomy. Whether uniportal VATS is similarly associated with lower early postoperative circulating levels of immunochemokines compared to multiportal VATS have not been studied. Selected patients who received uniportal or multiportal VATS major lung resection were recruited. Blood samples were collected preoperatively and on postoperative days 1 and 3 for enzyme linked immunosorbent assay of serum levels of Tissue Inhibitor of Metalloproteinase (TIMP)-1, Insulin Growth Factor Binding Protein (IGFBP)-3, and Matrix Metalloproteinase (MMP)-9. A linear mixed-effects models were used to analyze the effects of uniportal VATS on the postoperative circulating chemokine levels. From March 2014 to April 2017, 68 consecutive patients consented for the prospective study and received major lung resection by either uniportal VATS (N = 29) or multiportal VATS (N = 39) were identified. Uniportal VATS major lung resection was associated with lower post-operative levels of TIMP-1 and MMP-9 compared to multiportal VATS after controlling for the effects of the corresponding baseline level and the time of follow-up measurement. No difference was observed for the level of IGFBP-3. Less immunochemokine disturbances was observed after uniportal VATS major lung resection compared to multiportal VATS.

Hybrid Theater Facilitates Lung-Preserving Multimodal Treatment for Multiple Pulmonary Metastases.

A patient with a history of hepatocellular carcinoma was found to have multiple pulmonary metastases. Staged treatments were combined into a single operation session in the hybrid theater, encompassing bronchoscopic microwave ablation of central right upper lobe lesions and uniportal surgical wedge resections of peripheral right middle lobe lesions. All lung metastases were successfully treated with adequate margin clearance. Microwave ablation under the guidance of electromagnetic navigation bronchoscopy in the hybrid theater is a novel contribution to the multimodal operative management of multiple pulmonary neoplasms. It is a unique choice for patients with multilobar, subcentimeter metastases, and with concerns about lung function preservation.

Use of custom made 3-dimensional printed surgical guide for manubrio-sternal resection of solitary breast cancer metastasis: case report.

A 44-year-old lady with solitary 4.4-cm metastasis to the manubrium from a previously resected invasive ductal carcinoma of the left breast underwent manubrio-sternal resection. We describe our unique approach of using 3-dimensional (3D)-computed tomography (CT) image segmentation planning for reconstructing desirable resection boundaries, design of ideal superficial and deep surgical resection guides, and followed by 3D printing of guides using autoclavable thermoplastic for use during surgery. The surgical guides over the ribs and sternum rapidly and accurately define resection lines intraoperatively, achieve good surgical margins, and could reduce resection and reconstruction related morbidity for performing complex surgical resection of the chest wall. The patient was discharged 2 weeks postoperatively and remained free from local recurrence on CT scan 1-year after resection.

Management of acute type A intramural hematoma: upfront surgery or individualized approach? A retrospective analysis and meta-analysis.

BACKGROUND: Management of acute type A intramural hematoma (IMH) is a controversial topic. In our study, we aim to analyze the survival outcomes in local patients with acute type A IMH and a meta-analysis on survival in type A IMH treated medically versus surgically was performed. METHODS: From 2014 to 2019, 65 patients with acute type A IMH were selected for analysis. Primary outcome of interest was 1 year all cause survival. The rate of aortic-related events in the medical group was evaluated. PubMed and Embase were searched for meta-analysis. RESULTS: The mean age of our cohort was 61.7±9.7 years. Of the 65 patients, 40% had emergency operation. Overall 1-year survival was 96.9%. The 1-year survival was 94.9% for the medical group. 46.2% of the medical group required aortic intervention at a mean duration of 191±168 days. Maximal aortic diameter (MAD) ≥45 mm was predictive of aortic-related events in the medical group (OR: 7.0; 95% CI, 1.7-29.4; P=0.008). For the meta-analysis, 21 studies were identified, and 900 patients were included. Emergent surgery was associated with improved survival in type A IMH (OR: 0.76; 95% CI, 0.29-1.97, P=0.58; I2=27%). CONCLUSIONS: The 1-year survival after type A IMH was promising, regardless of approach. The conservative-first approach was found to be safe & feasible, and upfront surgery remained the management of choice in general. Patients with MAD ≥45 mm was associated with subsequent aortic intervention in the medical-first group.

10-year outcomes post coronary artery bypass grafting in Asian patients with ischemic cardiomyopathy: a comprehensive analysis of survival and cardiac performance.

