Novel Uses of Indocyanine Green in Thoracic Surgery: A Review and Case Series.

Indocyanine green (ICG) is a water-soluble molecule that emits fluorescence in the near-infrared light spectrum. Due to its fluorescence properties, safety profile, and cost-effectiveness, ICG is used in minimally invasive surgery, enabling real-time visualization of structures during the operation. Until recently, its use was mainly limited to robotic surgery, which required specific technological setups to visualize the fluorescence. With recent technological advancements, however, similar capabilities can now be integrated into smaller laparoscopic instruments, broadening the accessibility and usefulness of ICG. In this article, we present various innovative applications of ICG in thoracic surgery, drawing from recent developments in the field and our own experiences. Specifically, we focus on the novel role of ICG in the evaluation of gastric conduit perfusion, lung nodule localization, and thoracic duct ligation.

Tracheostomy and Improvement in Utilization of Hospital Resources During SARS-CoV-2 Pandemic Surge.

The SARS-CoV-2 pandemic has affected millions across the world. Significant patient surges have caused severe resource allocation challenges in personal protective equipment, medications, and staffing. The virus produces bilateral lung infiltrates causing significant oxygen depletion and respiratory failure thus increasing the need for ventilators. The patients who require ventilation are often requiring prolonged ventilation and depleting hospital resources. Tracheostomy is often utilized in patients requiring prolonged ventilation, and early tracheostomy in critical care patients has been shown in some studies to improve a variety of factors including intensive care unit (ICU) length of stay, ventilation weaning, and decreased sedation medication utilization. In a patient surge setting, as long as adequate personal protective equipment (PPE) is available to minimize spread to healthcare workers, early tracheostomy may be a beneficial management of these patients. Decreasing sedative medication utilization may help prevent shortages in future waves of infection and improve patient-provider communication as patients are more alert. Tracheostomy care is easier than endotracheal intubation and may have decreased viral aerosolization risk, particularly if repeat intubation is necessary after a weaning trial. Additionally, tracheostomy patients can be monitored with less staff, decreasing total healthcare worker exposure to infection. To manage risk of exposure, coordination of ventilation controlled by an anesthesiologist or a critical care physician with a surgeon during the procedure can minimize aerosolization to the team. Risk management and resource allocation is of the utmost importance in any global crisis and procedures must be appropriately planned and benefits to patients, as well as minimized exposure to healthcare providers, must be considered. Early tracheostomy could be a beneficial procedure for severe SARS-CoV-2 patients to minimize long-term virus aerosolization and exposure for healthcare workers while decreasing sedation, allowing for earlier transfer out of the ICU, and improving hospital resource utilization.

Blood test shows high accuracy in detecting stage I non-small cell lung cancer.

BACKGROUND: In a previous study (Goebel et. al, Cancer Genomics Proteomics 16:229-244, 2019), we identified 33 biomarkers for an early stage (I-II) Non-Small Cell Lung Cancer (NSCLC) test with 90% accuracy, 80.3% sensitivity, and 95.4% specificity. For the current study, we used a narrowed ensemble of 21 biomarkers while retaining similar accuracy in detecting early stage lung cancer. METHODS: A multiplex platform, 486 human plasma samples, and 21 biomarkers were used to develop and validate our algorithm which detects early stage NSCLC. The training set consisted of 258 human plasma with 79 Stage I-II NSCLC samples. The 21 biomarkers with the statistical model (Lung Cancer Detector Test 1, LCDT1) was then validated using 228 novel samples which included 55 Stage I NSCLC. RESULTS: The LCDT1 exhibited 95.6% accuracy, 89.1% sensitivity, and 97.7% specificity in detecting Stage I NSCLC on the blind set. When only NSCLC cancers were analyzed, the specificity increased to 99.1%. CONCLUSIONS: Compared to current approved clinical methods for diagnosing NSCLC, the LCDT1 greatly improves accuracy while being non-invasive; a simple, cost-effective, early diagnostic blood test should result in expanding access and increase survival rate.

Review of Procedures and Outcomes of Video-Assisted Thoracic Surgery for the Treatment of Non-Small Cell Lung Cancer in 45 Patients Undergoing Segmentectomy.

