Uniportal video-assisted thoracoscopic thymectomy and resection of a giant thymoma in a patient witness of Jehova

Perioperative strategies and management of giant anterior mediastinal tumors: a narrative review

Background and Objective

Giant anterior mediastinal tumors sometimes may cause circulatory collapse and respiratory failure, known as mediastinal mass syndrome (MMS). The prediction and prevention of MMS is challenging. The aim of this study is to summarize the evaluation methods for MMS and formulate treatment strategies for giant anterior mediastinal tumors.

Methods

We performed a thorough analysis of recent international literature on giant anterior mediastinal tumors (>10 cm in diameter) and MMS published in the PubMed database. The search spanned the duration of the preceding 10 years from August 19, 2023, and only studies published in English were included.

Key Content and Findings

Mature teratomas and liposarcomas are the most common giant anterior mediastinal tumors and MMS develops most frequently in case of malignant lymphomas. Here, we propose a new treatment strategy for giant anterior mediastinal tumors. Based on imaging findings, giant anterior mediastinal tumors can be classified as cystic or solid and further blood investigation data are useful for a definitive diagnosis. When malignant lymphoma or malignant germ cell tumor is highly suspected, the first choice of treatment is not surgery but chemotherapy and radiotherapy. Moreover, image-guided drainage may be effective if giant cystic anterior tumors develop into MMS. The risk classification of MMS is important for treating giant anterior mediastinal tumors. If the MMS risk classification is 'unsafe' or 'uncertain', the intraoperative management deserves special attention. The surgical approach should however be based on tumor localization and invasion of surrounding tissues. Multidisciplinary team coordination is indispensable in the treatment of giant anterior mediastinal tumors.

Conclusions

When giant anterior mediastinal tumors are encountered, it is important to follow the appropriate treatment strategy, focusing on the development of MMS based on imaging findings and symptoms.

Trends, Symptoms, and Outcomes of Resectable Giant Mediastinal Tumors

Describing the changes in surgical procedures and factors affecting the surgical outcome of patients who have undergone complete resection of giant mediastinal tumors (GMTs, diameter ≥ 10 centimeters) could improve preoperative decision-making and prognostic evaluations. We accessed data from three sources, which are case reports on surgical treatment of GMTs from PubMed, Web of Science, and EMBASE until June 1, 2019; patients with resected GMT from the Surveillance, Epidemiology, and End Results (SEER) database; and retrospective review of medical records in our institution from 2000 to 2019. The worldwide distribution, clinicopathological characteristics, symptom profile, prognosis of patients with GMT resection, and nomogram for surgical outcome prediction are reported. A total of 242 rare GMT cases from four continents (Asia, North America, South America, and Europe) were included. The median age of the patients was 40 (IQR: 27, range: 13–83) years, and the male-to-female ratio was 1.57:1. Dyspnea, shortness of breath, cough, and chest pain or discomfort were the major symptoms at presentation. The prognosis of benign and low-grade malignant GMTs was superior to that of high-grade malignant GMTs. Tumor malignancy played the most critical role in predicting postoperative survival, followed by longest tumor diameter and a posterior mediastinum location. The findings of this study suggest that the number of successful GMT surgeries has increased over the last decade and describe clinical features of GMTs. Physicians should prioritize tumor malignancy as a leading factor in predicting outcome rather than tumor size.

Uniportal video-assisted thoracoscopic surgery and robot-assisted thoracoscopic surgery are feasible approaches with potential advantages in minimally invasive mediastinal lesions resection

Background

This study aims to identify the feasibility of uniportal video-assisted thoracoscopic surgery (VATS) and robot-assisted thoracoscopic surgery (RATS) compared with multiportal VATS in the resection of mediastinal lesions.

Methods

Patients who underwent mediastinal lesion resection were enrolled and allocated to the uni-VATS, tri-VATS, and RATS groups according to the surgical approach. Propensity score-matched (PSM) analysis was performed between the VATS and RATS groups as well as the uni-VATS and tri-VATS groups. The operative and recovery parameters were compared.

