VATS Biportal Left Pneumonectomy

Pneumonectomy is defined as the removal of the entire lung. This surgical procedure can be performed intrapericardially or extrapericardially and is associated with the radical dissection of the mediastinal lymph node without the resection of the mediastinal chest wall or the diaphragm. Pneumonectomy remains the main surgical choice for managing locally advanced lung cancer that cannot be treated using other anatomic lung resections like lobectomy or parenchyma-sparing procedures such as sleeve resection. The first successful pneumonectomy for cancer was performed by Evarts Graham in 1933 (1). In recent years, pneumonectomy has been performed for 10% of major lung resections. Despite improvements in surgical techniques and perioperative medical care, pneumonectomy is often associated with high perioperative morbidity and mortality (2–5). The video-assisted thoracoscopic surgery (VATS) approach used to perform lobectomy is widely accepted as a superior alternative to open thoracotomy. This is due to the following benefits: less postoperative pain, lower surgical morbidity, fewer complications, shorter hospital stays, and lower costs (6, 7). Video-assisted thoracoscopic pneumonectomy was first described by Walker in 1994 (8). After that, few reports of thoracoscopic pneumonectomy were published because the VATS approach is associated with technical difficulties (9–11). The purpose of this video is to show the authors’ experience performing a left pneumonectomy using the biportal VATS approach

VATS mediastinal lymph node dissection. Surgical technique and literature review

Objective: With this review we have aimed to present our video-assisted thoracoscopic surgery mediastinal lymph node dissection (VATS MLND) technique and to discuss about its accuracy.Background: VATS resections (lobectomy) have proved to reach the same oncologic outcomes than thoracotomy ones for stage I non-small cell lung cancer. It is also shown that VATS MLND is not inferior to open thoracotomy in terms of accuracy of mediastinal lymph node dissection.Methods: From May 2012 to December 2020, 525 patients were operated of VATS lobectomy with a multiportal approach for NSCLC (468 stage I and 57 stage II-IV) at a high volume Italian Thoracic Surgery Unit: 42 procedures with a 4-port approach, 56 procedures with a 3-ports approach and 427 with a 2-port approach. The main post-operative complications are reported. We described the VATS MLND technique separately as right and left MLND to point out the technical peculiarities of each node station starting with the anatomy. The accuracy of the procedure presented is analyzed in terms of number of lymph node retrieved and upstaging rate comparing our data with that of the most authoritative literature on this topic. We also investigated for the presence of predictors of post-operative complications.Conclusions: We should learn further to became more skilled at performing an adequate VATS lymph node dissection. According to the data presented we can conclude that VATS MLND is a safe and accurate procedure

L’EMPIEMA PLEURICO NEI PAZIENTI HIV-NEGATIVI CON DIPENDENZA DA SOSTANZE E/O ALCOOL: CARATTERISTICHE, TRATTAMENTO E RISULTATI IN UN SINGOLO CENTRO.