BACKGROUND: Lung cancer is the leading cause of death due to cancer in the United States and survival is heavily dependent upon the cancer stage at diagnosis. In the treatment of Stage I or Stage II non-small cell lung cancer (NSCLC), cancerous lung nodules are removed through lobectomy or segmentectomy. Lobectomy removes an entire lobe of the lung. Segmentectomy removes only a portion of the lobe, minimizing removal of functional lung parenchyma. Both procedures can be completed through video-assisted thoracic surgery (VATS). In this retrospective review of the outcomes of VATS segmentectomy, the locations of nodules in relation to segmentectomy and the selection of patients to undergo segmentectomy are discussed. METHODS: A retrospective analysis of 60 patients who underwent VATS segmentectomy from January 2016 to December 2017 was performed. Forty-five patients were selected based on a diagnosis of NSCLC and the availability of reported outcomes. Patients were reviewed over 18 to 42 months for evidence of disease recurrence or progression. RESULTS: The patients had an average age of 71.2 years, and 31 (69%) were former or current smokers. Most of the lung nodules removed were located in the left upper lobe (LUL) and removed by LUL trisegmentectomy. The median lung nodule size was 18 mm. Most of the cancers diagnosed were Stage I adenocarcinoma. The median length of stay in the hospital was 3 days. The median chest tube retention was 2 days. Six patients had nodule recurrence or progression of disease. CONCLUSION: In decision-making between segmentectomy and lobectomy, adequate margins are required for the selection of segmentectomy, the most common of which is LUL trisegmentectomy. Technical challenges can be overcome with adequate training and simulation. Additional research could focus on the identification of factors associated with recurrence.

Stapled Diaphragmatic Plication: Is It Better Than Suture Plication?

Diaphragm dysfunction, which can be due to eventration or an abnormally high-positioned diaphragm, can cause respiratory compromise. Eventration is most commonly due to unilateral diaphragm paralysis, which reduces ventilatory function in adults by about 25%. Since the 1920s, this condition has been treated with diaphragm plication, which itself has evolved to include the use of several different techniques and materials. This review explores the relevant literature on diaphragm plication using sutures or staples for the treatment of eventration to determine if either provides a clinical benefit over the other.

Diaphragmatic Pacing: Is There a Benefit?

The diaphragm is the primary muscle of respiration and its injury can cause diaphragm dysfunction and respiratory deficits. Respiratory compromise has historically been managed with mechanical ventilation, however, its use has also been shown to result in poor functional outcomes. Therefore, stimulation of the phrenic nerve, called diaphragm pacing, has been used to replace and/or delay the need for mechanical ventilation. This article will review the relevant literature on diaphragm pacing, discuss the physiology of diaphragm dysfunction in a variety of patient populations, and address whether diaphragm pacing is a valuable and effective option for treatment of respiratory failure.

Extra-Thoracic Video-Assisted Thoracoscopic Surgery Rib Plating and Intra-Thoracic VATS Decortication of Retained Hemothorax.

We report a patient who presented with multiple rib fractures after falling off a horse and was initially managed medically. Several weeks later, the patient returned to the hospital complaining of dyspnea on exertion. Physical exam revealed severe chest wall malformation and imaging revealed moderate hemothorax and complete collapse of the right lower lobe. Considering the likelihood that this patient's multiple ribs fractures contributed to the hemothorax and trapped lung, the patient underwent surgical evacuation of the hemothorax followed by rib fixation of ribs three through six. The procedures were performed using both intra-thoracic and extra-thoracic video-assisted thoracoscopic surgery (VATS) and did not require the use of thoracotomy incision or open exposure of the thoracic cavity. This case report suggests that this operative technique is a viable option for delayed presentation of multiple rib fractures and complex sequela associated with this pathology.

Is There a Role for VATS Sleeve Lobectomy in Lung Cancer?

Lung cancer is the second most commonly diagnosed cancer and continues to be the leading cause of death for both men and women, with non-small cell lung cancer (NSCLC) accounting for 85% of all lung cancer cases. Once a lung mass is visualized on imaging, accurate staging is required for determination of treatment options and, when possible, surgical resection is recommended as it has been proven to have the best survival rates versus non-surgical treatment. If a patient has advanced or metastatic disease, therapeutic options include chemotherapy and radiation, while immunotherapy and specific agents that target tumor mutations are only recommended for appropriate candidates. Additionally, surgical options differ based on whether the tumor is peripherally or centrally located in the lung parenchyma. This article will review relevant literature concerning current surgical techniques for resection of centrally located NSCLC using thoracotomy and will emphasize the benefits and challenges of a video-assisted thoracic surgery (VATS) approach.

Novel Techniques and Approaches to Minimally Invasive Thoracic Surgery.

