Systemic Inflammation Differences in Brain-vs. Circulatory-Dead Donors: Impact on Lung Transplant Recipients.

Brain death triggers a systemic inflammatory response. Whether systemic inflammation is different in lung donors after brain- (DBD) or circulatory-death (DCD) is unknown, but this may potentially increase the incidence of primary graft dysfunction (PGD) after lung transplantation. We compared the plasma levels of interleukin (IL)-6, IL-8, IL-10 and TNF-α in BDB and DCD and their respective recipients, as well as their relationship with PGD and mortality after LT. A prospective, observational, multicenter, comparative, cohort-nested study that included 40 DBD and 40 DCD lung donors matched and their respective recipients. Relevant clinical information and blood samples were collected before/during lung retrieval in donors and before/during/after (24, 48 and 72 h) LT in recipients. Incidence of PGD and short-term mortality after LT was recorded. Plasma levels of all determined cytokines were numerically higher in DBD than in DCD donors and reached statistical significance for IL-6, IL-10 and IL-8. In recipients with PGD the donor's plasma levels of TNF-α were higher. The post-operative mortality rate was very low and similar in both groups. DBD is associated with higher systemic inflammation than DCD donors, and higher TNF-α plasma levels in donors are associated with a higher incidence of PGD.

Management of intra-operative major bleeding during single-port video-assisted thoracoscopic anatomic resection: two-center experience.

BACKGROUND: Our objective is to report on two centers' experience of intra-operative management of major vascular injury during single-port video-assisted thoracoscopic (SPVATS) anatomic resections, including bleeding control techniques, incidence, results, and risk factor analysis. METHODS: Consecutive patients (n = 442) who received SPVATS anatomic lung resections in two centers were enrolled. The different clinical parameters studied included age, previous thoracic surgery, obesity (BMI > 30), tumor location, neoadjuvant therapy, and pleural symphysis. In addition, peri-operative outcomes were compared between the groups, with or without vessel injury. RESULTS: There were no intra-operative deaths in our study. Overall major bleeding incidence was 4.5%, whereby 70% of major bleeding episodes could be managed with SPVATS techniques. In order to determine risk factors possibly related to intra-operative bleeding, we used case control matching to homogenize our study population. After case control matching, pleural symphysis was significantly related in the univariate (p = 0.005, Odds ratio 4.415, 95% CI 1.424-13.685) and multivariate analysis (p = 0.006, Odds ratio 4.926, 95% CI 1.577-15.384). Operative time (p < 0.001), blood loss (p < 0.001), and post-operative hospital stay (p = 0.012) were longer in patients with major vascular injury. There were no differences in 30-day mortality and 90-day morbidity. CONCLUSIONS: In summary, major intra-operative bleeding episodes during SPVATS anatomic lung resections are acceptable and most such bleeding episodes can be safely managed with SPVATS techniques.

Novice training: The time course for developing competence in single port video-assisted thoracoscopic lobectomy.

The competency in video-assisted thoracoscopic (VATS) lobectomy is expected to be achieved after surgeons practiced 30 to 50 cases according to previous reports. Does single port video-assisted thoracoscopic (SPVATS) lobectomy have a steeper learning curve and being harder to perform correctly, leading to long development times and high defect rates?From January, 2014 to February, 2017, 8 individual surgeons (3 were novices, 5 were pioneers in SPVATS surgery) submitted their cases chronologically to evaluate the learning curve of SPVATS lobectomy. Operating time (OT) was set as a surrogate marker for surgical competency. Postoperative outcomes and OT between the 2 groups were compared using propensity score matching (1:1 nearest neighbor). The learning curve for OT was evaluated using the cumulative sum (CUSUM) method.In the entire study cohort, a total of 356 cases were included (93 in junior consultant group [group A], 263 in senior consultant group [group B]). There were no significant differences between the 2 groups in operative time, conversion rate, postoperative complication rate, 30 and 90 days mortality rate. After propensity-score matching (86 pairs), operative time was longer in group A (214.33 ±â€Š62.18 vs 183.62 ±â€Š61.25 minutes, P = .001). Two-year overall survival rate was similar among 2 groups (P = .409). Competency was reached after junior surgeon completed 30th case of SPVATS lobectomy.SPVATS lobectomy is safe for the novice surgeon who wants to adopt this new surgical approach under well-developed training program. The learning curves for competence in SPVATS lobectomy are similar to VATS lobectomy in our series.

