Comparison between use of a pleural drainage system with flutter valve and a conventional water-seal drainage system after lung resection: a randomized prospective study.

BACKGROUND: There is still a debate regarding the most appropriate pleural collector model to ensure a short hospital stay and minimum complications. OBJECTIVES: To study aimed to compare the time of air leak, time to drain removal, and length of hospital stay between a standard water-seal drainage system and a pleural collector system with a unidirectional flutter valve and rigid chamber. DESIGN AND SETTING: A randomized prospective clinical trial was conducted at a high-complexity hospital in São Paulo, Brazil. METHODS: Sixty-three patients who underwent open or video-assisted thoracoscopic lung wedge resection or lobectomy were randomized into two groups, according to the drainage system used: the control group (WS), which used a conventional water-seal pleural collector, and the study group (V), which used a flutter valve device (Sinapi® Model XL1000®). Variables related to the drainage system, time of air leak, time to drain removal, and time spent in hospital were compared between the groups. RESULTS: Most patients (63%) had lung cancer. No differences were observed between the groups in the time of air leak or time spent hospitalized. The time to drain removal was slightly shorter in the V group; however, the difference was not statistically significant. Seven patients presented with surgery-related complications: five and two in the WS and V groups, respectively. CONCLUSIONS: Air leak, time to drain removal, and time spent in the hospital were similar between the groups. The system used in the V group resulted in no adverse events and was safe. REGISTRATION: RBR-85qq6jc (https://ensaiosclinicos.gov.br/rg/RBR-85qq6jc).

Endobronchial Valve Treatment Does Not Cause Significant Nickel Deposition in Lung Tissue.

Bronchoscopic lung volume reduction using endobronchial valves (EBVs) is a treatment option for patients with severe emphysema. These EBVs are made out of a nitinol mesh covered by a silicone layer. Nitinol is an alloy of nickel and titanium and is commonly used in implantable medical devices because of its biocompatibility and memory-shape properties. However, there are some concerns that nickel ions can be released from nitinol-containing devices which might cause adverse health effects, especially in patients with a known nickel hypersensitivity. In vitro, it was found that EBV release significant amounts of nickel in the first hours. Our aim was to assess the nickel concentration in lung tissue from a patient who previously underwent EBV treatment but, due to treatment failure, underwent lung volume reduction surgery and to compare this to a reference sample. We found no significant difference in the median nickel concentration between the EBV-treated patient and the non-EBV-treated patient (0.270 vs. 0.328 µg/g, respectively, p = 0.693) and these concentrations were also comparable to previously published nickel concentrations in human lung tissue samples not having any medically implanted devices in the lung. Our results suggest that there is no significant long-term nickel deposition in lung tissue after EBV treatment.

Interventional bronchoscopy for chronic obstructive pulmonary disease: more than a pipe dream.

Endoscopic lung volume reduction (ELVR) is recognised in both national and international expert guidelines as one of the few additive treatments to benefit patients with advanced chronic obstructive pulmonary disease (COPD) who are otherwise receiving optimal medical and supportive care. Despite these recommendations and a growing evidence base, these procedures are not widely offered across Australia and New Zealand, and general practitioner and physician awareness of this therapy can be improved. ELVR aims to mitigate the impact of hyperinflation and gas trapping on dyspnoea and exercise intolerance in COPD. Effective ELVR is of proven benefit in improving symptoms, quality of life, lung function and survival. Several endoscopic techniques to achieve ELVR have been developed, with endobronchial valve placement to collapse a single lobe being the most widely studied and commonly practised. This review describes the physiological rationale underpinning lung volume reduction, highlights the challenges of patient selection, and provides an overview of the evidence for current and investigational endoscopic interventions for COPD.

Preoperative computed tomographic-guided percutaneous coil localization of pulmonary nodules: 184 Cases in Single-center.

OBJECTIVES: The aim of this study was to evaluate the feasibility, accuracy, and safety of computed tomographic (CT)-guided coil localization before video-assisted thoracoscopic surgery. METHODS: One hundred and eighty-four consecutive patients with 200 pulmonary nodules who underwent CT-guided percutaneous coil localization before thoracoscopic surgery were retrospectively analyzed in this study. Success rate for localization, complication rates, CT findings, and pathological results of the lesions, as well as the data related to surgery were all recorded and analyzed. RESULTS: All 184 patients with 200 lesions completed localization and resection. The success rate of the coil localization on lesion baseline was 99.0% (198/200) and 98.9% (182/184) on patient baseline. The number of wedge resection, segmental resection, and lobectomy were 179 (89.5%), 19 (9.5%), and 2 (1.0%), respectively. The malignancy rates in a lesion-based analysis were 83.5% (91.1% in ground-glass nodules, 91.4% in part-solid nodules, and 37.9% in solid nodules). No serious complications occurred in all localization procedures. CONCLUSION: Preoperative CT-guided percutaneous coil localization is a safe and effective method to facilitate high success rates for both wedge and segmental resection for peripheral pulmonary nodules.

