Long-Term Performance of Epicardial versus Transvenous Left Ventricular Leads for Cardiac Resynchronization Therapy.

Aims: to study the technical performance of epicardial left ventricular (LV) leads placed via video assisted thoracic surgery (VATS), compared to transvenously placed leads for cardiac resynchronization therapy (CRT). Methods: From 2001 until 2013, a total of 644 lead placement procedures were performed for CRT. In the case of unsuccessful transvenous LV lead placement, the patient received an epicardial LV lead. Study groups consist of 578 patients with a transvenous LV lead and 66 with an epicardial LV lead. The primary endpoint was LV-lead failure necessitating a replacement or deactivation. The secondary endpoint was energy consumption. Results: The mean follow up was 5.9 years (epicardial: 5.5 ± 3.1, transvenous: 5.9 ± 3.5). Transvenous leads failed significantly more frequently than epicardial leads with a total of 66 (11%) in the transvenous leads group vs. 2 (3%) in the epicardial lead group (p = 0.037). Lead energy consumption was not significantly different between groups. Conclusions: Epicardial lead placement is feasible, safe and shows excellent long-term performance compared to transvenous leads. Epicardial lead placement should be considered when primary transvenous lead placement fails or as a primary lead placement strategy in challenging cases.

Staged single-port thoracoscopic R2 sympathicotomy as a reproducible, safe and effective treatment option for debilitating severe facial blushing.

OBJECTIVES: Our goal was to investigate the safety, feasibility, success rate, complication rate and side effects of staged single-port thoracoscopic R2 sympathicotomy in the treatment of severe facial blushing. Facial blushing is considered a benign condition; however, severe facial blushing can have a major impact on quality of life. When nonsurgical options such as medication and psychological treatments offer no or insufficient relief, surgical treatment with thoracoscopic sympathicotomy should be considered. METHODS: All patients who underwent a staged thoracoscopic sympathicotomy at level R2 for severe facial blushing between January 2016 and September 2021 were included. Clinical and surgical data were prospectively collected and analysed. RESULTS: A total of 16 patients with low operative risk (American Society of Anesthesiologists class 1) were treated. No major perioperative complications were encountered. One patient experienced postoperative unilateral Horner's syndrome that resolved completely after 1 week. Two patients experienced compensatory hyperhidrosis. The success rate was 100%. One patient experienced a slight recurrence of blushing symptoms after 3 years that did not interfere with their quality of life. All patients were satisfied with the results and had no regrets of having undergone the procedure. CONCLUSIONS: Staged single-port thoracoscopic R2 sympathicotomy is a reproducible, safe and highly effective surgical treatment option with low compensatory hyperhidrosis rates and the potential to significantly improve quality of life in carefully selected patients suffering from severe facial blushing. We would like to increase awareness among healthcare professionals for debilitating facial blushing and suggest timely referral for surgical treatment.

Treatment of resistant Raynaud's phenomenon with single-port thoracoscopic sympathicotomy: One-year follow-up.

OBJECTIVE: Follow-up of patients with treatment-resistant Raynaud's phenomenon (RP) one-year after single-port thoracoscopic sympathicotomy (SPTS). METHODS: Eight patients (six males, two females, median age of 45 years) with treatment-resistant RP underwent left-sided SPTS at the third rib (R3), unilaterally. Questionnaires were taken, and number and duration of RP attacks were reported over a 2-week period. Perfusion was assessed with a cooling and recovery procedure at baseline and one year after SPTS. Furthermore, laser speckle contrast analysis, pulse wave velocity, heart rate variability and nailfold capillary microscopy were performed. RESULTS: One year after SPTS the duration of the attacks of was reduced with 1.9 h in the left hand versus 0.3 h in the right hand. Furthermore, three aspects of the questionnaire showed a significant improvement (role limitations due to physical health (p = 0.017), pain (p = 0.027) and physical functioning (p = 0.025)). The total area under the curve of the total cooling and recovery procedure of the left hand was larger one year after surgery (101 (75-140) at baseline versus 118 (95-190) one year post-operatively, p = 0.012), implying a better perfusion in the fingers. This was mainly due to the improvement during the recovery phase (21 (1-41) at baseline versus 38 (24-43) one year post-operatively, p = 0.028). CONCLUSION: One year after unilateral R3 SPTS the benefit with regard to the majority of outcome variables persisted, though some effects seem to attenuate. Long-term effects and long-term follow-up results will be investigated in an on-going study. CLINICAL TRIAL REGISTRATION NUMBER: NCT02680509.