SCOPO DEL LAVORO L’empiema pleurico è una patologia temibile per gravità e frequenza che a volte è sottovalutata nei pazienti che abusano di sostanze stupefacenti e/o di alcool. Scopo del lavoro è studiare caratteristiche e trattamento di un gruppo di pazienti HIV-negativi con dipendenza patologica. MATERIALI E METODI Da Gennaio 2004 ad Aprile 2019 sono stati trattati chirurgicamente per empiema pleurico 121 pazienti (M/F: 81/40; età media 65 anni; range 21-83 anni) presso la nostra Unità Operativa. L’eziologia è stata principalmente parapneumonica con 103 casi (85%) e post-traumatica con 18 casi (15%). I pazienti sono stati retrospettivamente stratificati in due gruppi a seconda che avessero o no una dipendenza da sostanze e/o alcool fino a due anni prima (43 vs 78 pazienti – 36% vs 64%). Le caratteristiche dei pazienti con dipendenza sono state poi approfondite mediante analisi statistica univariata. Sono stati infine esclusi dallo studio i pazienti con empiema post-chirurgico e i casi dovuti a fistola bronco-pleurica. RISULTATI I casi di empiema pleurico parapneumonico sono stati 33 (77%; p=0,1) e post-traumatico 10 (23%; p=0,1) tra i pazienti con dipendenza patologica. L’età media era di 43 anni (range 21-56 anni) con un rapporto M/F di 28/15 (p=0,2). Ventiquattro pazienti (56%) sono stati sottoposti all’ingresso a posizionamento di drenaggio pleurico (p<0,05) e tutti i pazienti sono stati poi sottoposti, con buon esito, a intervento di empiemectomia e decorticazione (p<0,05) per persistenza di febbre e/o dispnea nonostante la terapia sistemica. La via di accesso finale è stata in tutti i casi la toracotomia (p<0,05), indipendentemente dallo stadio dell’empiema, a causa dell’estensione della flogosi. In 6 casi (14%, p=0,07) è stato necessario eseguire anche una lobectomia o wedge resection per la presenza di ascesso polmonare/micetoma (5 casi, 12%; p<0,05) o bronchiectasie (1 caso, 2%; p=1,00). All’analisi dei fattori di rischio la malnutrizione (BMI<19) è emersa come principale fattore con 15 pazienti (35%, p<0,05). Anche il diabete con 12 pazienti (28%, p<0,05) e la flebite con 4 pazienti (9%, p<0,05), associata o no ad ascesso nel sito d’iniezione della sostanza, rappresentano le comorbilità più frequenti in questo gruppo omogeneo di pazienti. È stato segnalato inoltre un caso di endocardite della valvola tricuspide (2%, p=0,4) e 4 pazienti erano HCV-positivi (9%, p=0,05) in assenza di cirrosi. CONCLUSIONI I pazienti con empiema pleurico e dipendenza presentano caratteristiche cliniche e comorbilità peculiari. L’intervento chirurgico di empiemectomia/decorticazione, più impegnativo in questi pazienti, è necessario per la persistenza di segni di sepsi anche dopo il posizionamento del drenaggio pleurico. La possibile spiegazione potrebbe essere, secondo noi, la presenza di malnutrizione e diabete oltre al già noto effetto immunosoppressore esercitato dagli oppiacei (eroina in primo luogo) e dall’alcool

Tips and tricks in video-assisted thoracoscopic surgery lobectomy

In 2012, open procedures represented 63% of the total number of lobectomies performed in our unit; in 2015, video-assisted thoracoscopic surgery (VATS) lobectomy numbers increased up to 66% of the total number of lobectomies performed. When carrying out the procedures, we followed the guidelines presented by the International VATS Lobectomy Consensus Group regarding indications, contraindications, preoperative investigations and conversions. In view of 280 VATS major lung resections from May 2012 to May 2016, we describe some tips and tricks that can be useful in this surgical technique, from general principles to single operative procedures

Pros-cons debate about the role and evolution of biportal video-assisted thoracoscopic surgery. Luigi Gaetano Andriolo, Camillo Lopez, Dario Gregori, Giovanna Imbriglio, Daniele Bottigliengo, Corrado Surrente, Valentina Larocca, Gaetano Di Rienzo.

Thoracoscopic surgical techniques have numerous advantages compared to open techniques such as decreasing hospital stay, analgesic requirements and postoperative pain. Since the first video-assisted thoracoscopic surgery (VATS) lobectomy performed 20 years ago this procedure, associated with mediastinal lymph node dissection, has been widely accepted as a standard surgical treatment for early stage non-small cell lung cancer. Traditionally the videoscopic approach is based on the three- or four-port approach but more than 50% of the patients developed post-operative chest wall paraesthesia due to nerve injury. In order to avoid this postoperative complication traditional VATS approach has been modified by using few and smaller working ports developing the so called two-portal VATS. The purpose of this study is to establish the advantages of biportal VATS reviewing a series of 400 consecutive cases of VATS lobectomy performed from May 2012 to December 2017, using progressively less ports (4-3-2 ports), at our Institution. There were 42 patients in four-port, 56 patients in three-port and 302 patients in two-port group. A propensity-score analysis showed that, as compared with two- and three-port group, patients in the four-port group had increased duration of chest tube (respectively difference and 95% CI are 1.493, 0.965; 2.053 and 1.246, 0.472; 2.002), increased postoperative length of stay (respectively difference and 95% CI are 2.564, 1.336; 3.952 and 2.205, 0.672; 3.740), increased postoperative pain only in comparison with two-ports (difference and 95% CI in VAS score 1.482, 0.909; 2.055). There were no significant differences in terms of demographic characteristics, histology, type of intervention, number of complications, operative time, number of lymph nodes retrieved and pStage between the three groups