[Application of Two Ultrafine Chest Tube for Drainage after
Pulmonary Uniportal Video-assisted Thoracoscopic Surgery].

BACKGROUND: At present, an ultrafine chest tube combined with a traditional thick tube were often used after pulmonary uniportal video-assisted thoracoscopic surgery (U-VATS). However, the thick tube was often placed in the incision, which increased the risk of poor wound healing and postoperative pain. The aim of this study is to investigate the feasibility and safety of using two ultrafine chest tubes (10 F pigtail tube) for drainage after pulmonary U-VATS. METHODS: The medical records of patients who underwent pulmonary U-VATS during June 2018 and June 2020 in the department of cardiothoracic surgery of the second affiliated hospital of Soochow university were retrospectively reviewed to compare two different drainage strategies, receiving two 10 F pigtail tubes as chest tube (group A) or one 10 F pigtail tube as lower chest tube combined with one 24 F tube as upper chest tube (group B). RESULTS: 106 patients in group A receiving two 10 F pigtail tubes during June 2019 and June 2020 and 183 patients in group B receiving one 10 F pigtail tube as lower chest tube combined with one 24 F tube as upper chest tube during June 2018 and June 2019 were included. There was no significant difference between two groups in terms of the postoperative thoracic drainage (mL) (1st: 199.54±126.56 vs 203.59±139.32, P=0.84; 2nd: 340.30±205.47 vs 349.74±230.92, P=0.76; 3rd: 435.19±311.51 vs 451.37±317.03, P=0.70; 4th: 492.58±377.33 vs 512.57±382.94, P=0.69; Total: 604.57±547.24 vs 614.64±546.08, P=0.88), drainage time (d) (upper chest tube: 2.54±2.20 vs 3.40±2.07, P=0.21; lower chest tube: (2.24±2.43 vs 3.82±2.12, P=0.10), postoperative hospital stays (d) (6.87±3.17 vs 7.06±3.21, P=0.63), poor wound healing (0 vs 3.28%, P=0.09), replacement of lower chest tube (0.94% vs 2.19%, P=0.66) and the VAS1 (3.00±0.24 vs 2.99±0.15, P=0.63). Notably, there were significant differences between two groups in terms of the VAS2 (2.28±0.63 vs 2.92±0.59, P<0.01) and VAS3 (2.50±1.58 vs 2.79±1.53, P=0.02), as well as the frequency of using additional analgesics (25.47% vs 38.25%, P=0.03) and replacement of the upper chest tube (0 vs 4.37%, P=0.03). CONCLUSIONS: It's feasible and safe to use two 10 F pigtail tubes for drainage after pulmonary U-VATS, which can achieve less postoperative pain and lower frequency of replacement of the upper chest tube on some specific patients.

Endobronchial Coil System versus Standard-of-Care Medical Management in the Treatment of Subjects with Severe Emphysema.

BACKGROUND: Bronchoscopic lung volume reduction using endobronchial coils is a new treatment for patients with severe emphysema. To date, the benefits have been modest and have been suggested to be much larger in patients with severe hyperinflation and nonmulti-comorbidity. OBJECTIVE: We aimed to evaluate the efficacy and safety of endobronchial coil treatment in a randomized multicenter clinical trial using optimized patient selection. METHOD: Patients with severe emphysema on HRCT scan with severe hyperinflation (residual volume [RV] ≥200% predicted and RV/total lung capacity [TLC] >55%) were randomized to coil treatment or control. Primary outcome measures were differences in the forced expiratory volume in 1 s (FEV1) and St George's Respiratory Questionnaire (SGRQ) total score at 6 months. RESULTS: Due to premature study termination, a total of 120 patients (age 63 ± 7 years, FEV1 29 ± 7% predicted, RV 251 ± 41% predicted, RV/TLC 67 ± 6%, and SGRQ 58 ± 13 points), instead of 210 patients, were randomized. At study termination, 91 patients (57 coil and 34 control) had 6-month results available. Analyses showed significantly greater improvements in favor of the coil group. The increase in FEV1 was greater in the coil group than that in the control group by + 10.3 [+4.7 to +16.0] % and in SGRQ by -10.6 [-15.9 to -5.4] points. At study termination, there were 5 (6.8%) deaths in the coil cohort reported. CONCLUSION: Despite early study termination, coil treatment compared to control results in a significant improvement in the lung function and quality of life benefits for up to 6 months in patients with emphysema and severe hyperinflation. These improvements were of clinical importance but were associated with a higher likelihood of serious adverse events.