Minimally Invasive Sympathicotomy for Palmar Hyperhidrosis and Facial Blushing: Current Status and the Hyperhidrosis Expert Center Approach.

Hyperhidrosis, the medical term for excessive sweating beyond physiological need, is a condition with serious emotional and social consequences for affected patients. Symptoms usually appear in focal areas such as the feet, hands, axillae and face. Non-surgical treatment options such as topical antiperspirants or systemic medications are usually offered as a first step of treatment, although these therapies are often ineffective, especially in severe and intolerable cases of hyperhidrosis. In the treatment algorithm for patients suffering from hyperhidrosis, surgical thoracoscopic sympathicotomy offers a permanent solution, which is particularly effective in the treatment of palmar hyperhidrosis and facial blushing. In this review, we describe the current status of thoracoscopic sympathicotomy for palmar hyperhidrosis and facial blushing. In addition, we share the specific treatment approach, technique and results of our Hyperhidrosis Expert Center. Last, we share recommendations to ensure an effective, reproducible and safe application of single-port thoracoscopic sympathicotomy for palmar hyperhidrosis and facial blushing, based on our extensive experience.

An approach to avoid phrenic nerve injury during epicardial VT ablation.

Elimination of ventricular tachycardia with epicardial substrate may be limited due to close proximity of the phrenic nerve. In this case report we illustrate the use of a decapolar catheter in a Foley catheter for deviating the prenic nerve to safely perform epicardial ventricular tachycardia ablation.

Bilateral one-stage single-port sympathicotomy in primary focal hyperhidrosis, a prospective cohort study: treat earlier?

BACKGROUND: Primary Focal Hyperhidrosis (PFH) has a detrimental effect on Quality of Life. Repetitive, non-curative symptomatic strategies dominate current treatment of PFH, in spite of the availability of an effective and permanent curative treatment like Endoscopic Thoracic Sympathectomy (ETS). Current surgical optimization may allow for a re-established position of sympathetic modulation in this treatment algorithm. We sought to evaluate the safety, effectiveness, and long-term results of a Bilateral One-stage Single-port Sympathicotomy (BOSS) procedure in PFH patients and to identify subgroups benefitting most. METHODS: Prospective analysis of 163 patients, 35 (21.5%) underwent Rib-3 (R3) BOSS for palmar PFH, 58 (35.6%) R3-R5 BOSS for axillary PFH and 70 (42.9%) R3-R5 BOSS for combined palmar/axillary PFH. Effectiveness was measured using Skindex-29 and the Hyperhidrosis Disease Severity Scale (HDSS). RESULTS: Overall Skindex-29-rating (46.5 ± 14.8 preoperatively vs 20.1 ± 20.6 postoperatively, p < 0.001), and HDSS score (3.71 ± 0.45 preoperatively vs 1.82 ± 0.86 postoperatively, p < 0.001) indicated a significant improvement in health-related quality of life after BOSS. R3 BOSS was superior to R3-R5 BOSS in terms of HDSS score (1.49 vs 1.91 respectively, p = 0.004) and in terms of severe compensatory hyperhidrosis, a frequently reported side-effect (17.1% vs 32.8% respectively, p < 0.001). No major complications occurred. CONCLUSIONS: BOSS is safe, effective, and offers a long-term curative solution in the treatment of PFH. Especially in the palmar PFH subgroup, R3 BOSS treatment results compare favorably to the treatment results of non-curative alternatives published in the current literature. Therefore, R3 BOSS should be offered to all patients with severe PFH, reporting insufficient benefit of treatment options such as oral and/or local agents.

Thoracoscopic sympathicotomy for the treatment of intolerable palmar and axillary hyperhidrosis in children is associated with high recurrence rates.

