Thoracoscopic lobectomy for benign disease--a single centre study on 64 cases

Three-dimensional imaging assisted segmentectomy in the treatment of localized bronchiectasis: a retrospective analysis

BACKGROUND

Surgical treatment is crucial in managing bronchiectasis. Segmentectomy, although a complex procedure, has become more feasible with advancements in thin-slice CT and three-dimensional imaging. These technologies enhance preoperative anatomical understanding and surgical planning. This study aims to demonstrate the viability of using three-dimensional imaging assistance for treating localized bronchiectasis through segmentectomy.

METHODS

From 2021 to 2023, a total of 34 patients with bronchiectasis underwent segmentectomy. We collected and then analyzed potential factors including general conditions, preoperative clinical symptoms, surgical procedures, length of postoperative hospital stay, incidence of postoperative complications and postoperative follow-ups.

RESULTS

Of the 34 surgical patients, 8 were men and 26 were women, resulting in a total of 34 operations. The average surgical time for segmentectomy was 157.7 ± 63.4 min. The average intraoperative blood loss was 115.9 ± 107.4 ml. Postoperative tube placement lasted an average of 6.5 ± 2.4 days, with an average drainage volume of 724.7 ± 500.9 ml. The average hospital stay was 8.2 ± 3.4 days. Among these patients, 2 developed pneumothorax and 2 experienced air leaks. Additionally, 4 patients developed pneumonia postoperatively. Over an average follow-up period of 14.3 months, most patients showed symptom improvement, with only two cases of recurrence.

CONCLUSIONS

Segmentectomy has acceptable postoperative morbidity, mortality, and outcomes. Therefore, segmentectomy is a viable option for the treatment of localized bronchiectasis.

[Management of adult bronchiectasis - Consensus-based Guidelines for the German Respiratory Society (DGP) e. V. (AWMF registration number 020-030)]

Bronchiectasis is an etiologically heterogeneous, chronic, and often progressive respiratory disease characterized by irreversible bronchial dilation. It is frequently associated with significant symptom burden, multiple complications, and reduced quality of life. For several years, there has been a marked global increase in the prevalence of bronchiectasis, which is linked to a substantial economic burden on healthcare systems. This consensus-based guideline is the first German-language guideline addressing the management of bronchiectasis in adults. The guideline emphasizes the importance of thoracic imaging using CT for diagnosis and differentiation of bronchiectasis and highlights the significance of etiology in determining treatment approaches. Both non-drug and drug treatments are comprehensively covered. Non-pharmacological measures include smoking cessation, physiotherapy, physical training, rehabilitation, non-invasive ventilation, thoracic surgery, and lung transplantation. Pharmacological treatments focus on the long-term use of mucolytics, bronchodilators, anti-inflammatory medications, and antibiotics. Additionally, the guideline covers the challenges and strategies for managing upper airway involvement, comorbidities, and exacerbations, as well as socio-medical aspects and disability rights. The importance of patient education and self-management is also emphasized. Finally, the guideline addresses special life stages such as transition, family planning, pregnancy and parenthood, and palliative care. The aim is to ensure comprehensive, consensus-based, and patient-centered care, taking into account individual risks and needs.

Early and late outcomes of video thoracoscopic versus open approach for bronchiectasis lung resections

OBJECTIVES

To evaluate the early and late results of surgical treatment of patients with bronchiectasis, comparing the Video-Assisted Thoracic Surgery (VATS) vs. the open thoracotomy (OT).

METHODS

Observational retrospective study of patients who underwent surgery for bronchiectasis. Patients were divided into two groups according to surgical access OT/VATS. Variables collected included gender, age, preoperative symptoms, etiology, segments involved, FVC and FEV1, type of surgical resection, complications, mortality, and length of hospital stay. Late surgical results were classified as excellent, complete remission of symptoms; good, significative improvement; and poor, little/no improvement.

RESULTS

108 surgical resections (103 patients). OT group 54 patients (52.4%) vs. VATS 49 (47.6%). A high percentage of complications was observed, but no difference between the OT (29.6%) and VATS (24.5%) groups was found. Post-operative hospital stay was shorter in the VATS group (5.4 days) vs. the OT group (8.7 days (p=0.029). 75% of the patients had a late follow-up; the results were considered excellent in 71.4%, good in 26%, and poor in 2.6%. Regarding bronchiectasis distribution, an excellent percentage was obtained at 82.1% in patients with localized bronchiectasis and 47.5% with non-localized bronchiectasis, p=0.003.

CONCLUSIONS

VATS leads to similar results regarding morbidity, compared to OT. However, VATS was related to shorter hospital stays, reflecting the early recovery. Late results were excellent in most patients, being better in patients with localized bronchiectasis. VATS should be considered a preferable approach for bronchiectasis lung resection whenever possible.

Analysis of bronchiectasis patients who underwent video-assisted thoracoscopic surgery in a tertiary thoracic surgery center: Ten years of experience

Background

This study aimed to analyze our video-assisted thoracic surgery (VATS) experience in the surgical treatment of bronchiectasis and the reasons limiting VATS application.

Methods

Two hundred one patients (106 males, 95 females; mean age: 39.7±14.1 years; range, 12 to 68 years) who underwent surgical treatment for bronchiectasis between January 2012 and October 2021 were included in the retrospective study. Three groups were created based on the surgical technique used: VATS, thoracotomy, and patients who were converted from VATS to thoracotomy.