Predictive factors of postoperative complications in single-port video-assisted thoracoscopic anatomical resection: Two center experience.

The purpose of this study was to identify the risk factors for adverse events during single-port video-assisted thoracoscopic (SPVATS) anatomical resections.We retrospectively reviewed patients who had undergone SPVATS anatomic resections between January 2014 and February 2017 in Coruña University Hospital's Minimally Invasive Thoracic Surgery Unit (CHUAC, Spain) and Chang Gung Memorial Hospital (CGMH, Taiwan). Four hundred forty-two patients (male: 306, female: 136) were enrolled in this study. Logistic regression analysis was performed on variables for postoperative complications.Postoperative complications with a 30-day mortality occurred in 94 patients (21.3%) and with a 90-day mortality in 3 patients (0.7%) while the major complication rate was 3.9%. Prolonged air leak (PAL > 5 days) was the most common complication and came by postoperative arrhythmia. Logistic regression indicated that pleural symphysis (odds ratio (OR), 1.91; 95% confidence interval (CI), 1.14-3.18; P = .014), computed tomography (CT) pulmonary emphysema (OR, 2.63; 95% CI, 1.41-4.76; P = .002), well-developed pulmonary CT fissure line (OR, 0.49; 95% CI, 0.29-0.84; P = .009), and tumor size (≥3 cm) (OR, 2.15; 95% CI, 1.30-3.57; P = .003) were predictors of postoperative complications.Our preliminary results revealed that SPVATS anatomic resection achieves acceptable 30- and 90-day surgery related mortality (0.7%) and major complications rate (3.9%). Prolonged Air leak (PAL > 5 days) was the most common postoperative complication. Pleural symphysis, pulmonary emphysema, well-developed pulmonary CT fissure line and tumor size (≥3 cm) were predictors of adverse events during SPVATS anatomic resection.

Mid-term survival outcome of single-port video-assisted thoracoscopic anatomical lung resection: a two-centre experience.

OBJECTIVES: Single-port video-assisted thoracoscopic surgery (SPVATS) anatomical resection has been shown to be a feasible technique for lung cancer patients. Whether SPVATS has equivalent or better oncological outcomes for lung cancer patients remains controversial. The purpose of this study was to evaluate the perioperative and mid-term survival outcomes of SPVATS in 2 different medical centres. METHODS: We retrospectively reviewed patients who underwent SPVATS anatomical resections between January 2014 and February 2017 in Coruña University Hospital's Minimally Invasive Thoracic Surgery Unit (Spain) and Chang Gung Memorial Hospital (Taiwan). Survival outcomes were assessed by pathological stage according to the American Joint Committee on Cancer (AJCC) 7th and 8th classifications. RESULTS: In total, 307 patients were enrolled in this study. Mean drainage days and postoperative hospital stay were 3.90 ± 2.98 and 5.03 ± 3.34 days. The overall 30-day mortality, 90-day morbidity and mortality rate were 0.7%, 20.1% and 0.7%, respectively. The 2-year disease-free survival and 2-year overall survival of the cohort were 80.6% and 93.4% for 1A, 68.8% and 84.6% for 1B, 51.0% and 66.7% for 2A, 21.6% and 61.1% for 2B, 47.6% and 58.5% for 3A, respectively, following the AJCC 7th classification. By the AJCC 8th classification, these were 92.3% and 100% for 1A1, 73.7% and 91.4% for 1A2, 75.2% and 93.4% for 1A3, 62.1% and 85.9% for 1B, 55.6% and 72.7% for 2A, 47.1% and 64.2% for 2B and 42.1% and 60.3% for 3A. CONCLUSIONS: Our preliminary results revealed that SPVATS anatomical resection achieves acceptable 2-year survival outcomes for early-stage lung cancer and is consistent with AJCC 8th staging system 2-year survival data. For advanced stage non-small-cell lung cancer patients, further evaluation is warranted.