Identifying Responders and Exploring Mechanisms of Action of the Endobronchial Coil Treatment for Emphysema.

BACKGROUND: So far, 3 randomized controlled trials have shown that the endobronchial treatment using coils is safe and effective. However, the more exact underlying mechanism of the treatment and best predictors of response are unknown. OBJECTIVES: The aim of the study was to gain more knowledge about the underlying physiological mechanism of the lung volume reduction coil treatment and to identify potential predictors of response to this treatment. METHODS: This was a prospective nonrandomized single-center study which included patients who were bilaterally treated with coils. Patients underwent an extensive number of physical tests at baseline and 3 months after treatment. RESULTS: Twenty-four patients (29% male, mean age 62 years, forced expiratory volume in 1 s [FEV1] 26% pred, residual volume (RV) 231% pred) were included. Three months after treatment, significant improvements were found in spirometry, static hyperinflation, air trapping, airway resistance, treated lobe RV and treated lobes air trapping measured on CT scan, exercise capacity, and quality of life. The change in RV and airway resistance was significantly associated with a change in FEV1, forced vital capacity, air trapping, maximal expiratory pressure, dynamic compliance, and dynamic hyperinflation. Predictors of treatment response at baseline were a higher RV, larger air trapping, higher emphysema score in the treated lobes, and a lower physical activity level. CONCLUSIONS: Our results confirm that emphysema patients benefit from endobronchial coil treatment. The primary mechanism of action is decreasing static hyperinflation with improvement of airway resistance which consequently changes dynamic lung mechanics. However, the right patient population needs to be selected for the treatment to be beneficial which should include patients with severe lung hyperinflation, severe air trapping, and significant emphysema in target lobes.

Resorbable self-locking device for canine lung lobectomy: A clinical and experimental study.

OBJECTIVE: To test the feasibility of a resorbable self-locking device for sealing of lung tissue in lung lobectomy in experimental dogs and dogs with pulmonary mass, and to study its resorption with CT. STUDY DESIGN: Experimental study and clinical case series. ANIMALS: Five beagles in the experimental group; six canine patients with a pulmonary mass in the clinical group. METHODS: In both groups, an intercostal incision into thorax was performed. A resorbable self-locking device, LigaTie, was applied at the hilum of left cranial lobe in the experimental group and the affected lobe in the clinical group. Each lobe was removed by cutting the tissue just distal to the device. Video-assisted thoracic surgery was used in the experimental group; postoperative diagnostic imaging was repeated monthly until the device was not apparent on CT. RESULTS: Application of LigaTie was feasible for lung lobectomy in all dogs. The device enabled en bloc ligation of the hilum of the affected lobe including the pulmonary arteries and veins and lobular bronchus. No air leakage from the resection stump was observed in any dog. Trace of the device on CT images gradually decreased and was undetectable at 4 months postoperatively in experimental dogs. CONCLUSION: This study suggested that the resorbable self-locking device may be used for sealing of airways in complete lung lobectomy. CLINICAL RELEVANCE: The resorbable self-locking device is suggested to be useful for canine lung lobectomy and may facilitate thoracoscopic lung lobectomy. Further investigations on its clinical application in small animal surgery are warranted.

Comparison of Multiple Diagnostic Tests to Measure Dynamic Hyperinflation in Patients with Severe Emphysema Treated with Endobronchial Coils.

PURPOSE: For this study, we aimed to compare dynamic hyperinflation measured by cardiopulmonary exercise testing (CPET), a six-minute walking test (6-MWT), and a manually paced tachypnea test (MPT) in patients with severe emphysema who were treated with endobronchial coils. Additionally, we investigated whether dynamic hyperinflation changed after treatment with endobronchial coils. METHODS: Dynamic hyperinflation was measured with CPET, 6-MWT, and an MPT in 29 patients before and after coil treatment. RESULTS: There was no significant change in dynamic hyperinflation after treatment with coils. Comparison of CPET and MPT showed a strong association (rho 0.660, p < 0.001) and a moderate agreement (BA-plot, 202 ml difference in favor of MPT). There was only a moderate association of the 6-MWT with CPET (rho 0.361, p 0.024). CONCLUSION: MPT can be a suitable alternative to CPET to measure dynamic hyperinflation in severe emphysema but may overestimate dynamic hyperinflation possibly due to a higher breathing frequency.