Results

The most significant presenting symptoms were cough (43%) and excessive sputum expectoration (40%). Surgical intervention was applied to the left side of 60% of the patients, and the most common resection performed in all three groups was left lower lobectomy. The rate of conversion from VATS to thoracotomy was 28.8%, and it was found that dense pleural adhesions were the most common reason. Revision surgery was performed on a total of 11 (5.47%) patients. The frequency of revision surgery did not differ significantly among the three groups (p=0.943). The most common postoperative complication was prolonged air leakage. There was no statistically significant difference in postoperative complication rates among the groups (p=0.417). The rate of surgical treatment of bronchiectasis with VATS was observed to have increased from 11.1% to 77.7% in our clinic.

Conclusion

In experienced hands, VATS can be safely applied in the surgical treatment of bronchiectasis.

Surgery for bronchiectasis-destroyed lung: feasibility of video-assisted thoracoscopic surgery, and surgical outcomes

OBJECTIVES

To provide the experience of surgical treatment for bronchiectasis-destroyed lung (BDL) and evaluate the feasibility of video-assisted thoracoscopic surgery (VATS).

METHODS

BDL patients underwent surgical treatment between January 2013 and June 2018 were included. Logistic regression was performed to assess factors for major complications, and Cox's regression was performed to assess factors affected symptomatic outcome.

RESULTS

Totally, 143 patients were treated by VATS (n = 64) and thoracotomy (n = 79). Nine (14.1%) cases scheduled for VATS were converted to thoracotomy for dense adhesions (n = 6) and frozen hilum (n = 3). The VATS group had a median chest tube duration, hospitalization and a time of returning to full activity of 4 days, 5 days and 1.5 months, respectively. Major complications occurred in 28 (19.6%) of all patients, 50.0% after pneumonectomy and 13.4% after lobectomy/extensive lobectomy. Multivariable analysis identified pneumonectomy [odds ratio, 3.64; 95% confidence interval (CI), 1.18-11.21] as a significant predictor for major complications. Overall, 141 (98.6%) patients benefitted from surgery (completely asymptomatic, n = 109; acceptable alleviation, n = 32). Thirty-four patients experienced relapse of the disease, including 13 with productive cough, 11 with haemoptysis and 10 with recurrent infections. Pseudomonas aeruginosa infection [hazard ratio (HR), 3.07; 95% CI, 1.38-6.83] and extent of remanent bronchiectatic areas (HR, 1.03; 95% CI, 1.00-1.05) were independent risk factors for shorter relapse free interval.

CONCLUSIONS

VATS for BDL is feasible in well-selected patients. Pneumonectomy increased the risk of postoperative major complications. Removing all BDL lesions contributed to satisfactory prognosis.

In patients with localized bronchiectasis, does thoracoscopic lung resection result in improved clinical outcomes compared to open surgery?

A best evidence topic was constructed according to a structured protocol. The question addressed was whether video-assisted thoracoscopic surgery (VATS), compared to open lung resection, resulted in improved postoperative clinical outcomes, in patients with localized bronchiectasis indicated for surgery. A total of 1352 papers were found using the reported search, of which 5 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All of the identified studies were retrospective. The conversion rate from VATS to open procedure ranged from 0% to 15.3%. In comparison to thoracotomy, VATS resulted in a significant reduction of postoperative blood loss (1 study), length of hospital stay (2 studies), postoperative complication rate (2 studies), pain scales (2 studies) and chest tube duration (1 study). However, there was a significant increase in operative time (1 study) and whole cost (2 studies). There was no significant difference in the clinical recovery, which was defined by the disappearance or improvement of preoperative symptoms during the follow-up period (3 studies). We conclude that although there is limited high-level evidence, retrospective studies have suggested that VATS could significantly reduce complications rate, postoperative blood loss, pain scales, length of hospital stay and chest tube duration compared to open lung resection in selected patients with localized bronchiectasis.

The Deteriorating Patient: Therapies Including Lung Transplantation

In this review paper, we discuss the characteristics that define severe bronchiectasis and which may lead to deterioration of noncystic fibrosis bronchiectasis. These characteristics were used to establish the current severity scores: bronchiectasis severity index (BSI), FACED, and E-FACED (exacerbation frequency, forced expiratory volume in 1 second, age, colonization, extension and dyspnea score). They can be used to predict mortality, exacerbation rate, hospital admission, and quality of life. Furthermore, there are different treatable traits that contribute to severe bronchiectasis and clinical deterioration. When present, they can be a target of the treatment to stabilize bronchiectasis.One of the first steps in treatment management of bronchiectasis is evaluation of compliance to already prescribed therapy. Several factors can contribute to treatment adherence, but to date no real interventions have been published to ameliorate this phenomenon. In the second step, treatment in deteriorating patients with bronchiectasis should be guided by the predominant symptoms, for example, cough, sputum, difficulty expectoration, exacerbation rate, or physical impairment. In the third step, we evaluate treatable traits that could influence disease severity in the deteriorating patient. Finally, in patients who are difficult to treat despite maximum medical treatment, eligibility for surgery (when disease is localized), should be considered. In case of end-stage disease, the evaluation for lung transplantation should be performed. Noninvasive ventilation can serve as a bridge to lung transplantation in patients with respiratory failure.

