The Overweight Paradox: Impact of Body Mass Index on Patients Undergoing VATS Lobectomy or Segmentectomy

The aim of this study was to assess the impact of BMI on perioperative outcomes in patients undergoing VATS lobectomy or segmentectomy. Data from 5088 patients undergoing VATS lobectomy or segmentectomy, included in the VATS Group Italian Registry, were collected. BMI (kg/m²) was categorized according to the WHO classes: underweight, normal, overweight, obese. The effects of BMI on outcomes (complications, 30-days mortality, DFS and OS) were evaluated with a linear regression model, and with a logistic regression model for binary endpoints. In overweight and obese patients, operative time increased with BMI value. Operating room time increased by 5.54 minutes (S.E. = 1.57) in overweight patients, and 33.12 minutes (S.E. = 10.26) in obese patients (P < 0.001). Compared to the other BMI classes, overweight patients were at the lowest risk of pulmonary, acute cardiac, surgical, major, and overall postoperative complications. In the overweight range, a BMI increase from 25 to 29.9 did not significantly affect the length of stay, nor the risk of any complications, except for renal complications (OR: 1.55; 95% CI: 1.07-2.24; P = 0.03), and it reduced the risk of prolonged air leak (OR: 0.8; 95% CI: 0.71-0.90; P < 0.001). 30-days mortality is higher in the underweight group compared to the others. We did not find any significant difference in DFS and OS. According to our results, obesity increases operating room time for VATS major lung resection. Overweight patients are at the lowest risk of pulmonary, acute cardiac, surgical, major, and overall postoperative complications following VATS resections. The risk of most postoperative complications progressively increases as the BMI deviates from the point at the lowest risk, towards both extremes of BMI values. Thirty days mortality is higher in the underweight group, with no differences in DFS and OS.

Second Surgery for Recurrent Malignant Pleural Mesothelioma after Multimodality Treatment: A Systematic Review

Malignant pleural mesothelioma (MPM) is an aggressive asbestos-related tumour with poor prognosis. To date, a multimodality treatment, including chemotherapy and surgery, with or without radiotherapy, is the gold standard therapy for selected patients with epithelioid and early-stage MPM. In this setting, the goal of surgery is to achieve the macroscopic complete resection, obtained by either extrapleural pneumonectomy or pleurectomy/decortication. Failure, in local and/or distant sites, is one of the major concerns; in fact, there has been no established treatment for the recurrence of MPM after the multimodal approach, and the role of surgery in this context is still controversial. By using electronic databases, studies that included recurrent MPM patients who underwent a second surgery were identified. The endpoints included were: a pattern of recurrence, post-recurrence survival (PRS), and the type of second surgery. When available, factors predicting better PRS and perioperative mortality and morbidity were collected. This systematic review offers an overview of the results that are currently obtained in patients undergoing a second surgery for relapsed MPM, with the aim to provide a comprehensive view on this subject that explores if a second surgery leads to an improvement in survival.

The role of Ivor Lewis esophagectomy in the treatment of achalasia with megaesophagus: A case report

Introduction

Achalasia with megaesophagus is a pathology characterized by widespread and irregular dilation of the esophageal lumen. In most cases, this dilation is caused by contraction and subsequent failed relaxation of the lower esophageal sphincter (LES). It may be associated with a partial or complete slowing of the esophageal peristalsis.

Case overview

We present the case of a 58-year-old woman who developed dysphagia, regurgitation, and substantial weight loss (11 kg) over a span of 1 year. Symptomatic achalasia with megaesophagus was diagnosed following chest and abdominal computed tomography (CT) with contrast and transit RX with gastrografin and esophageal manometry. The patient refuse all minimally endoscopic treatments and opted straightly for the treatment with esophagectomy sec. Ivor-Lewis. At the 6-month follow-up, the patient appeared in excellent general clinical condition and oral gastrografin radiography (OGR) showed good channeling.