BACKGROUND: Coronary artery bypass grafting (CABG) is the standard of care for patients with ischemic cardiomyopathy (ICM). Despite recent evidence supporting the role of CABG, long term outcomes for patients with ICM remain poor and 10-year results post CABG in ICM patients are under-reported, especially among Asians. Uncertainty on whether CABG improves cardiac performance and survival in the long term remains. In this study, we aim to analyze 10-year results concerning cardiac performance and survival post CABG in Asian patients with left ventricular ejection fraction (LVEF) ≤35% and predominant heart failure symptoms, and identify perioperative risk factors affecting long term survival and cardiac function. METHODS: Thirty-six patients with LVEF <35% who had CABG performed between the year 2006-2009 were selected from local hospital records for retrospective analysis. Outcomes of interest included post-operative cardiac symptoms, LVEF & 10-year all-cause and cardiac-event free survival. Survival analysis was performed using Kaplan Meier analysis, and predictive factors were identified with log- rank test and logistic regression analysis. RESULTS: The mean age of the cohort was 62.9±9.9 years. Operative mortality within 30 days was 5.6%. The 10-year all-cause mortality rate was 55.6%. The mean duration of survival was 105.9±8.3 months. Of the patients who did not survive till 10 years, 65.0% died of cardiac-related causes, with non-ST elevation myocardial infarction being the commonest cause. CABG improved LVEF (24.9% to 32.2%; P<0.001) and 66.7% of patients remained with impaired LVEF ≤35% post CABG. Post op NYHA class 3-4 symptoms (OR: 6.3; P=0.012) was the only predictive factor for 10 year all-cause mortality and post op LVEF improvement ≥5% (OR: 5.8; 95% CI, 1.1-29.9; P=0.036) was associated with improvement in NYHA class. Completeness of revascularization and viability of myocardium were not predictive of survival or changes in LVEF or NYHA class. CONCLUSIONS: The 10-year survival rates of Asian patients with ICM were similarly disappointing as its counterparts in the west. A majority of patients still suffered from cardiac-event related deaths. Post CABG NYHA class was found to be important in determining success and adequacy of treatment in patients with ICM and improvement in LVEF ≥5% was predictive of improvement of symptoms. Neither completeness of revascularization or presence of myocardial viability had any impact on survival in our patient cohort.

The comparison of electromagnetic with virtual bronchoscopic navigation accuracy at hybrid operating room in patient with sternal wires.

We describe a case of a 63-year-old lady with an incidental small right upper lobe ground glass opacity (GGO) lesion, who had history of open-heart surgery with bypass grafts for coronary artery disease. Video-assisted thoracic surgery (VATS) excisional biopsy with pre-operative localization was planned. Localization by percutaneous approach is challenging due to position of GGO shielded by both the scapular and ribs. Electromagnetic navigation accuracy may be affected by steel sternal wires but its effect has not been reported on literature. Both virtual and electromagnetic navigation bronchoscopy platforms were used with real-time cone-beam CT confirmation in the hybrid operating room to perform dye marking. Both navigation methods successfully marked the GGO for lung resection. Our case demonstrated that the accuracy of electromagnetic navigation in the presence of steel sternal wire is satisfactory for dye marking and the use of intra-operative cone-beam CT in hybrid operating room is invaluable for the success of navigational bronchoscopy.

Surgical access trauma following minimally invasive thoracic surgery.

Surgical access trauma has important detrimental implications for immunological status, organ function and clinical recovery. Thoracic surgery has rapidly evolved through the decades, with the advantages of minimally invasive surgery becoming more and more apparent. The clinical benefits of enhanced recovery after video-assisted thoracoscopic surgery (VATS) may be, at least in part, the result of better-preserved cellular immunity and cytokine profile, attenuated stress hormone release and improved preservation of pulmonary and shoulder function. Parameters of postoperative pain, chest drain duration, hospital stay and even long-term survival are also indirect reflections of the advantages of reduced access trauma. With innovations of surgical instruments, optical devices and operative platform, uniportal VATS, robotic thoracic surgery and non-intubated anaesthesia represent the latest frontiers in minimizing trauma from surgical access.

Application of Cerebral Protection System in Open Mitral Replacement with Extensive Calcified Left Atrial Thrombus.

Neurological complications remain a major burden in cardiac surgery, despite various intraoperative measures attempting to reduce its occurrence. Advancement of percutaneous approach in valve replacement has brought focus to the use of cerebral protection system (CPS). We reported a novel application of percutaneous CPS in open heart surgery for a patient with an extensive calcified left atrial thrombus to reduce risk of embolic stroke. Although, there is no evidence to advocate routine use of CPS in all open cardiac surgical patients, we believe it is a technically feasible and probably safe approach for neurological protection in high-risk patients.

Devising the guidelines: the techniques of pulmonary nodule localization in uniportal video-assisted thoracic surgery-hybrid operating room in the future.

Pulmonary nodules beneath the pleura can be hard to visualize or palpate, especially during the uniportal thoracoscopic surgery. Conventionally, thoracic surgeons would use adjuvant modalities to localize the lesion preoperatively, of which computed tomography-guided hookwire implantation has been adopted most widely due to its feasibility and high success rate. However, procedure-associated complications such as pneumothorax and wire dislodgement can cause patient discomfort or localization failure. Occasionally more healthy tissue is resected than needed to guarantee the lesion is removed and with an adequate margin. A thoracotomy is necessary for specific scenario. With the development of imaging technology, it is now possible to replace the traditional workflow carried out in the radiology suite by centralizing the hookwire placement and uniportal minimally-invasive pulmonary resection inside the hybrid theater which equipped with advanced imaging devices. Theoretically, the advanced intra-operative imaging-guided techniques help to precisely locate and resection pulmonary lesion in a potentially tissue-sparing and quick paradigm.