Pulmonary resection for nontuberculous mycobacterial pulmonary disease: outcomes and risk factors for recurrence

OBJECTIVES

As the number of patients with nontuberculous mycobacterial pulmonary disease (NTMPD) increases, surgical treatment to control disease becomes more important. However, postoperative outcomes and predictors of recurrence have been insufficiently evaluated.

METHODS

We retrospectively investigated 100 patients with NTMPD who underwent pulmonary resection from 2009 to 2016 at our institution. Clinical data of patients with and without postoperative recurrence were statistically compared. Recurrence was defined as microbiological re-identification or computed tomography findings highly suspicious for relapse after excluding other diseases. Recurrence-free survival was calculated using the Kaplan-Meier method. Survival curves were compared using the log-rank test. Predictive factors were evaluated using univariate and multivariate analyses.

RESULTS

Nine patients experienced recurrence. A significant difference in recurrence-free survival was detected between patients with and without a positive preoperative sputum culture (P = 0.000942). Moreover, patients with a positive preoperative sputum smear (≥ 2 +) had a significantly higher recurrence rate than those who did not (P = 0.000216). Multivariate analysis revealed that preoperative sputum smear (≥ 2 +) is an independent risk factor for recurrence after pulmonary resection for NTMPD (odds ratio, 7.38; 95% confidential interval, 1.29-42.2; P = 0.024).

CONCLUSIONS

NTM discharge might have an impact on postoperative recurrence of NTMPD patients without residual cavitary lesions. Preoperative NTM discharge should be minimized by optimizing medical therapy before surgical treatment to improve the postoperative course. Intensive follow-up and prolonged postoperative medical therapy should be considered for patients without a sufficient reduction in bacterial discharge before pulmonary resection.

Brazilian consensus on non-cystic fibrosis bronchiectasis

Bronchiectasis is a condition that has been increasingly diagnosed by chest HRCT. In the literature, bronchiectasis is divided into bronchiectasis secondary to cystic fibrosis and bronchiectasis not associated with cystic fibrosis, which is termed non-cystic fibrosis bronchiectasis. Many causes can lead to the development of bronchiectasis, and patients usually have chronic airway symptoms, recurrent infections, and CT abnormalities consistent with the condition. The first international guideline on the diagnosis and treatment of non-cystic fibrosis bronchiectasis was published in 2010. In Brazil, this is the first review document aimed at systematizing the knowledge that has been accumulated on the subject to date. Because there is insufficient evidence on which to base recommendations for various treatment topics, here the decision was made to prepare an expert consensus document. The Brazilian Thoracic Association Committee on Respiratory Infections summoned 10 pulmonologists with expertise in bronchiectasis in Brazil to conduct a critical assessment of the available scientific evidence and international guidelines, as well as to identify aspects that are relevant to the understanding of the heterogeneity of bronchiectasis and to its diagnostic and therapeutic management. Five broad topics were established (pathophysiology, diagnosis, monitoring of stable patients, treatment of stable patients, and management of exacerbations). After this subdivision, the topics were distributed among the authors, who conducted a nonsystematic review of the literature, giving priority to major publications in the specific areas, including original articles, review articles, and systematic reviews. The authors reviewed and commented on all topics, producing a single final document that was approved by consensus.

Uniportal thoracoscopic treatment in bronchiectasis patients: preliminary experience

Introduction

Bronchiectasis is defined as a permanent and abnormal dilation of the bronchi due to destruction of the bronchial wall. The thoracoscopic approach is represented in the literature by a few reports, and multiple port incisions are observed in these studies.

Aim

To investigate the effectiveness and outcomes of the single port video-assisted thoracoscopic surgery (VATS) method in the surgical treatment of bronchiectasis. To our knowledge, this is the first study reporting surgical treatment of bronchiectasis via the uniportal thoracoscopic approach.

Material and methods

The medical records of 15 patients undergoing surgery for bronchiectasis between 2013 and 2017 were reviewed. The patients were evaluated with regard to age, gender, duration of symptoms, localization, types and duration of the surgery, presence of pleural adhesion, intraoperative complications, amount of intraoperative bleeding, conversion to open surgery, postoperative drainage amount, chest tube removal time, length of hospital stay, mortality and morbidity, follow-up period, duration of narcotic analgesic usage, pain according to visual analog scale evaluation and satisfaction score.

Results

A total of 15 patients initially underwent single port thoracoscopic resection and 14 procedures were completed thoracoscopically. In terms of anatomic resections, 6 patients underwent left lower lobectomy, 4 right lower lobectomy, 1 right upper lobectomy, 1 left lower lobectomy + lingulectomy, 1 right basal segmentectomy and 1 patient underwent lingulectomy. The mean operative time was 137.1 ±24.5 min and the mean length of hospital stay was 4.78 ±1.52 days. The mean postoperative analgesic requirement was 2.85 ±0.66 days.

Conclusions

We believe that uniportal VATS is a safe, feasible, and effective technique for selected bronchiectasis patients.

Video-assisted thoracoscopic surgery lobectomy: The first Indian report

INTRODUCTION

The fear of pleural adhesions and densely stuck lymph nodes in India, a country where tuberculosis is endemic, is one major factor keeping our surgeons away from video-assisted thoracoscopic surgery (VATS) lobectomy. In this paper, we aim to report our experience with performing VATS lobectomy in 102 cases using a standardised three-port anterior approach.