Discussion

Patients require medical attention when presenting with achalasia that has eroded the esophageal wall enough to form a megaesophagus. Early and minimally invasive treatments (i.e., medical therapy, endoscopic dilation, and myotomy) are insufficient at this stage, and thus esophageal surgery is required. Among the most common surgical approaches, we must mention esophagectomy sec. McKeown and esophagectomy with interposition of a colic loop sec. Wilkins; however, based on our experience, esophagectomy sec. Ivor-Lewis with intrathoracic anastomosis leads to excellent results and can therefore be considered a valid alternative for treating complex cases.

Conclusions

Subtotal esophagectomy sec. Ivor-Lewis with intrathoracic anastomosis is effective in treating achalasia with megaesophagus.

Totally thoracoscopic versus standard VATS lobectomies: perioperative differences

BACKGROUND

Minimally invasive surgery is considered the gold standard approach for early stage lung cancer. Techniques range from a standard three-port approach to uniportal lobectomies, with no technique emerging as superior thus far. We retrospectively compared the pain outcomes of a standard approach using a utility incision with a totally thoracoscopic technique.

METHODS

Between January 2015 and December 2019, 168 patients received a VATS lobectomy in our centers. Two groups were created, Group A (82 patients, totally thoracoscopic approach) and Group B (86 patients, standard approach with utility incision). Perioperative outcomes, such as operative time, complications, length of stay, perioperative and chronic pain using visual analog scale (VAS), and rescue doses of painkillers were examined. A one-way analysis of covariance (ANCOVA) was conducted to investigate the impact of surgical time and days of drainage on VAS score.

RESULTS

Pain was less on postoperative day (POD) 1 and 2 (p = 0.025 and p = 0.020, respectively) in Group A. No differences were found in the baseline and perioperative characteristics of the two groups, in the mean VAS score at 1 month (p = 0.429), 1 year (p = 0.561), doses of NSAIDs (p = 0.609), and chronic pain (3vs7 patients, p = 0.220). The ANCOVA test showed no significant effect of surgical time and days of drainage on VAS score (p > 0.05).

CONCLUSIONS

In our experience, a totally thoracoscopic approach may improve acute postoperative pain without compromising the oncological results of the procedure and the safety of the patients.

The success of Eso-SPONGE® therapy in the treatment of anastomotic dehiscence after Ivor-Lewis subtotal esophagectomy: A case report

Introduction

Eso-SPONGE® has proved to be an excellent method for the treatment of persistent dehiscence of the intrathoracic esophagogastric anastomosis during the operation of subtotal esophagectomy sec. Ivor Lewis.

Clinical case presentation

The case presented is of a 72-year-old patient with esophageal adenocarcinoma (ADK) who underwent sub-total esophagectomy and esophagoplasty sec. Ivor Lewis complicated by an esophageal leak. The Eso-SPONGE® therapy has been successful halving the index of inflammation after the first two sessions and generation of a neowall after seven sessions.

Discussion

Eso-SPONGE® therapy has proven to be a valuable resource as a treatment for esophageal anastomotic dehiscences because it is easily repeatable in suburban centers, provided that they have a digestive endoscopy specialized in the positioning process.

Conclusions

Eso-SPONGE® is a minimally invasive method that delivers excellent results in the treatment of fragile patients, such as those who have post-esophageal anastomotic dehiscence.

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Anastomotic dehiscence is an adverse event in esophageal surgery.

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Eso-SPONGE® is an excellent method to treat the esophageal post-surgery dehiscence.

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Eso-SPONGE® has provided better results than previous methods.

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Eso-SPONGE® is easily repeatable even in not-expert centers.

Sleeve Lobectomy: To Wrap or Not to Wrap the Bronchial Anastomosis?

BACKGROUND

Bronchoplastic procedures have become the reference standard in the lung parenchyma-sparing treatment of centrally located bronchopulmonary tumors. Two schools of thought exist regarding performing a bronchial sleeve resection: those who wrap the anastomosis with a pedicled flap and those who leave the anastomosis unprotected. We performed a study comparing these 2 methods.