BACKGROUND: Treatment of palmar and axillary primary focal hyperhidrosis (PFH) in children up to 16 years using thoracoscopic sympathicotomy is supported by scarce evidence. Therefore, this study aimed to summarize the results of our standardized bilateral, one-stage, single-port sympathicotomy (BOSS) in children up to 16 years of age. METHODS: Consecutive children (n = 14) up to 16 years of age undergoing BOSS between October 2011 and June 2015 in our institution were included in this retrospective study. RESULTS: Recurrence of primary hyperhidrosis was noted in seven patients (50.0%), of whom five patients (35.7%) underwent reoperation. Reoperations were associated with placement of additional thoracoscopic ports (n = 1; 12.5%), intraoperative placement of pleural drains (n = 2; 25%), and prolonged air leak (n = 1; 12.5%). Despite the high recurrence and reoperation rates, overall patient satisfaction was high with a median satisfaction score of 7.5 (interquartile range of 1.75; range: 4-9). CONCLUSION: Although the overall patient satisfaction score in our cohort was good, BOSS for the treatment of intolerable palmar and axillary PFH in children up to 16 years of age is associated with a high recurrence and reoperation rate.

Treatment of resistant Raynaud's phenomenon with single-port thoracoscopic sympathicotomy: a novel minimally invasive endoscopic technique.

OBJECTIVE: To assess the minimally invasive single-port thoracoscopic sympathicotomy feasibility and efficacy in patients with treatment-resistant RP. METHODS: Single-port thoracoscopic sympathicotomy was performed unilaterally on the left side in eight patients with RP (six males, two females, with a median age of 45.2 years). Five patients had primary and three had secondary RP. Perfusion effects in the hands were assessed at baseline and after 1 month by using a cooling and recovery procedure, and by using laser speckle contrast analysis. Number and duration of RP attacks were reported over a 2-week period. RESULTS: Patient satisfaction was 100% after surgery. After surgery, a unilateral improvement in perfusion was observed in the left hand compared with the right hand, with cooling and recovery (P = 0.008) and with laser speckle contrast analysis (P = 0.023). In addition, the number and duration of the attacks in the left hand decreased compared with the right hand (both P = 0.028). No serious adverse events occurred in a follow-up period of at least 10 months. CONCLUSION: Single-port thoracoscopic sympathicotomy is feasible and can be effective in improving hand perfusion in patients with RP. However, long-term efficacy needs to be established. CLINICAL TRIAL REGISTRATION NUMBER: NCT02680509.

Analysis of Released Circulating Tumor Cells During Surgery for Non-Small Cell Lung Cancer.

PURPOSE: Tumor cells from patients with lung cancer are expelled from the primary tumor into the blood, but difficult to detect in the peripheral circulation. We studied the release of circulating tumor cells (CTCs) during surgery to test the hypothesis that CTC counts are influenced by hemodynamic changes (caused by surgical approach) and manipulation. EXPERIMENTAL DESIGN: Patients undergoing video-assisted thoracic surgery (VATS) or open surgery for (suspected) primary lung cancer were included. Blood samples were taken before surgery (T0) from the radial artery (RA), from both the RA and pulmonary vein (PV) when the PV was located (T1) and when either the pulmonary artery (T2 open) or the PV (T2 VATS) was dissected. The CTCs were enumerated using the CellSearch system. Single-cell whole-genome sequencing was performed on isolated CTCs for aneuploidy. RESULTS: CTCs were detected in 58 of 138 samples (42%) of 31 patients. CTCs were more often detected in the PV (70%) compared with the RA (22%, P < 0.01) and in higher counts (P < 0.01). After surgery, the RA but not the PV showed less often CTCs (P = 0.02). Type of surgery did not influence CTC release. Only six of 496 isolated CTCs showed aneuploidy, despite matched primary tumor tissue being aneuploid. Euploid so-called CTCs had a different morphology than aneuploid. CONCLUSIONS: CTCs defined by CellSearch were identified more often and in higher numbers in the PV compared with the RA, suggesting central clearance. The majority of cells in the PV were normal epithelial cells and outnumbered CTCs. Release of CTCs was not influenced by surgical approach.