MATERIALS AND METHODS

Between March 2012 and September 2016, we performed 102 VATS lobectomies. Sixty patients (58.8%) were males and 42 females (41.2%), with a mean age of 42.02 years. Diagnoses were as follows: benign disease (72), lung cancer (27) and pulmonary metastases (3). Among the cases with primary lung cancer, twenty out of 27 (74%) were adenocarcinoma and 7 cases of squamous carcinoma (25.92%). All patients underwent lobectomy by a standardised three-port anterior approach.

RESULTS

The overall conversion rate was 8.82% (n = 9). We observed no postoperative complications in 82 (80.4%) patients. The average blood loss was 211.37 ml. Mean operative time was 173 min. Median length of hospital stay was 5 with median chest tube duration of 4.9 days. There was no in hospital or 30-day mortality. The most common complication was prolonged air leak.

CONCLUSION

From this first Indian series, it is clear that VATS lobectomy is feasible in both benign and malignant cases. It also shows that the fear of adhesions is unwarranted and properly selected benign cases can also undergo VATS lobectomy safely.

Lung decortication in phase III pleural empyema by video-assisted thoracoscopic surgery (VATS)-results of a learning curve study

Background

Pleural empyema (PE) is a devastating disease with a high morbidity and mortality. According to the American Thoracic Society it is graduated into three phases and surgery is indicated in intermediate phase II and organized phase III. In the latter, open decortication of the lung via thoracotomy is the gold standard whereas the evidence for feasibility and safety of a minimally-invasive video-assisted thoracoscopic approach is still poor.

Methods

Retrospective single-center analysis of patients undergoing surgery for phase III PE from 02/2011 to 03/2015 [n=138, including n=130 VATS approach (n=3 of them with bilateral disease) and n=8 open approach]. The learning curve was assessed by grouping those 127 patients with unilateral disease who underwent a video-assisted thoracoscopic approach into two groups: VATS-1 (03/2011 to 06/2012, n=43) and VATS-2 (06/2012 to 03/2015, n=84).

Results

ASA-scores (P=0.0279) and rate of pre-operative drainage therapy (P=0.0534) were higher in VATS-2 patients. Operating times were longer in VATS-1 (P=0.0308), intra-operative complication as well as conversion to open surgery rates did both not differ. Rates of post-operative vasoconstrictive therapy (P=0.0191) and prolonged mechanical ventilation (P=0.0560) were both higher in VATS-2, however, post-operative length of stay (LOS) at intensive care unit, overall post-operative LOS and post-operative complication rate were similar in both groups.

Conclusions

Video-assisted thoracoscopic surgery is feasible for evacuation and decortication in late phase III PE. A learning curve of approximately 40 cases is sufficient to gain procedure-specific surgical skills and thus reduce the operating times sufficiently.

The Feasibility of Thoracoscopic Resection in Bronchiectasis

INTRODUCTION

Minimally invasive surgery is the treatment of choice in early-stage lung cancer. However, experience in infectious lung disease, primarily bronchiectasis, is limited probably because of the presence of dense pleural adhesions, multiple lymph nodes, and spiral bronchial arteries. The present study shows our experience of video-assisted thoracoscopic surgery (VATS) lobectomy and segmentectomy in the treatment of bronchiectasis.

MATERIALS AND METHODS

Patients who underwent VATS lobectomy or segmentectomy in our clinic between April 2008 and 2015 were retrospectively evaluated. Surgery was indicated in patients with radiologic localized bronchiectasis who also had a history of recurrent lower respiratory tract infection or expectorating mucopurulent secretion. The patients were analyzed in terms of age, sex, thoracotomy conversion rate, postoperative drainage amount, chest tube removal time, length of hospital stay, morbidity, and mortality.

RESULTS

A total of 44 patients initially underwent VATS pulmonary anatomic resection and 41 procedures were completed on 40 patients. One patient had bilateral resection. Fifteen patients were male individuals and 26 were female individuals. The average age was 31.4 (15 to 57) years. Forty lobectomies and 1 segmentectomy were performed. The conversion rate was 6.8%. VATS was performed on 28 patients by 3 ports, 8 patients by 2 ports, and 5 patients by a single port. In terms of anatomic resections, 18 patients underwent left lower lobectomy, 8 right lower lobectomy, 8 middle lobectomy, 6 right upper lobectomy, and 1 patient underwent lingular segmentectomy. No major postoperative complication or mortality was observed. Prolonged air leak was observed in 2 patients and subcutaneous emphysema occurred in 2 patients. The average postoperative drainage amount, chest tube removal time, and length of hospital stay were 320 mL, 3.1 (1 to 11) days, and 4.6 (2 to 11) days, respectively.

CONCLUSIONS

VATS pulmonary resection is a safe, feasible, and effective treatment in the surgery of bronchiectasis with low morbidity and mortality rates. Moreover, because of cosmetic results, patients with benign diseases such as bronchiectasis could be initiated by minimally invasive surgery options just like patients with malignancies.