Utility of the powered stapler for radical pulmonary resection: a propensity score-matched analysis.

PURPOSE: Anatomical pulmonary resection, such as lobectomy, is a common procedure. Staplers play an important role in dividing an incomplete interlobular fissure, especially in thoracoscopic surgery. This study evaluates the effectiveness of a powered stapler for reducing the need for intraoperative fibrin glue and the incidence of air leakage after radical pulmonary resection. METHODS: The subjects of this retrospective study were 478 patients who underwent radical pulmonary resection. Propensity score analysis generated two matched pairs of 177 patients treated using powered and manual staplers, respectively. RESULTS: The need for fibrin glue intraoperatively during radical pulmonary resection was significantly less in the powered-stapler group (47.5%) than in the manual-stapler group (58.8%, p = 0.033). The incidence of postoperative air leakage following radical pulmonary resection was also significantly lower in the powered-stapler group (2.8%) than in the manual-stapler group (10.7%, p = 0.003). Logistic regression analysis identified use of the powered stapler as a factor independently associated with both non-use of fibrin glue intraoperatively (odds ratio, 0.63; p = 0.040) and no postoperative air leakage (odds ratio, 0.26; p = 0.010). CONCLUSION: Using a powered stapler to divide the incomplete interlobular fissure decreased the need for additional intraoperative management using fibrin glue and reduced postoperative air leakage in radical pulmonary resection.

Single-Port vs Conventional Three-Port Video-Assisted Thoracoscopic Pulmonary Wedge Resection: Comparison of Postoperative Pain and Surgical Costs.

PURPOSE: Single-port video-assisted thoracoscopic (VATS) pulmonary wedge resection was reported in 2004. We started using single-port VATS (SPVATS) pulmonary wedge resection in 2017 and compared results between conventional three-port VATS (VATS group) and SPVATS (SPVATS group). METHODS: We identified 145 consecutive patients with VATS group and SPVATS group. Perioperative characteristics including pain and the number of stapler cartridges used were examined as the surgical outcomes, retrospectively. RESULTS: In all, 66 cases of SPVATS group and 79 cases of VATS group pulmonary wedge resection were compared. The rate of epidural anesthesia (p <0.0001) was significantly higher and operative time (p <0.0001) was significantly longer with VATS group than with SPVATS group. The number of stapler cartridges used, duration of drain insertion, and rate of postoperative complications did not differ significantly between groups. Average numerical rating scale (NRS) score on postoperative day 1 and postoperative day 7 (p <0.0001 each), maximum NRS score on postoperative day 7 (p = 0.0082) and amount of 25 mg tramadol (p = 0.0062) were significantly lower in SPVAS group than in VATS group. CONCLUSION: Our results suggest that SPVATS pulmonary wedge resection offers better pain control and cost-effectiveness than three-port VATS pulmonary wedge resection. These findings should contribute to the body of evidence for SPVATS.

Troubleshooting in thoracoscopic anatomical lung resection for lung cancer.

Video-assisted thoracoscopic surgery (VATS) anatomical lung resection (ALR) has been gaining popularity in the treatment of lung cancer in line with remarkable advances in both equipment and technique. The development and refinement of its technique have allowed thoracic surgeons to perform a wide variety of challenging and complex procedures in a minimally invasive fashion. Careful and meticulous preparation may shift in the future with the increasing sophistication and capabilities of VATS ALR. Moreover, constant awareness and a structured plan of the procedure are imperative to reducing or preventing complications. Intraoperative major complications during VATS ALR are infrequent, but can have catastrophic consequences. The decision to continue with VATS should take into consideration the surgeon's skill level and ease with the approach and the relative potential benefit against the risk to the patient. We conducted this study to investigate the possible problems during VATS ALR and identify how to solve them based on the previous literature and our institutional data sampling.

Efficacy of Xenon Light With Indocyanine Green for Intersegmental Visibility in Thoracoscopic Segmentectomy.