Uniportal VATS lobectomy.

Uniportal Video-Assisted Thoracic Surgery (uniportal VATS) lobectomy represents the last evolution of minimally invasive techniques for the surgical treatment of lung cancer. Uniportal VATS was developed from two-ports approach, with two main advantages: only one intercostal space is damaged and the direct view to the target tissue. Improvements in camera systems, instruments and stapler technology have facilitated this development. The operative technique is well defined for the different lobectomies and for the mediastinal lymphadenectomy. The parallel instrumentation achieved during the single port approach mimics the inside maneuvers performed during open surgery, together with the direct view facilitates the dissection and division of the hilar structures and the fissure. This makes possible the direct transition from open surgery to uniportal VATS. Uniportal VATS is feasible and reproducible. This is why its use is spreading in many centers in Spain, Europe and Asia, with good results. Training at centers with major experience or in wetlabs, and the proper patient selection are the best recommendations for the learning curve. In our center, as we gain experience with the approach, we performed advanced cases with similar results to the initial stages. Segmentectomies, bronchovascular reconstructions and selected cases that need chest wall resection were also carried out by uniportal VATS. The last advance is the uniportal VATS lobectomy in non-intubated patients with spontaneous breathing, the less invasive surgical approach in combination with a less invasive anesthetic management.

Non-intubated video-assisted thoracoscopic lung resections: the future of thoracic surgery?

Thanks to the experience gained through the improvement of video-assisted thoracoscopic surgery (VATS) technique, and the enhancement of surgical instruments and high-definition cameras, most pulmonary resections can now be performed by minimally invasive surgery. The future of the thoracic surgery should be associated with a combination of surgical and anaesthetic evolution and improvements to reduce the trauma to the patient. Traditionally, intubated general anaesthesia with one-lung ventilation was considered necessary for thoracoscopic major pulmonary resections. However, thanks to the advances in minimally invasive techniques, the non-intubated thoracoscopic approach has been adapted even for use with major lung resections. An adequate analgesia obtained from regional anaesthesia techniques allows VATS to be performed in sedated patients and the potential adverse effects related to general anaesthesia and selective ventilation can be avoided. The non-intubated procedures try to minimize the adverse effects of tracheal intubation and general anaesthesia, such as intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade, and postoperative nausea and vomiting. Anaesthesiologists should be acquainted with the procedure to be performed. Furthermore, patients may also benefit from the efficient contraction of the dependent hemidiaphragm and preserved hypoxic pulmonary vasoconstriction during surgically induced pneumothorax in spontaneous ventilation. However, the surgical team must be aware of the potential problems and have the judgement to convert regional anaesthesia to intubated general anaesthesia in enforced circumstances. The non-intubated anaesthesia combined with the uniportal approach represents another step forward in the minimally invasive strategies of treatment, and can be reliably offered in the near future to an increasing number of patients. Therefore, educating and training programmes in VATS with non-intubated patients may be needed. Surgical techniques and various regional anaesthesia techniques as well as indications, contraindications, criteria to conversion of sedation to general anaesthesia in non-intubated patients are reviewed and discussed.

Left lower sleeve lobectomy by uniportal video-assisted thoracoscopic approach.

Endobronchial tumours requiring sleeve resection have been usually considered a contraindication for video-assisted thoracoscopic surgery (VATS). However, with new technical advances and the experience gained in VATS, sleeve lobectomy has been performed by thoracoscopy in experienced VATS centres. Right-sided sleeve anastomoses are easier to perform by VATS than left-sided ones because of the presence of the pulmonary artery and aortic arch on the left side. Most surgeons use a 3 to 4 incision VATS technique for sleeve anastomosis but the surgery can be performed by using only one incision. This is the first report of a left-sided sleeve lobectomy by uniportal approach.