An update on pediatric bronchiectasis

INTRODUCTION

The prevalence and awareness of bronchiectasis not related to cystic fibrosis (CF) is increasing and it is now recognized as a major cause of respiratory morbidity, mortality and healthcare utilization worldwide. The need to elucidate the early origins of bronchiectasis is increasingly appreciated and has been identified as an important research priority. Current treatments for pediatric bronchiectasis are limited to antimicrobials, airway clearance techniques and vaccination. Several new drugs targeting airway inflammation are currently in development. Areas covered: Current management of pediatric bronchiectasis, including discussion on therapeutics, non-pharmacological interventions and preventative and surveillance strategies are covered in this review. We describe selected adult and pediatric data on bronchiectasis treatments and briefly discuss emerging therapeutics in the field. Expert commentary: Despite the burden of disease, the number of studies evaluating potential treatments for bronchiectasis in children is extremely low and substantially disproportionate to that for CF. Research into the interactions between early life respiratory tract infections and the developing immune system in children is likely to reveal risk factors for bronchiectasis development and inform future preventative and therapeutic strategies. Tailoring interventions to childhood bronchiectasis is imperative to halt the disease in its origins and improve adult outcomes.

Anatomic lung resections for benign pulmonary diseases by video-assisted thoracoscopic surgery (VATS)

PURPOSE

Based on increasing evidence of its benefits regarding perioperative and oncologic outcome, video-assisted thoracoscopic surgery (VATS) has gained increasing acceptance in the surgical treatment of early stage non-small cell lung cancer (NSCLC). However, the evidence for a VATS approach in anatomic lung resection for benign pulmonary diseases is still limited.

METHODS

Between March 2011 and May 2014, data from 33 and 63 patients who received VATS anatomic lung resection for benign diseases (VATS-B) and early stage NSCLC (VATS-N), respectively, were analyzed retrospectively. For subgroup analyses, VATS-B was subdivided by operation time and underlying diseases. Subgroups were compared to VATS-N.

RESULTS

Three patients from VATS-B and four from VATS-N experienced conversion to open surgery. Causes of conversion in VATS-B were intraoperative complications, whereas conversions in VATS-N were elective for oncological concerns (p < 0.05). Operation time and duration of postoperative mechanical ventilation were longer by tendency; postoperative stay on intensive care unit and chest tube duration were significantly longer in VATS-B. Subgroup analyses showed a longer operation time as a predictor for worse perioperative outcome regarding postoperative mechanical ventilation, postoperative stay on intensive care unit, chest tube duration, and length of hospital stay. Patients with longer operation time suffered from more postoperative complications. Differences in perioperative outcome data were not significantly dependent on the underlying benign diseases compared to VATS-N.

CONCLUSIONS

VATS is feasible and safe in anatomic lung resection for benign pulmonary diseases. Not the underlying disease, but a longer operation time is a factor for worse postoperative outcome.

Video-assisted thoracoscopic surgery is a safe option for benign lung diseases requiring lobectomy

BACKGROUND

Lobectomy for benign lung disease is renowned to be technically complex and to be subjected to an increased complication rate. The objective of this study was to evaluate whether the results obtained with video-assisted surgery (VATS) in benign disease are comparable to those obtained in oncologic surgery, where VATS has been validated.

METHODS

We have reviewed the files of 246 consecutive patients who underwent VATS lobectomy from January 2012 to August 2015. The cohort was divided into two groups according to pathology (benign or malignant). Outcome parameters on scrutiny were demographics, pathology, duration of air leak, drainage and hospital stay, conversion, and perioperative complication rate. Comparisons were made with the χ ² test and Student's t test; any p value ≤0.05 was considered as significant.

RESULTS

Group 1 (36 patients) included patients who underwent lobectomy for benign disease and group 2 (210 patients) patients affected by lung cancer or pulmonary metastases. The two groups differed with reference to age (p < 0.001), history of cancer (p < 0.001), history of stroke (p = 0.05), and the presence of pleural adhesions (p = 0.03). There was no difference for duration of air leaks, chest tube drainage and hospital stay, conversion rate, and perioperative complication rate.

CONCLUSIONS

We conclude that pathology did not impact on outcomes after VATS lobectomy. This study suggests that VATS is as a safe option in selected patients with benign disease requiring lobectomy, despite a more complex technical context.

Association between Image Characteristics on Chest CT and Severe Pleural Adhesion during Lung Cancer Surgery

The aim of this study was to investigate the association between image characteristics on preoperative chest CT and severe pleural adhesion during surgery in lung cancer patients. We included consecutive 124 patients who underwent lung cancer surgeries. Preoperative chest CT was retrospectively reviewed to assess pleural thickening or calcification, pulmonary calcified nodules, active pulmonary inflammation, extent of emphysema, interstitial pneumonitis, and bronchiectasis in the operated thorax. The extent of pleural thickening or calcification was visually estimated and categorized into two groups: localized and diffuse. We measured total size of pulmonary calcified nodules. The extent of emphysema, interstitial pneumonitis, and bronchiectasis was also evaluated with a visual scoring system. The occurrence of severe pleural adhesion during lung cancer surgery was retrospectively investigated from the electrical medical records. We performed logistic regression analysis to determine the association of image characteristic on chest CT with severe pleural adhesion. Localized pleural thickening was found in 8 patients (6.5%), localized pleural calcification in 8 (6.5%), pulmonary calcified nodules in 28 (22.6%), and active pulmonary inflammation in 22 (17.7%). There was no patient with diffuse pleural thickening or calcification in this study. Trivial, mild, and moderate emphysema was found in 31 (25.0%), 21 (16.9%), and 12 (9.7%) patients, respectively. Severe pleural adhesion was found in 31 (25.0%) patients. The association of localized pleural thickening or calcification on CT with severe pleural adhesion was not found (P = 0.405 and 0.107, respectively). Size of pulmonary calcified nodules and extent of emphysema were significant variables in a univariate analysis (P = 0.045 and 0.005, respectively). In a multivariate analysis, moderate emphysema was significantly associated with severe pleural adhesion (odds ratio of 11.202, P = 0.001). In conclusion, severe pleural adhesion might be found during lung cancer surgery, provided that preoperative chest CT shows substantial pulmonary calcified nodules or emphysema.