Randomised phase 3 study of adjuvant chemotherapy with or without nadroparin in patients with completely resected non-small-cell lung cancer: the NVALT-8 study.

BACKGROUND: Retrospective studies suggest that low molecular weight heparin may delay the development of metastasis in patients with resected NSCLC. METHODS: Multicentre phase 3 study with patients with completely resected NSCLC who were randomised after surgery to receive chemotherapy with or without nadroparin. The main exclusion criteria were R1/2 and wedge/segmental resection. FDG-PET was required. The primary endpoint was recurrence-free survival (RFS). RESULTS: Among 235 registered patients, 202 were randomised (nadroparin: n = 100; control n = 102). Slow accrual enabled a decrease in the number of patients needed from 600 to 202, providing 80% power to compare RFS with 94 events (α = 0.05; 2-sided). There were no differences in bleeding events between the two groups. The median RFS was 65.2 months (95% CI, 36-NA) in the nadroparin arm and 37.7 months (95% CI, 22.7-NA) in the control arm (HR 0.77 (95% CI, 0.53-1.13, P = 0.19). FDG-PET SUVmax ≥10 predicted a greater likelihood of recurrence in the first year (HR 0.48, 95% CI 0.22-0.9, P = 0.05). CONCLUSIONS: Adjuvant nadroparin did not improve RFS in patients with resected NSCLC. In this study, a high SUVmax predicted a greater likelihood of recurrence in the first year. CLINICAL TRIAL REGISTRATION: Netherlands Trial registry: NTR1250/1217.

Hybrid bronchoscopic and surgical resection of endotracheal angiomatoid fibrous histiocytoma.

BACKGROUND: Angiomatoid fibrous histiocytoma (AFH) is a soft-tissue tumor that generally affects the extremities of children and young adults. AFH overlaps with primary pulmonary myxoid sarcoma (PPMS) and can occur in unusual locations. CASE PRESENTATION: We present a case of a 22-year-old female with AFH in the distal trachea. In addition to describing the challenge in making a correct diagnosis of AFH, we describe the first case of successful hybrid bronchoscopic and surgical resection of endotracheal AFH. A staged removal procedure was required to quickly secure the airway, allowing a lower-risk elective distal tracheal resection through a cervical approach for complete resection. A more conventional, but more invasive, more painful and cosmetically less satisfying thoracotomy was avoided. CONCLUSIONS: A distal tracheal resection for AFH can be safely performed in young adults through a cervical approach with excellent follow-up results.

Axillary Chest Wall Hibernoma With Intrathoracic Extension Presenting as Thoracic Outlet Syndrome.

Hibernomas are rare benign soft tissue tumors derived from brown fat. This case report describes an axillary hibernoma with intrathoracic extension, presenting as a thoracic outlet syndrome. A multimodality imaging series illustrates the classic radiologic features of hibernoma as well as its highly unusual pattern of growth. The latter resulted in TOS with vascular displacement and osseous remodeling, features that are generally absent in lipomatous masses. Detailed preoperative imaging allowed to plan a single surgical procedure in which an extrathoracic axillary approach was combined with intrathoracic video-assisted thoracic surgery.

Surgical experience and patient-related restrictions predict the adequacy of cervical mediastinoscopy in non-small cell lung carcinoma lymph node staging.

BACKGROUND: Until recently, cervical mediastinoscopy was considered to be the reference standard for mediastinal staging for Non-Small Cell Lung Carcinoma (NSCLC). In the absence of metastases, mediastinal lymph node involvement is the most important prognostic factor and as such it determines therapeutic strategies. In this study we evaluated the adequacy of cervical mediastinoscopy in NSCLC lymph node staging in a large university hospital over more than a decade. In addition, we determined the influence of: (1) surgeon's experience (2) video-assisted mediastinoscopy (VAM) and (3) patient-related restrictions (PRR) on the adequacy of lymph node sampling. METHODS: Between January 2001 and December 2014, 225 patients underwent cervical mediastinoscopy for lymph node staging. Surgical and histological data were reviewed. Thirty-day follow-up was available for all patients. Lymph node sampling was considered adequate when stations 4 L, 4R and 7 were sampled (ESTS guidelines). A surgeon was considered to be experienced when he or she performed at least 40 procedures during the study-period. RESULTS: Intraoperative mortality was 0%. Thirty-day mortality was 1.3%. Overall adequacy of lymph node sampling was 56%. Univariate and multivariate logistic regression analyses of lymph node sampling adequacy revealed level of surgical experience and PRR as independent predictors of lymph node sampling adequacy. CONCLUSIONS: Surgical experience and PRR independently predict the adequacy of cervical mediastinoscopy in NSCLC lymph node staging. VAM does not independently predict the adequacy of mediastinal lymph node sampling. In light of the expected further decline in mediastinoscopy numbers, we recommend to limit this procedure exclusively to the armamentarium of the experienced thoracic surgeon.