Bronchovascular right upper lobe reconstruction by uniportal video-assisted thoracoscopic surgery.

Lung cancer requiring double bronchial and vascular reconstruction of the pulmonary artery is a challenging procedure usually performed by thoracotomy. However, recent development of video-assisted thoracoscopic techniques allows experienced and skilled surgeons to perform these cases through a minimally invasive approach. Most of these complex thoracoscopic resections are performed by using 3 to 4 incisions. We present the first report of a right side combined vascular reconstruction and bronchoplasty performed through a single-incision video-assisted thoracoscopic surgery (VATS) technique.

Is uniportal thoracoscopic surgery a feasible approach for advanced stages of non-small cell lung cancer?

OBJECTIVES: Conventional video-assisted thoracoscopic (VATS) lobectomy for advanced lung cancer is a feasible and safe surgery in experienced centers. The aim of this study is to assess the feasibility of uniportal VATS approach in the treatment of advanced non-small cell lung cancer (NSCLC) and compare the perioperative outcomes and survival with those in early-stage tumors operated through the uniportal approach. METHODS: From June 2010 to December 2012, we performed 163 uniportal VATS major pulmonary resections. Only NSCLC cases were included in this study (130 cases). Patients were divided into two groups: (A) early stage and (B) advanced cases (>5 cm, T3 or T4, or tumors requiring neoadjuvant treatment). A descriptive and retrospective study was performed, comparing perioperative outcomes and survival obtained in both groups. A survival analysis was performed with Kaplan-Meier curves and the log-rank test was used to compare survival between patients with early and advanced stages. RESULTS: A total of 130 cases were included in the study: 87 (A) vs. 43 (B) patients (conversion rate 1.1 vs. 6.5%, P=0.119). Mean global age was 64.9 years and 73.8% were men. The patient demographic data was similar in both groups. Upper lobectomies (A, 52 vs. B, 21 patients) and anatomic segmentectomies (A, 4 vs. B, 0) were more frequent in group A while pneumonectomy was more frequent in B (A, 1 vs. B, 6 patients). Surgical time was longer (144.9±41.3 vs. 183.2±48.9, P<0.001), and median number of lymph nodes (14 vs. 16, P=0.004) were statistically higher in advanced cases. Median number of nodal stations (5 vs. 5, P=0.165), days of chest tube (2 vs. 2, P=0.098), HOS (3 vs. 3, P=0.072), and rate of complications (17.2% vs. 14%, P=0.075) were similar in both groups. One patient died on the 58th postoperative day. The 30-month survival rate was 90% for the early stage group and 74% for advanced cases. CONCLUSIONS: Uniportal VATS lobectomy for advanced cases of NSCLC is a safe and reliable procedure that provides perioperative outcomes similar to those obtained in early stage tumours operated through this same technique. Further long term survival analyses are ongoing on a large number of patients.

Uniportal video-assisted thoracoscopic sleeve lobectomy and other complex resections.

Thanks to the recent improvements in thoracoscopy, a great deal of complex lung resections can be performed without performing thoracotomies. During the last years, experience gained through video-assisted thoracoscopic techniques, enhancement of the surgical instruments and improvement of high definition cameras have been the greatest advances. The huge number of surgical videos posting on specialized websites, live surgery events and experimental courses has contributed to the rapid learning of minimally invasive surgery during the last years. Nowadays, complex resections, such as post chemo-radiotherapy resections, lobectomies with chest wall resection, bronchial and vascular sleeves are being performed by thoracoscopic approach in experienced centers. Additionally, surgery has evolved regarding the thoracoscopic surgical approach, allowing us to perform these difficult procedures by means of a small single incision, with excellent postoperative results.

Uniportal video-assisted thoracoscopic lobectomy in the animal model.

We introduce the training on uniportal video-assisted thoracoscopic (VATS) lobectomy in sheep. This animal model is helpful to learn the different view, the importance of lung exposure and the key points of the instrumentation. In this article we present three videos with the left upper lobectomy, the left lower lobectomy and the right upper lobectomy in the sheep.