The Role of Video-Assisted Thoracoscopic Therapeutic Resection for Medically Failed Pulmonary Tuberculosis

There are few reports regarding video-assisted thoracoscopic therapeutic resection for medically failed pulmonary tuberculosis (TB). We reviewed our surgical results of video-assisted thoracoscopic surgery (VATS) therapeutic resection for pulmonary TB with medical failure, and its correlation with image characteristics on chest computed tomography (CT) scan.Between January 2007 and December 2012, among the 203 patients who had surgery for TB, the medical records of 89 patients undergoing therapeutic resection for medically failed pulmonary TB were reviewed. Clinical information and the image characteristics of CT scan were investigated and analyzed.Forty-six of the 89 patients undergoing successful VATS therapeutic resection had significantly lower grading in pleural thickening (P < 0.001), peribronchial lymph node calcification (P < 0.001), tuberculoma (P = 0.015), cavity (P = 0.006), and aspergilloma (P = 0.038); they had less operative blood loss (171.0 ± 218.7 vs 542.8 ± 622.8 mL; P < 0.001) and shorter hospital stay (5.2 ± 2.2 vs 15.6 ± 15.6 days; P < 0.001). They also had a lower percentage of anatomic resection (73.9% vs 93.0%; P = 0.016), a higher percentage of sublobar resection (56.5% vs 32.6%; P = 0.023), and a lower disease relapse rate (4.3% vs 23.3%; P = 0.009). Eighteen of the 38 patients with multi-drug resistant pulmonary tuberculosis (MDRTB) who successfully underwent VATS had significantly lower grading in pleural thickening (P = 0.001), peribronchial lymph node calcification (P = 0.019), and cavity (P = 0.017). They were preoperatively medicated for a shorter period of time (221.6 ± 90.8 vs 596.1 ± 432.5 days; P = 0.001), and had more sublobar resection (44.4% vs 10%), less blood loss (165.3 ± 148.3 vs 468.0 ± 439.9 mL; P = 0.009), and shorter hospital stay (5.4 ± 2.6 vs 11.8 ± 6.9 days; P = 0.001).Without multiple cavities, peribronchial lymph node calcification, and extensive pleural thickening, VATS therapeutic resection could be safely performed in selected patients with medically failed pulmonary TB as an effective adjunct with satisfactory results.

Using Cystic Fibrosis Therapies for Non-Cystic Fibrosis Bronchiectasis

Non-cystic fibrosis bronchiectasis (NCFB) is an increasingly prevalent disease that places a significant burden on patients and health systems globally. Although many of the therapies used to treat NCFB were originally developed as cystic fibrosis (CF) therapies, not all of them have been demonstrated to be efficacious in NCFB and some may even be harmful. This article explores the evidence for which therapeutic strategies used to treat CF have been translated into the care of NCFB. The conclusion is that therapies for adult NCFB cannot be simply extrapolated from CF clinical trials, and in some instances, doing so may actually result in harm.

Technical difficulties and extending the indications for VATS lobectomy

BACKGROUND

Data on advantages of video-assisted thoracoscopic surgery (VATS) lobectomies has been accumulated during the last 10 years then number of thoracoscopic anatomic pulmonary resections rapidly increased. But still there is no agreement about limitations of the method. The most popular "technical contraindications" for VATS anatomic pulmonary resections are: dense pleural adhesions, incompleteness of interlobar fissure, previous chemo- or/and radiotherapy, perivascular or/and peribronchial fibrosis, tumor larger than 5 cm, chest wall involvement, centrally located tumor, severe comorbidity, advanced age, severe COPD and emphysema. Extending of indications for the VATS anatomic pulmonary resection and its influence on the immediate outcomes was investigated.

METHODS

Ninety two consecutive cases of VATS anatomic pulmonary resection performed by the single surgeon from January 2012 till December 2013 at the Federal University Hospital #122 in Saint Petersburg, Russia were retrospectively analyzed. Forty three males and 49 females at the age from 21 to 87 years old (mean age 59±7.2). The most of the cases were comprised by lung cancer of I-III stage together with bronchiectasis and tuberculomas. Conversion rate was 3.2% mostly due to perivascular calcification and/or fibrosis. There were no cases of 30-days mortality and readmission. All those patients retrospectively divided into two groups: with standard and extended indications for the VATS lobectomy. Inclusion in "extended" group was made if patients had one or more technical challenges among following: size of the lesion 5 cm and more; strong pleural adhesions and/or "bad fissure"; adjacent structures involvement; hilar or mediastinal lymph nodes enlargement or involvement; centrally located tumors; previous chemo- or chemoradiotherapy or previous thoracic surgery.