METHODS

This study was a retrospective multicenter observational analysis of 90 consecutive patients undergoing bronchial sleeve resections for neoplastic disease between June 2009 and July 2019. Group A (60 patients) underwent bronchial wrapping and group B (30 patients) did not undergo wrapping.

RESULTS

The only difference between group A, which had 5 patients (8.3%), and group B, which had 10 patients (33.3%), regarding general characteristics was the presence of diabetes (P = .003). There were no differences in surgical, postoperative, and follow-up characteristics. There was no statistically significant difference between groups (group A, 9 patients [15%]; and group B, 6 patients [20%]) in terms of anastomotic complications at 1 year (P = .425). Diabetes was an independent predictive factor for anastomotic complications at 1 year (P = .035). The number of postoperative complications (P < .001) was an independent risk factor for length of hospital stay.

CONCLUSIONS

We found no differences between groups in terms of postoperative complications and length of hospital stay, which confirmed previous reports that sleeve resections may be performed safely without bronchial wrapping.

A strange case of foreign body embolism in the right lower pulmonary artery

Foreign bodies in the pulmonary circulation have been documented in the literature, with almost all cases being iatrogenic, involving venous catheters, or due to penetrating foreign body emboli. Foreign body pulmonary emboli are often difficult to diagnose due to their varied clinical presentation, the nature of the embolizing material and dubious radiological features. We describe the case of a patient who experienced episodes of massive hemoptysis with inconclusive radiological findings, who underwent a thoracotomy with the discovery of a wooden object of 7 cm in length in the right lower lobe artery, with no apparent mechanism of injury.

Conversion due to vascular injury during video-assisted thoracic surgery lobectomy: A multicentre retrospective analysis from the Italian video-assisted thoracic surgery group registry

OBJECTIVES

Vascular injuries are among the most severe causes of unplanned conversion during VATS lobectomies. The study aimed to analyse the incidence of vascular injuries and their risk factors during VATS lobectomy.

METHODS

The Italian VATS lobectomy Registry was used to collect data from 66 Thoracic Surgery Units. From 2013 to October 2016 (out of more than 3,700 patients enrolled) only information from Units with an enrollment >100 VATS lobectomies were retrospectively analysed. Logistic regression analysis was performed on selected variables of the univariate analysis.

RESULTS

Ten institutions contributed a total of 1,679 patients. Vascular injuries leading to conversion occurred in 44 (2.6%) patients. Years of experiences were inversely related to the risk of vascular injuries. Univariate analysis showed age, gender, surgical activity, Charlson Index Score and number of resected lymph nodes like significantly associated variables. Multivariate analysis revealed that number of resected lymph nodes, VATS experience ratio (number of VATS lobectomies/total lobectomies performed in the same year at same centre), and surgical activity of the centre were significantly associated with the risk of conversion. Unplanned thoracotomy was correlated with postoperative morbidity.

CONCLUSION

Vascular injuries in VATS lobectomies represented a rare complication which could directly affect the postoperative outcomes. The predictive factors for conversion were multifactorial and depended on characteristics of centres and surgeons' seniority. Minimally invasive VATS lobectomy approaches did not influence the risk of vascular damages.

National adoption of video-assisted thoracoscopic surgery (VATS) lobectomy: the Italian VATS register evaluation

Background

The expertise curve of video-assisted thoracoscopic surgery (VATS) lobectomies still stirs debate and controversy both because of the number of procedures to carry out and of the evaluation of the learning threshold. The purpose of our study was the examination of the variables related to the learning curve of the video-assisted approach, to establish what may be an expression of the technical maturity of the surgeon.

Methods

The National Register for VATS lobectomy built in 2013 was used to collect data from 65 Thoracic Surgery Units. Out of more than 3,700 patients enrolled, only information from Units with ≥100 VATS lobectomies were retrospectively analysed. Unpaired Student's t-tests, Fisher's exact tests, Pearson's χ² were applied as needed. Cumulative summative analysis and one-way ANOVA were used to identify the expertise curve of VATS lobectomy.