Single-port video-assisted thoracoscopic lobectomy with pulmonary artery reconstruction.

Despite the advances in video-assisted thoracoscopic surgery (VATS), vascular reconstruction of the pulmonary artery (PA) is still infrequently performed by thoracic surgeons because of the technical difficulties and the increased operative risk during thoracoscopy. The few published reports have been performed by using 3-4 incisions. We present the first report of a pulmonary artery reconstruction procedure performed by a single-incision VATS technique. A 73-year old male patient was operated on by the thoracoscopic approach through a single 4-cm incision with no rib spreading. The postoperative recovery was uneventful.

Single-incision thoracoscopic right upper lobectomy with chest wall resection by posterior approach.

Lobectomy requiring chest wall resection is usually performed by thoracotomy, but thanks to the advances in the field of thoracoscopic surgery, this procedure can be performed by video-assisted thoracoscopic surgery (VATS). Recent improvements in surgical devices and previous VATS experience have allowed this complex surgery for advanced stages to be undertaken safely. Most of the thoracoscopic lobectomies with rib resection are performed using three to four incisions. We report a different minimally invasive technique for chest wall resection (minimally invasive posterior approach) and VATS right upper lobectomy (single-incision anterior approach).

Uniportal video-assisted thoracoscopic lobectomy.

Over the past two decades, video-assisted thoracic surgery (VATS) has revolutionized the way thoracic surgeons diagnose and treat lung diseases. The major advance in VATS procedures is related to the major pulmonary resections. The best VATS technique for lobectomy has not been well defined yet. Most of the authors describe the VATS approach to lobectomy via 3 to 4 incisions but the surgery can be performed by only one incision with similar outcomes. This single incision is the same as we normally use for VATS lobectomies performed by double or triple port technique with no rib spreading. As our experience with VATS lobectomy has grown, we have gradually improved the technique for a less invasive approach. Consequently the greater the experience we gained, the more complex the cases we performed were, hence expanding the indications for single-incision thoracoscopic lobectomy.

Uniportal video-assisted thoracoscopic pneumonectomy.

Video-assisted thoracoscopic surgery (VATS) was introduced nearly 2 decades ago and has experienced an exponential increase for lung cancer treatment. A pneumonectomy can be performed by video-assisted thoracoscopic surgery and the lung usually fits through the incision as usually used for VATS lobectomy. The most common approach for pneumonectomy is undertaken with 3 or 4 incisions, including a utility incision of about 3-6 cm. However, this resection is amenable by using only a single utility-incision. This chapter describes the technique for pneumonectomies by single-incision thoracoscopic approach with no rib spreading.

Uniportal video-assisted thoracoscopic lobectomy: two years of experience.

BACKGROUND: A video-assisted thoracoscopic approach to lobectomy varies among surgeons. Typically, 3 to 4 incisions are made. Our approach has evolved from a 3-port to a 2-port approach to a single 4- to 5-cm incision with no rib spreading. We report results with single-incision video-assisted thoracic major pulmonary resections during our first 2 years of experience. METHODS: In June 2010, we began performing video-assisted thoracoscopic lobectomies through a uniportal approach (no rib spreading). By July 12, 2012, 102 patients had undergone this single-incision approach. RESULTS: Of 102 attempted major resections, 97 were successfully completed with a single incision (operations in 3 patients were converted to open surgery and 2 patients needed 1 additional incision). Five uniportal pneumonectomies were not included in the study. We have analyzed early outcomes of successful uniportal lobectomies (92 patients studied). Right upper lobectomy was the most frequent resection (28 cases). Mean surgical time was 154.1 ± 46 minutes (range, 60-310 minutes), mean number of lymph nodes was 14.5 ± 7 (range, 5-38 nodes), and mean number of explored nodal stations was 4.6 ± 1.2 (range, 3-8 stations). The mean tumor size was 2.8 ± 1.5 cm (0-6.5 cm). The median duration of time a chest tube was in place was 2 days and the median length of hospital stay was 3 days. There were complications in 14 patients; no postoperative 30-day mortality was reported. CONCLUSIONS: Single-incision video-assisted thoracoscopic anatomic resection is a feasible and safe procedure with good perioperative results, especially when performed by surgeons experienced with the double-port technique and anterior thoracotomy.