MAY THE DIGITAL CHEST DRAINAGE ATTENUATE PREDICTORS OF PROLONGED AIR LEAK AFTER VATS PULMONARY LOBECTOMY? RESULTS OF A PROSPECTIVE MULTICENTER RANDOMIZED STUDY BETWEEN ELECTRONIC AND TRADITIONAL CHEST DRAINAGE SYSTEMS.

OBJECTIVES Prolonged air leak (PAL >5 days) is an important factor affecting the fast-track discharge protocol. Our goal is to identify which patients are at high risk for PAL after VATS lobectomy and whether the use of a digital chest drain could mitigate predictors. METHODS From January 2017 to November 2020, 465 patients were operated of VATS lobectomy. The patients were randomized (1:1) in two groups depending on the type of drainage connected with their single (28Ch) chest tube: traditional “bubble-in-chamber” chest drainage or digital chest drainage (Drentech™ Palm EVO). To identify potential predictors of PAL and to assess if the digital drainage could reduce the impact of the predictors, we considered separately the two groups of patients. RESULTS We performed 268 right lobectomies and 197 left lobectomies (M/F: 274/191) and we observed 29 pts. with PAL (> 20 ml/min or FE >1; 11 pts. in digital and 18 pts. in traditional group). Mean age was 67.39 years (±9.58) and the histology was, with the exception of 1 case, malignant (primitive or secondary). In the multivariate analysis, in the digital group, pre-operative FEV1 (OR, 0.16, 95%CI: 0.03;0.76, p=0.021) can be considered as a predictor of prolonged air leak. Referring, instead, to traditional chest drainage group, pre-operative FEV1 (OR, 0.95, 95%CI: 0.92;0.99, p=0.006) as well as pre-operative TLC (OR, 2.11, 95%CI: 1.11;4.40, p=0.047) have a role in the development of an air leakage. Comparing pleural pressure values (differential, Δ) of PAL cases Δ pleural pressure is significantly lower (5 cmH2O, IQR:2-7 versus 7 cmH2O, IQR:6-12, p<0.001) than no PAL patients. CONCLUSIONS Video thoracoscopic surgical procedure have different pros such as decreased of duration of chest tube and fast discharge. The analysis identified predictors of PAL in both groups considered and reported that digital chest drainage could lead to further improvement

Bubbles-in-the-chamber vs digital screen in chest drainage: A blind analysis of compared postoperative air leaks evaluation

Background Chest drainage systems are affected by intra and inter-observer variability and poor sensibility in detecting minimal or apparent air leaks. Objectives Overcome intra and inter-observer variability in detecting air leaks. Methods After surgery, a single apical chest tube was connected to the Drentech™ PalmEVO device and air leaks were checked twice a day by observation of both bubbles-in-the-chamber and digital data. Results On a total of 624 observations, disagreement between digital and traditional systems was recorded in 60(9.6%) cases. In 25(21.4%) patients, a disagreement was recorded. Overall, the digital evaluation influenced clinical management in 13(52%). In 10(40%) patients with temporary discordant features, the presence of high pleural fluid output led to a progressive final concordance. Conclusions Disagreement between traditional and digital systems in checking air leaks is not negligible. Digital systems could give advantages in making an objective assessment of air leaks, standardizing the timing of chest tube removal