Totally Thoracoscopic Pulmonary Vein Isolation: A Simplified Technique.

Since the introduction of thoracoscopic ablation for atrial fibrillation (AF), the field of minimally invasive AF treatment has evolved toward an established treatment option for AF, with an overall 2-year antiarrhythmic drug free success rate of 77%. Complications are usually minor, and the incidence of bleeding needing conversion to sternotomy or (mini-)thoracotomy varies between 0% and 1.6%. Bleeding is often related to encircling the pulmonary veins, which is a blind maneuver that has to be done without direct camera vision. We propose here a modified surgical technique to simplify the procedure, shorten the operating time, and lower the risk of complications.

Long-term Outcome of Surgery or Stereotactic Radiotherapy for Lung Oligometastases.

Local treatment for pulmonary oligometastases (one to five lesions) using metastasectomy or stereotactic ablative radiotherapy (SABR) was investigated in a cohort that received multidisciplinary tumor board-based treatment decisions. The first choice of treatment was surgery; SABR was recommended in cases of adverse clinical factors. Propensity score-adjusted and unadjusted overall survival was the primary end point; local control and time to failure of a local-only treatment strategy were also analyzed. With a minimum follow-up time of 5.8 years, the 5-year overall survival rate was 41% for surgery (n = 68) and 45% for SABR (n = 42). Again not different for the two modalities, 40% of patients were free from failure of a local-only treatment strategy, and 20% were free from any progression at 5 years. The 5-year local control rate was 83% for SABR and 81% for surgery. Despite treatment selection clearly disadvantaging SABR against surgery, even unadjusted outcome was not better when pulmonary oligometastases were surgically removed rather than irradiated.

CT-guided percutaneous hookwire localization increases the efficacy and safety of VATS for pulmonary nodules.

BACKGROUND AND OBJECTIVES: The diagnosis of pulmonary nodules of unknown origin is challenging, and such nodules are not always suitable for transthoracic needle biopsy. With the advent of video assisted thoracic surgery (VATS) and CT-guided percutaneous hookwire localization (CT-PHL) we hypothesized that the combination of these two procedures will improve early diagnosis. METHODS: Selection criteria were a nodule not well approachable with fine needle biopsy and the therapeutic consequences of a diagnosis as assessed by the multidisciplinary oncology board. Efficacy and safety of the combination of CT-PHL prior to VATS was studied in terms of, histological diagnosis, complete resection rate, complications, conversion rate to thoracotomy, and duration of procedures. RESULTS: A total of 150 pulmonary nodules were located and resected in 150 patients. The median nodule diameter was 9 mm (range 4-24) and located within 30 mm of the pleural surface (median 7, range 0-29). The resection was complete in 96%, and in 100% a definitive histological diagnosis was obtained. Complications requiring intervention during the CT-procedure occurred in 11 patients (7.3%). Complications of VATS consisted of major complications (2.0%) and minor complications (4.0%). The 30 Day mortality was 1.4% and in hospital mortality 0.7%. Conversion to thoracotomy occurred in 4.7% patients. Median CT-localization time was 25 min (range 5-72), median VATS time was 49 min (range 14-169). CONCLUSIONS: CT-PHL is a very efficient and safe procedure prior to VATS for pulmonary nodules and allows in 96% radical resection with a diagnostic accuracy of 100%.