Results

Totally, 274 patients were enrolled. There was no difference in the operative parameters among the groups. Compared with multiportal VATS, uniportal VATS and RATS had a significantly shorter chest tube placement time (2.43±0.88 vs. 1.78±1.22 vs. 2.21±1.11 days, P<0.001) and hospital length of stay (LOS) (4.07±1.75 vs. 3.27±1.05 vs. 3.62±1.21 days, P=0.001) without increasing the incidence rate of complications (5.6% vs. 7.2% vs. 5.7%, P=0.864). After PSM, the RATS group showed a significantly lower unplanned conversion rate than the VATS group (0.0% vs. 8.2%, P=0.041), while the uni-VATS group had a shorter chest tube placement time (1.83±1.20 vs. 2.35±0.86 days, P=0.013) and hospital LOS (3.23±1.03 vs. 3.95±2.00 days) than the tri-VATS group.

Conclusions

Compared with multiportal VATS, uniportal VATS and RATS are technically safe and feasible with potential advantages for mediastinal lesion resection.

Uniportal video-assisted thoracoscopic thymectomy: the glove-port with carbon dioxide insufflation

Background

Since 2004, uniportal video-assisted thoracic surgery (VATS) approach was progressively widespread and also applied in the treatment of thymoma, with promising results. We report the first series of patients who undergone uniportal VATS thymectomy using a homemade glove-port with carbon dioxide (CO₂) insufflation. The aim of this article is to analyze the safety and feasibility to perform an extended thymectomy (ET).

Methods

A prospective, single-centre, short-term observational study including patients with mediastinal tumours undergoing scheduled uniportal VATS resection using a glove-port with CO₂. Operations were performed through a single incision of 3.5 cm at the fifth intercostal space, right or left anterior axillary line. A 5 mm-30° camera and working instruments were employed through a glove-port with CO₂.

Results

Thirty-eight patients (20 men; mean age 61.6 years) underwent ET between September 2016 and October 2019. Thirteen patients had a history of Myasthenia Gravis (MG) with thymoma and 8 had incidental findings of thymoma. Additionally, 8 mediastinal cysts and 9 thymic hyperplasia were included. Mean diameter of the tumor was 5.1 cm (range, 1.6-14 cm) and mean operation time was 143 minutes. Mean postoperative drainage duration and hospital stay were 2.3 and 4.3 days, respectively. Mean blood loss was 41 mL. There was no occurrence of surgical morbidity or mortality. During the follow-up period (1-36 months), no recurrence was noted.

Conclusions

Our results suggest that uniportal VATS thymectomy through glove-port and CO₂ is safe and feasible procedure, even with large thymomas. Furthermore, the glove-port system represents a valid, cheap and widely available alternative to the commercial devices usually adopted in thoracic surgery.

Intermediate oncologic outcomes after uniportal video-assisted thoracoscopic thymectomy for early-stage thymoma

Background

Recent years have seen a trend towards utilizing a video-assisted thoracic surgery (VATS) approach for treatment of thymoma. Although increasing in practice, intermediate- and long-term oncologic outcome data is lacking for the VATS approach. There is no oncologic data for the uniportal VATS approach. We sought to evaluate the feasibility and impact on patient survival of uniportal VATS thymectomy for early-stage thymoma.

Method

The clinical outcomes for 17 patients with Masaoka stage I to II thymomas treated between January of 2009 and July of 2014 at a single institution were collected retrospectively. Primary endpoint was overall survival (OS) and secondary endpoint was recurrence-free survival (RFS).

Results

Ten women and seven men underwent uniportal VATS thymectomy; eleven had stage I thymoma and six had stage II thymoma. There were no conversions to open surgery. Operative mortality was zero. Mean tumor size was 3.8±1.0 centimeters, with a range of 1.9 to 6.0 centimeters. All patients underwent a R0 resection. Five-year survival was 100%, and the estimated RFS was 100%.