RESULTS

According to these criteria, 45 standard (S) and 47 extended (E) patients were pair-matched with no statistically significant differences between the groups in common patients' characteristics. Postoperative comparison of "standard" and "expanded" groups revealed some differences in average operation time (152 vs. 189 min), in number of resected mediastinal lymph nodes (10.2 vs. 13.1), and in the mean time before removal of the chest tube (3.9 vs. 5.2 days). But the blood loss, morbidity and the length of hospital stay were almost the same in the two groups.

CONCLUSIONS

Extension of indications to VATS lobectomy does not compromise the short-term results. Incompleteness of interlobar fissures, pleural adhesions, preoperative chemotherapy, big size of lesion, and some cases of centrally located tumors are not supposed to be the contraindications for VATS lobectomy. Peribronchial and perivascular lymph node calcification may complicate and even preclude lobectomy by VATS.

Is video-assisted thoracic surgery lobectomy in benign disease practical and effective?

BACKGROUND

The aim of this study was to analyze the surgical outcomes of video-assisted thoracic surgery (VATS) lobectomy for benign pulmonary disease and to propose surgical guidelines based on the retrospective cohort study.

METHODS

From January 2004 to December 2009, all lobectomies performed in a university-based tertiary care hospital were analyzed. The inclusion criteria were as follows: (I) VATS lobectomy for benign disease; (II) thoracotomy conversion cases initially approached by VATS lobectomy. All malignant cases were excluded. Electronic medical records were retrospectively analyzed and patients were divided into two groups: with infection and without infection. The primary outcomes were the thoracotomy conversion rate, length of hospital stay, period of thoracic drainage and complications.

RESULTS

VATS was performed in 163 (42%) of 385 patients who underwent lobectomy for benign disease. There were 68 in the infection group and 95 in the group without infection. VATS lobectomy was successful in 157 (96%) patients while 6 were converted into thoracotomy. The mean operation time and blood loss were 160 minutes and 326 mL. Comparing two groups, operation time and blood loss were not statistically different (P value =0.92, 0.63). Moreover conversion rate, length of hospital stay, period of thoracic drainage and complications (P value =0.67, 0.18, 0.25, and 0.50) were not different.

CONCLUSIONS

VATS lobectomy for benign disease is practical and effective in selected cases regardless of the presence of infection. However, because various technical obstacles may be encountered during the procedure, therefore, careful patient selection is needed.

Is video-assisted thoracic surgery lobectomy better? Quality of life considerations

Video-assisted thoracic surgery lobectomy has controversial advantages over traditional open surgical approaches. Subjective concerns such as pain, dyspnea, physical functioning, and overall satisfaction generally favor VATS but vary depending on survey timing. Independence, a major quality of life component, favors video-assisted thoracic surgery because fewer objective hospital and discharge resources are needed because pulmonary function, activity level, muscle strength, and walking capacity are better. Video-assisted thoracic surgery often hastens return to work and facilitates adjuvant chemotherapy or subsequent urgent surgical procedures. Video-assisted thoracic surgery-related quality of life benefits are amplified by advanced age (or other frailties) and reduced by advanced cancer stage or comorbid illness.

Thoracoscopic lobectomy is a safe and versatile procedure: experience with 500 consecutive patients

OBJECTIVE

Advantages of thoracoscopic lobectomy for early stage non-small cell lung cancer (NSCLC), as compared with lobectomy by conventional thoracotomy, include less postoperative pain and shorter length of hospitalization. The outcomes after thoracoscopic lobectomy in patients with more complex pulmonary conditions are analyzed to determine safety, efficacy, and versatility.

METHODS

A prospective database of 500 consecutive patients who underwent thoracoscopic lobectomy between June 1999 and January 2006 was queried. Demographic, histopathologic, perioperative, and outcome variables were assessed using standard descriptive statistics and Kaplan-Meier survival analyses.

RESULTS

Thoracoscopic lobectomy was successfully performed in 492 patients (conversion rate, 1.6%). Pathologic analysis included primary NSCLC in 416 patients (83.2%), centrally located secondary pulmonary malignancy in 37 patients (7.4%), and a variety of benign conditions in 45 patients (9%). Among the 416 patients with NSCLC, pathologic analysis demonstrated stage I in 330 patients (55.3%), stage II in 40 patients (9.6%), and stage III or greater NSCLC in 44 patients (10.6%). The operative and perioperative (30-day) mortality was 0% and 1%, respectively. The overall 2-year survival rate for the entire cohort was 80%, and the 2-year overall survival rates for stage I NSCLC, stage II or greater NSCLC, secondary pulmonary malignancy, and granulomatous disease patients were 85%, 77%, 73%, and 89%, respectively.

CONCLUSIONS

Thoracoscopic lobectomy is applicable to a spectrum of malignant and benign pulmonary disease and is associated with a low perioperative morbidity and mortality rate. Survival rates are comparable to those for lobectomy with thoracotomy.

Video-assisted thoracic surgery for pleural empyema

BACKGROUND

After we gained considerable experience with video-assisted thoracic surgery (VATS) and became familiar with its advantages, we started to use it for the treatment of thoracic empyema.

METHODS

We treated 130 patients with pleural empyema in whom chest tube drainage and antibiotic therapy had failed to produce a satisfactory result. Six months after surgery they had clinical and radiologic assessment and spirometry.