Evidence for surgical resections in oligometastatic lung cancer.

With the advent of advanced technology in performing diagnostics for lung cancer, an incremental increase in the number of patients with oligometastatic disease is currently being managed with intent to cure. As treatment of selected types of patients with oligometastasis show favourable outcomes, the past notion of managing these patients palliatively is fast becoming extinct. Selection of patients based on established criterion together with surgical metastasectomy combined with multiple ablative techniques with or without systemic chemotherapy offers a reasonable rate of treatment success which provides basis for treating such patient population. As more evidence becomes available to suggest that the oligometastatic state of lung cancer does exist, and are potentially curable, a better understanding of the condition is necessary for clinicians, and surgeons to provide optimal care. In this review we present some of the clinical basis which may cause a paradigm shift in management of patients with oligometastatic lung disease.

Video-assisted thoracic surgery for tiny pulmonary nodules with real-time image guidance in the hybrid theatre: the initial experience.

BACKGROUND: Localization of tiny lung nodules during video-assisted thoracic surgery (VATS) resection can be challenging. Real-time image-guided hookwire localization of the target lesions immediately followed by VATS lung resection in the hybrid operating theatre setting is an emerging approach. METHODS: We retrospectively reviewed our experience with this form of hybrid operating theatre image-guided VATS (iVATS) for lung nodules 1.5 cm or less, or soft in consistency. These patients were compared with matched cohort who received standard hookwire localization in the radiology department. RESULTS: From February 2014 to September 2017, lung nodules of indeterminate nature in 32 consecutive patients with mean size 9.1±4.6 mm underwent iVATS. All were accurately localized by hookwire and successfully resected. There was no postoperative mortality. There were 21 (66%) malignant lesions, all with adequate resection margins. Major outcomes were compared with a comparable cohort of 8 patients who received standard hookwire localization and VATS (sVATS) performed at separate departments operation suites. sVATS groups has significantly longer 'at-risk' period for pneumothorax progression and hookwire dislodgement (109.5±57.1 minutes for sVATS vs. 41.1±15.0 minutes for iVATS, P=0.011), and a higher risk of hookwire dislodgement (25% for sVATS vs. 0 for iVATS, P=0.036). CONCLUSIONS: Real-time image-guided hookwire localization in the hybrid theatre setting is an effective facilitator of VATS resection of tiny lung nodules in selected patients, and may have added advantages in terms of safety and localization accuracy over the conventional sVATS method.

Multi-dimensional printing in thoracic surgery: current and future applications.

Three-dimensional (3D) printing has been gaining much attention in the medical field in recent years. At present, 3D printing most commonly contributes in pre-operative surgical planning of complicated surgery. It is also utilized for producing personalized prosthesis, well demonstrated by the customized rib cage, vertebral body models and customized airway splints. With on-going research and development, it will likely play an increasingly important role across the surgical fields. This article reviews current application of 3D printing in thoracic surgery and also provides a brief overview on the extended and updated use of 3D printing in bioprinting and 4D printing.

Massive pericardial effusion after Nuss procedure: to drain or not to drain?

A 11-year-old boy presented with refractory fever and dyspnoea after Nuss procedure. Massive pericardial effusion was detected on computer tomography scan performed under corticosteroid cover for his asthmatic history. With rapid clinical improvement following corticosteroids, a clinical diagnosis of post-pericardiotomy syndrome (PPS) was made. Following a course of oral prednisolone, serial blood test and echocardiogram showed gradual resolution of inflammation and pericardial effusion. This rarely-reported case serves as a poignant reminder to PPS after Nuss procedure as a cause of febrile massive pericardial effusion. Early therapeutic trial of corticosteroids may prevent clinical deterioration, and have invasive pericardial drainage avoided.

Endovascular Fenestration for Distal Aortic Sealing After Frozen Elephant Trunk With Thoraflex.

We describe a case of total arch replacement with frozen elephant trunk for chronic type B aortic dissecting aneurysm, which resulted in inadvertent landing of the frozen elephant trunk into the false lumen. A radiofrequency puncture system-assisted controlled endovascular fenestration of the dissection flap was performed at the upper abdominal aorta and subsequent thoracic endovascular stenting, successfully redirecting the blood flow from the false to the true lumen. Our case illustrated a possible way to seal distal reentry in chronic type B aortic dissection.

Laser resection of pulmonary nodule via uniportal thoracoscopic surgery.

Uniportal video-assisted thoracic surgery (VATS) lung wedge resection usually requires three devices, thoracoscope, lung retracting instrument and an endo-stapler cutter to perform the procedure. With advances in miniaturization of the thoracoscope and lung retracting instruments, a major limitation to operating through a smaller uniportal incision has become the endo-stapler. We describe the surgical technique for uniportal VATS laser lung resection which uses a much narrower laser catheter device to replace the endo-stapler for resection. The new approach to limited lung resection can potentially reduce instrument fencing and the uniportal incision wound size, while achieving satisfactory hemostasis and pneumostasis.