Approximately two decades ago, thoracic surgery witnessed the leap from thoracotomy to the first video-assisted thoracic surgery (VATS) lobectomy. Minimally invasive lobectomy and hilar lymphadenectomy is now widely established as a safe and oncological sound technique that is the standard of care for early-stage lung cancer. The move toward less invasive surgery has no doubt driven the innovation of sophisticated instruments and technology to cope with the demanding need of working through a restricted incision. We will discuss the use of minimally invasive thoracic surgery techniques for sympathectomy, cardiac arrhythmia, and first rib resection, as well as traditional lung resections (e.g., pneumonectomy, lobectomy, and segmentectomy). We will also discuss thoracic incisions and approaches using VATS, single port VATS, and robot-assisted thoracic surgery.

Surgical Treatment of Lung Cancer.

In this chapter, we discuss the preoperative evaluation that is necessary prior to surgical resection, stage-specific surgical management of lung cancer, and the procedural steps as well as the indications to a variety of surgical approaches to lung resection.

Retrospective Review of Preoperative Wire Localization for Peripheral Ground Glass Opacities.

Video-assisted thoracoscopy (VATS) is performed for diagnosis and treatment of peripheral lung nodules. Localization of peripherally located ground-glass opacities (GGOs) can be challenging. We report the results and usefulness of preoperative computed tomography (CT)-guided wire localization. Records for patients who underwent CT-guided wire localization prior to VATS resection for peripherally located GGOs were analyzed. Our technique for targeting the GGOs, complications, and histopathology of GGOs is reviewed. Forty patients (mean age 68 years) underwent pulmonary resections following CT-guided wire localization. The mean diameter of the GGO was 11.0 mm. The mean distance from the pleural surface to the peripheral margin of the GGO was 18.6 mm. Complications from the wire localization included pneumothorax in 5 patients (12.5%), none of whom required insertion of a chest tube; parenchymal hemorrhage in 3 patients (7.5%); and pleural effusion requiring chest tube drainage (unrelated to the wire) in 1 patient (2.5%). The mean operative time was 74 (range: 21-186 ) minutes. Pathological examination revealed lung malignancy in 36 patients (90%). The diagnostic yield was 100%. Preoperative CT-guided wire localization for solitary or multiple peripherally located GGOs allows for determination of histopathologic diagnosis and high diagnostic yield.

Diagnosis of Non-small Cell Lung Cancer for Early Stage Asymptomatic Patients.

BACKGROUND/AIM: In 2016 in the United States, 7 of 10 patients were estimated to die following lung cancer diagnosis. This is due to a lack of a reliable screening method that detects early-stage lung cancer. Our aim is to accurately detect early stage lung cancer using algorithms and protein biomarkers. PATIENTS AND METHODS: A total of 1,479 human plasma samples were processed using a multiplex immunoassay platform. 82 biomarkers and 6 algorithms were explored. There were 351 NSCLC samples (90.3% Stage I, 2.3% Stage II, and 7.4% Stage III/IV). RESULTS: We identified 33 protein biomarkers and developed a classifier using Random Forest. Our test detected early-stage Non-Small Cell Lung Cancer (NSCLC) with a 90% accuracy, 80% sensitivity, and 95% specificity in the validation set using the 33 markers. CONCLUSION: A specific, non-invasive, early-detection test, in combination with low-dose computed tomography, could increase survival rates and reduce false positives from screenings.

Novel extra-thoracic VATS minimally invasive technique for management of multiple rib fractures.

We report an elderly patient with chronic obstructive pulmonary disease (COPD), Alzheimer's disease and early dementia who presented with multiple displaced rib fractures of left ribs 4 through 9 with flail segments of ribs 4 through 8 and an associated traumatic pneumatocele from rib puncture of the left upper lobe. The decision to treat this patient operatively was based on the presence of flail chest, the patient's age, baseline co-morbidities and limited physiological reserve. Surgical rib fixation is traditionally performed with a thoracotomy incision and open exposure for extra-thoracic rib fixation, however, this patient underwent chest wall stabilization using an extra-thoracic video-assisted thoracic surgery (VATS) technique. We discuss our operative technique using universal rib plating system, optimal retraction for exposure and use of balloon dilation to create an accessible extra-thoracic working space. This surgical approach provided a faster recovery to this patient's baseline with minimal use of narcotics thereby highlighting the impact and importance of this surgical technique for patients presenting with multiple fib fractures, especially the elderly. We show that VATS assisted minimally invasive technique for operative management of multiple rib fractures is a viable surgical option demonstrated by this patient's recovery and return to function with minimal need for pain control despite her advanced age and baseline co-morbidities.