RESULTS

Video-assisted surgery was performed in all patients. Mean operative time was 93 minutes (range, from 55 to 180 minutes), mean duration of postoperative chest tube drainage was 10 days (range, from 5 to 32 days), and mean hospital stay was 16 days (range, from 3 to 56 days). The rate of conversion to open thoracotomy was 3.1%. Complications for which reoperation was necessary occurred in 9% of patients. At follow-up after six months, the mean forced expiratory volume in 1 second was 87.7% (range, from 69.5% to 105.9%), the mean postoperative vital capacity was 84.4%, (range, from 59.9% to 97.9%). There were no postoperative or procedure-related deaths.

CONCLUSIONS

Video-assisted thoracic surgery is a safe and effective treatment option for fibropurulent empyema with low morbidity and mortality. Conversion to thoracotomy should be used if necessary to remove all of the fibropurulent material and achieve complete expansion of the lung to insure a good outcome.

Postoperative Bleeding: Coagulopathy, Bleeding, Hemothorax

Several issues are involved in determining a patient's risk for postoperative hemorrhage and in managing this potential postoperative complication. The impact of minimally invasive procedures on the incidence of this complication is addressed in this article.

Laparoscopic inferior vena cava and right atrial thrombectomy utilizing deep hypothermic circulatory arrest

BACKGROUND AND PURPOSE

Surgery for renal cancer associated with a level III or IV tumor thrombus often involves cardiopulmonary bypass, deep hypothermia, and exploration of the right atrium and inferior vena cava (IVC). This major open operation necessitates a large median sternotomy incision and a midline abdominal or chevron incision. Herein, we investigate the feasibility of purely laparoscopic IVC and right atrial thrombectomy utilizing deep hypothermic circulatory arrest.

MATERIALS AND METHODS

In six male calves weighing 70 to 80 kg, the right common carotid artery and right internal jugular vein were cannulated for subsequent cardiopulmonary bypass. One laparoscopic team performed right radical nephrectomy and complete mobilization of the intra-abdominal IVC by a four-port approach. Simultaneously, a second laparoscopic team obtained three-port thoracoscopic access to incise the pericardium and expose the right atrium. In sequence, cardiopulmonary bypass, complete exsanguination, cardiac arrest, and core hypothermia of 18 degrees C were achieved. A coagulum thrombus was created by needle injection into the IVC. Combined laparoscopic and thoracoscopic incision, exploration, and thrombectomy of the IVC and the right atrium were then performed in a bloodless field. An angioscope was inserted inside the heart and the IVC to confirm complete thrombus clearance visually. The IVC and right atrium were then laparoscopically suture repaired, cardiopulmonary bypass was reestablished, and the animal was gradually rewarmed. Once sinus rhythm was reestablished at normal body temperature, the animal was weaned off the pump.

RESULTS

The mean total operative time was 494.5 minutes (range 355-705 minutes). The mean time needed to lower the core temperature was 63.5 minutes (range 50-120 minutes), and the mean time required to rewarm the animal was 101.8 minutes (range 70-130 minutes). The mean blood volume drained into the pump was 2633.3 mL (range 1400-3200 mL), and the mean estimated blood loss was 350 mL (range 200-750 mL). Reestablishment of sinus cardiac rhythm and weaning off the pump was successful in all animals prior to acute euthanasia.

CONCLUSIONS

Laparoscopic radical nephrectomy with thrombectomy for level III or IV tumor thrombi utilizing deep hypothermic circulatory arrest is feasible in the calf model using minimally invasive techniques exclusively. The procedure is technically complex and requires the combined efforts of expert urologic and cardiac operative teams. Survival studies are planned.

Thoracoscopic lobectomy: a safe and effective strategy for patients with stage I lung cancer

BACKGROUND

Thoracoscopic lobectomy is emerging as a potential alternative to thoracotomy for early stage lung cancer. The issues of safety and oncologic efficacy should be analyzed before recommending this procedure for widespread use.

METHODS

Thoracoscopic lobectomy was attempted in 110 consecutive patients (age, 35 to 81 years) with tumors that were judged to be amenable to lobectomy over a 26-month period. Exclusion criteria included tumors greater than 5 cm in diameter, T3 tumors, endobronchial tumors visible at bronchoscopy, the use of induction therapy, extensive N1 disease on computed tomographic scan, and N2 disease at mediastinoscopy. The procedures were performed without rib spreading using two ports and included anatomic hilar dissection and individual vessel stapling.

RESULTS

Thoracoscopic lobectomy and mediastinal lymph dissection was successfully performed in 108 patients (98.2%); 2 patients required conversion to thoracotomy to control bleeding in the setting of dense hilar adenopathy. There were no intraoperative deaths and 4 perioperative deaths (3.6%) caused by pneumonia and associated adult respiratory distress syndrome (3 patients) and stroke (1 patient). Major complications included pneumonia (5 patients), stroke (1 patient), and return to the operating room to revise the bronchial closure (1 patient). Minor complications included prolonged air leak (6 patients), atrial fibrillation (4 patients), blood transfusion (2 patients) and ileus (1 patient). Median time to chest tube removal was 3 days, and median length of stay was 3 days.

CONCLUSIONS

Thoracoscopic lobectomy is a safe and effective strategy for patients with early stage lung cancer. Long-term follow-up is required to determine if recurrence rate and 5-year survival are comparable with thoracotomy for lobectomy.