BACKGROUND: We previously reported useful methods that can be implemented to identify intersegmental boundary lines (IBLs) by using an intravenous indocyanine green (ICG) fluorescence imaging system (ICG-FS) during a thoracoscopic anatomical segmentectomy (TAS). The aim of this study was to evaluate the recently released third-generation ICG-FS that features an emphasizing xenon-light source for IBL identification. METHODS: We prospectively studied cases involving 106 consecutive patients who underwent TAS. Intraoperatively, we used the third-generation ICG-FS, the conventional ICG methods (CIM) emphasizing xenon-light (CIM-X), and the spectra-A method (SAM) emphasizing xenon-light (SAM-X), for IBL identification. Furthermore, 16 of the 106 patients (15%) could be simultaneously evaluated using old-generation ICG-FSs, CIM, and SAM. All images were completely quantified for illuminance and for three colors, red, green, and blue. RESULTS: IBLs were successfully identified in all the patients (100%) with no adverse events. The SAM-X significantly increased the illuminance, especially in the resecting segments, compared to the CIM (39.0 versus 22.2, P < 0.01) and SAM (39.0 versus 29.3, P < 0.01), with enhanced red color compared to the CIM (33.1 versus 21.9, P < 0.01) and SAM (33.1 versus 14.0, P < 0.01). Furthermore, the SAM-X significantly increased the illuminance contrast compared to the CIM-X (34.1 versus 15.3, P < 0.01). CONCLUSIONS: The present study suggests that the SAM-X potentially provided images with the highest visibility and colorfulness compared to the older generation ICG-FSs or CIM-X. Secure IBL identification can be more easily and safely performed using the SAM-X.

Endobronchial Valves for the Treatment of Advanced Emphysema.

Bronchoscopic lung volume reduction with one-way endobronchial valves is a guideline treatment option for patients with advanced emphysema that is supported by extensive scientific data. Patients limited by severe hyperinflation, with a suitable emphysema treatment target lobe and with absence of collateral ventilation, are the responders to this treatment. Detailed patient selection, a professional treatment performance, and dedicated follow up of the valve treatment, including management of complications, are key ingredients to success. This treatment does not stand alone; it especially requires extensive knowledge of COPD for which the most appropriate treatment is discussed in a multidisciplinary approach. We discuss the endobronchial valve treatment for emphysema and provide a guideline for patient selection, treatment guidance, and practice tools, based on our own experience and literature.

Powered articulation by the SigniaTM stapling system for stapling position adjustments: optimizing safe surgical margins in thoracoscopic sublobar resection.

Accumulation of experience and advances in techniques and instruments have enabled surgeons to perform video-assisted thoracic surgery (VATS) safely for sublobar resection, including segmentectomy and wedge resection. A key to successful VATS sublobar resection is to have adequate resection margins and the appropriate use of articulated surgical staplers is essential for this purpose. The SigniaTM stapling system (Covidien Japan, Tokyo) has been used extensively in the fields of thoracic surgery. Its features include high maneuverability with fully powered articulation, rotation, clamping, and firing, which the surgeon can control with one hand. We introduce the "sliding technique" using the SigniaTM system, which allows for adjustment of the resection lines of the pulmonary parenchyma to optimize safe surgical margins with minimal stapler movement, and without repetitively moving the stapler in and out of the pleural cavity, during VATS sublobar resection.

Endobronchial valve vs coil for lung volume reduction in emphysema: results from a tertiary care centre in Turkey.

BACKGROUND: Bronchoscopic lung volume reduction (BLVR) by either the endobronchial valve (EBV) or coil (EBC) procedure is recommended for severe emphysematous patients. BLVR applications generally help healthy lung areas ventilate more comfortably by reducing the hyperinflation and improving the contraction capacity of diaphragm. OBJECTIVES: Compare our experience with valve and coil BLVR devices. DESIGN: Retrospective. SETTING: Single tertiary care centre. PATIENTS AND METHODS: Demographic data, vital signs, pulmonary function tests (PFTs), the six-minute walking test (6MWT), vital signs, arterial blood gases and complications were recorded. MAIN OUTCOME MEASURES: Change in PFTs and completion of the 6MWT. SAMPLE SIZE: 60 Turkish men with a diagnosis of chronic pulmonary lung disease. RESULTS: Clinical and demographic characteristics were similar in patients who underwent EBV and EBC. Thirty (96.8%) EBV patients and 27 (93.1%) of the EBC patients were able to properly complete the PFT before the procedures, but all complied after the procedures. Significant improvement in PFTs were achieved after the procedure and there were no statistically significant differences in post-procedure performance. For the 6MWT, the completion rate improved from 15 (48.4%) to 19 (61.3%) patients in the EBV patients (P=.125) and from 19 (65.5%) to 21 (72.4%) patients in the EBC patients (P=.500). There was no significant difference in completion rates for the walking test for either group (median 32 meters in EBV patients and 37 meters in EBC patients; P=.652). Vital signs and arterial blood gases were similar in the two groups. The rates of complications were similar in both groups. CONCLUSION: Endobronchial valves and coils are safe and effective methods for BLVR for patients with severe emphysema. LIMITATIONS: Relatively small sample, retrospective design, single-centre retrospective study. CONFLICT OF INTEREST: None.