Conclusions

Our findings suggest that uniportal VATS thymectomy for early-stage thymoma is feasible, and the intermediate-term oncologic outcomes are comparable to historic standards for open and multi-incision VATS thymectomy. However, additional follow-up is required to evaluate for long-term oncologic outcomes.

Giant mature teratoma in thymic tissue removed with uniportal vats approach

INTRODUCTION

Teratomas are tumours composed by different tissues derived from one or more of the three primitive germ cell layers. The frequency of mediastinal teratomas ranged from 1 to 5 %, in most cases with localization in the anterior/superior mediastinum.

PRESENTATION OF CASE

We report a case report of a 29 years old male who presented an occasional and asymptomatic mediastinal mass. Computer Tomography (CT) scan showed a 6.8 × 4.5 cm mass in the anterior mediastino, located below the left brachio-cephalic vein, next to aortic arch and left pulmonary artery. Complete excision of the mass "en block" with anterior mediastinal adipose tissue was achieved, using uniportal VATS approach. The postoperative course was regular, without air leak or other pulmonary complication.

DISCUSSION

VATS technique is minimally invasive and, moreover, it is characterized by a shorter recovery period, a minor blood loss and a shorter hospital stay. VATS has been advocated since 2010 for pulmonary resections, but today it is also performed for mediastinal intervention and a series of reports have demonstrated that it is feasible and safe.

CONCLUSION

The report aims at pointing out the possibility of undergoing this kind of surgery not only in case of pulmonary mass (on which the previous literature has focused) but also when mediastinum lesions occur, as in our case.

Devising the guidelines: the concept of uniportal video-assisted thoracoscopic surgery-incisions and anesthetic management

Uniportal video-assisted thoracoscopic surgery (VATS) is an already established minimally invasive technique in the field of thoracic surgery. The feasibility, safety and efficacy of the technique are already well documented. Comparative studies and meta-analyses have shown a clear advantage over open surgery and other minimally invasive techniques in terms of pain, length of stay (LOS), chest drain duration and morbidity. It covers a broad spectrum of indications for both malignant and benign diseases, including pulmonary and mediastinal tumor resections, diaphragm procedures (plication), esophageal surgery and airway surgery (bronchial resections, carinal resections). Its swift and wide adoption has resulted into many variations, all of whom are common in the fact they utilize a single incision to enter the chest and conduct the planned procedure. With this article, we attempt to standardize the technique as to the incision and the anesthetic management.

Ectopic thoracic thyroid removed by uniportal VATS approach. A case report

INTRODUCTION

We speak of "Ectopic thyroid gland" when a piece of thyroid tissue is placed at a certain distance from the second to fourth tracheal cartilages.

PRESENTATION OF CASE

This case report focuses on a case of a hyperplastic cystic nodule of ectopic thyroid in a 30-year-old woman treated with uniportal video-assisted thoracic surgery (VATS). The patient, was admitted to Emergency Unit for abdominal pain and vomit, underwent a CT which highlighted a mass of significant dimension on the right side of the mediastinum, in contact with close structures. The lesion has been removed with an innovative mini-invasive technique, which is characterized, differently from traditional surgical approaches, by reduced loss of blood and time of hospitalization and, in addiction to that, an aesthetic small-dimensioned scar.

DISCUSSION

VATS technique is minimally invasive and, moreover, it is characterized by a shorter recovery period, a minor blood loss and a shorter hospital stay. VATS has been advocated since 2010 for pulmonary resections, but today it is also performed for mediastinal intervention and a series of reports have demonstrated that it is feasible and safe.

CONCLUSION

The report aims at pointing out the possibility of undergoing this kind of surgery not only in case of pulmonary mass (on which the previous literature has focused) but also when mediastinum lesions occur, as in our case.