Results

Ten institutions contributed a total of 1,679 patients, who were divided into three uniform groups according to the chronological sequence of surgery. The length of utility incision, the number of dissected lymph nodes and the operative time were not statistically significant (P=0.999, P=0.972 and P=0.307, respectively) among groups. Conversion to thoracotomy and postoperative air leaks occurred in 125 (7.44%) and 109 (6.49%) patients, gradually declined in Group 3 with statistical significance (P=0.048 and P=0.00086).

Conclusions

The conversion rate and the percentage of air leaks seem to define the expertise of VATS lobectomy, being linked to the ability to manage more complicated surgical cases or intraoperative adverse events.

Uniportal video-assisted thoracoscopic surgery in hemothorax

The management of hemothorax (spontaneous or, more often, due to thoracic trauma lesions), follows basic tenets well-respected by cardiothoracic surgeons. In most, a non-operative approach is adequate and safe, with a defined group of patients requiring only tube thoracostomy. Only a minority of patients need a surgical intervention due to retained hemothorax, persistent bleeding or incoming complications, as pleural empyema or entrapped lung. In the early 1990s, the rapid technological developments determined an increase of diagnostic and therapeutical indications for multiport video-assisted thoracoscopic surgery (VATS) as the gold standard therapy for retained and persistent hemothorax, allowing an earlier diagnosis, total clots removal and better tubes placement with less morbidity, reduced post-operative pain and shorter hospital stay. There is no consensus in the literature regarding the timing for draining hemothorax, but best results are obtained when the drainage is performed within the first 5 days after the onset. The traditional multi-port approach has evolved in the last years into an uniportal approach that mimics open surgical vantage points utilizing a non-rib-spreading single small incision. Currently, in experienced hands, this technique is used for diagnostic and therapeutic interventions as hemothorax evacuation as like as the more complex procedures, such as lobectomies or bronchial sleeve and vascular reconstructions.

Materials and techniques in chest wall reconstruction: a review

Extensive chest wall resection and reconstruction are a challenging procedure that requires a multidisciplinary approach, including input from thoracic surgeon, plastic surgeon and oncologist. In particular chest wall neoplastic pathology is associated with high surgical morbidity and can result in full thickness defects hard to reconstruct. The goals of a successful chest wall reconstruction are to restore the chest wall rigidity, preserve pulmonary mechanic and protect the intrathoracic organs minimizing the thoracic deformity. In case of large full thickness defects synthetic, biologic or composite meshes can be used, with or without titanium plate to restore thoracic cage rigidity as like as more recently the use of allograft to reconstruct the sternum. After skeletal stability is established full tissue coverage can be achieved using direct suture, skin graft or local advancement flaps, pedicled myocutaneous flaps or free flaps. The aim of this article is to illustrate the indications, various materials and techniques for chest wall reconstruction with the goal to obtain the best chest wall rigidity and soft tissue coverage.

Unilateral pulmonary artery agenesia complicated by massive haemoptysis in an adult female

Isolated unilateral pulmonary artery agenesis is a rare congenital abnormality. We report a case of right pulmonary artery agenesis in an adult female without other cardiovascular anomalies. The patient presented with massive haemoptysis four years after the original diagnosis. The patient underwent right pneumonectomy with stapled suture of the main bronchus covered by an intercostal muscle flap. The clinical course was complicated by a bronchopleural fistula one month after the first operation. The fistula was successfully treated with a videothoracoscopic omentoplasty and serratus muscle flap. In these patients the surgical approach can be particularly complex because of the high risk of bleeding from the highly vascularised and extensive adhesions between the lung and the chest wall, associated with hyperplasia of the bronchial and intercostal arterial trees. In spite of these difficulties, access to the pulmonary veins and the main bronchus during pneumonectomy is not challenging.