En bloc lymphadenectomy of the right thorax via a uniportal thoracoscopic approach.

The uniportal approach to an en bloc complete lymphadenectomy is significantly more challenging than a multiportal approach or a thoracotomy because of the limited angulation available to the surgeon and the limited number of usable surgical instruments. Because of these limitations, it is very important to completely master the specific surgical steps in order to achieve success. Additionally, it is important to make sure the lymph nodes remain structurally intact, taking care not to cause damage by grasping them during lymphadenectomy, in order to prevent the dissemination of malignant cells into the thorax. In this video tutorial, we demonstrate our surgical technique for lymphadenectomy in the right upper (2R/4R) or lower (7/8/9) mediastinal zone, which is suitable for a uniportal approach, and explain the nuances of performing it.

Video-assisted left lower lobectomy with intrapericardial pulmonary vein isolation.

The thoracoscopic approach to lobectomy is now the gold standard in cases of pulmonary malignancies because it is associated with a significant reduction in both  postoperative hospital stay and pain. Even in cases of complex resection, as in the case reported here, the procedure can be performed safely after careful pre-operative planning.  This video tutorial describes our technique for the intrapericardial isolation of the left inferior pulmonary vein in a patient affected by a left lower lobe metastasis from a colonic carcinoma.  The lesion was retracting the inferior vein to such an extent that an intrapericardial approach was required in order to obtain a radical resection. The operation was carried out using a 3-port technique to allow for safe and unhindered manipulation of the hilar structures and the parenchyma. The pericardial sac was easily opened and the feasibility of the procedure was readily confirmed.  The patient made an uneventful recovery; specifically, we did not record any arrhythmia or hemodynamic instability. She was discharged home on the 4th postoperative day.

Bronchoscopic lung volume reduction using coil therapy: complications and management.

Nonsurgical approaches involving bronchoscopic lung volume reduction (BLVR) have been developed in the last decade. One of these, the BLVR coil procedure, is a treatment option for patients with homogeneous and heterogeneous end-stage emphysema and a forced expiratory volume in 1 second (FEV1) of 15-45%. This treatment decreases hyperinflation and improves lung function, the quality of life, and exercise capacity. It is very important to prepare patients for treatment, premedications, anesthesia applications, intubation, post-procedure follow-up and treatments. Further, it has been observed that various complications can develop during and after the procedure. Generally, the observed and reported complications are chronic obstructive pulmonary disease (COPD) exacerbation, chest pain, mild bleeding, pneumonia, pneumothorax, and respiratory failure. Rarely, aspergillus cavitation (coil-related aspergilloma), bronchopleural fistula and penetration into the pleural space, bronchiectasis, coil-associated inflammatory response and opacities, and hiccups are observed. Common complications are usually mild or moderate, while the rare ones can be life-threatening (except hiccup), so early diagnosis and treatment are necessary. However, patients treated with BLVR have lower mortality rates than untreated patients with similar morbidity. Based on the findings of this review, we can estimate that premedication one day before and just before the procedure may reduce potential complications. Some medical centers apply and recommend 30-day macrolide treatment after the procedure. New generation supraglottic devices may be preferred to avoid complications due to endotracheal intubation. Moreover, further research is needed to identify risk factors, prevent potential complications, and a common consensus is required for routine preventive treatment.

Uniportal thoracoscopic lateral and posterior basal (S9+10) segmentectomy.

Among uncommon pulmonary segmentectomies, the lateral and posterior basal (S9+10) segmentectomy is one of the most challenging because it requires exposure and recognition of common basal pulmonary vein branches located deep in lung parenchyma. In order to achieve an optimal thoracoscopic S9+10 via a uniportal approach the surgeon must first select the most suitable uniportal method, because the angulation of surgical instruments is limited in this minimally invasive approach and this makes it especially difficult to perform.  In this video tutorial, we demonstrate our technique for a uniportal thoracoscopic S9+10 segmentectomy; we discuss our successful results, and explain the nuances of performing the procedure.