Single-port video-assisted thoracoscopic anatomic segmentectomy and right upper lobectomy.

Video-assisted thoracoscopic surgery (VATS) segmentectomies are usually more complex procedures than lobectomies. With the gained experience in the field of thoracoscopic surgery, many thoracic surgery departments have progressively adopted this technique to preserve lung parenchyma, especially in cases of metastasis or benign conditions. The majority of surgeons use three incisions but the procedure can be performed by only one port. We report the first anatomic segmentectomy performed by uniportal VATS with no rib spreading.

Video-assisted thoracoscopic lobectomy in the treatment of intralobar pulmonary sequestration.

Pulmonary sequestration is a congenital malformation characterised by cystic, non-functioning embryonic lung tissue with vascularisation of an abnormal systemic artery. They are classified as intralobar (75%) and extralobar (25%) and are more common in the left lung and lower lobes (60-90%). We report two cases of intralobar pulmonary sequestration located in the lower lobe of the left lung which were subjected to video-assisted thoracoscopic surgery (VATS). Both patients had recurrent infections for which, after performing imaging tests, they were diagnosed with intralobar pulmonary sequestration in the left lower lobe, with an afferent arterial branch to the malformation from the aorta. A lower lobectomy was performed by video-assisted surgery, dividing the aberrant aortic artery with an endostapler. A single thoracic chest tube was placed and removed on postoperative day 2 and the patients were discharged on the same day. In both cases, the pathology examination revealed intralobar pulmonary sequestration. Pulmonary sequestrations are uncommon malformations that can be operated on using minimally invasive techniques, thereby permitting early discharge and a low rate of complications.

The two-incision approach for video-assisted thoracoscopic lobectomy: an initial experience.

OBJECTIVE: The video-assisted thoracoscopic approach (video-assisted thoracic surgery (VATS)) to lobectomy for non-small-cell lung cancer (NSCLC) is not standardised. Although three to four incisions are usually made, with the right surgical technique, the operation can be successfully carried out using only two incisions. We have analysed retrospectively, the characteristics and postoperative evolution of patients undergoing VATS lobectomies using two ports. METHODS: From June 2007 to November 2009, we carried out 131 major pulmonary resections by VATS, of which 40 (February 2009 to November 2009) were realised using only two incisions: one 1-cm incision through the 7th/8th intercostal space in the mid-axillary line, and a 3-5-cm anterior utility incision in the 5th intercostal space. The patients' mean age was 60.8±11.4 years (75% male, 25% female). RESULTS: The conversion rate was 10% (four patients). Of the remaining 36 cases, the diagnosis in six patients was benign, and in four was metastatic disease. Of the 26 cases with NSCLC, the most frequent stage was that of interactive application (IA) (58%) and histology mostly revealed adenocarcinoma (33%). Mean duration of surgery in the 36 resections completed by VATS was 168.6±54.0 min (range 80-300 min). The median chest tube duration was 2.5 days and the median length of stay in hospital was 3 days. There was no perioperative mortality in completed VATS cases, and no patient needed to be re-operated. Those patients with chronic obstructive pulmonary disease (COPD) needed longer hospital stays (p=0.046). Similarly, extreme cases of adhesion during surgery needed more days of thoracic drainage (p=0.040) and longer hospital stays (p=0.011), as well as displaying a higher percentage of postoperative complications (p=0.008). If the group of patients is divided in two periods (February to July 2009 and August to November 2009), more extended lymphadenectomies are observed among those performed during the latter period. CONCLUSIONS: VATS lobectomy with two incisions is a safe and reliable procedure producing good postoperative results. As we obtain more experience over time, results improve, especially in the performance of more extended lymphadenectomies.