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

We report an elderly patient with chronic obstructive pulmonary disease (COPD), Alzheimer\u27s disease and early dementia who presented with multiple displaced rib fractures of left ribs 4 through 9 with flail segments of ribs 4 through 8 and an associated traumatic pneumatocele from rib puncture of the left upper lobe. The decision to treat this patient operatively was based on the presence of flail chest, the patient\u27s age, baseline co-morbidities and limited physiological reserve. Surgical rib fixation is traditionally performed with a thoracotomy incision and open exposure for extra-thoracic rib fixation, however, this patient underwent chest wall stabilization using an extra-thoracic video-assisted thoracic surgery (VATS) technique. We discuss our operative technique using universal rib plating system, optimal retraction for exposure and use of balloon dilation to create an accessible extra-thoracic working space. This surgical approach provided a faster recovery to this patient\u27s baseline with minimal use of narcotics thereby highlighting the impact and importance of this surgical technique for patients presenting with multiple fib fractures, especially the elderly. We show that VATS assisted minimally invasive technique for operative management of multiple rib fractures is a viable surgical option demonstrated by this patient\u27s recovery and return to function with minimal need for pain control despite her advanced age and baseline co-morbidities

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

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

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

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

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

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

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

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

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

We report a patient who presented with multiple rib fractures after falling off a horse and was initially managed medically. Several weeks later, the patient returned to the hospital complaining of dyspnea on exertion. Physical exam revealed severe chest wall malformation and imaging revealed moderate hemothorax and complete collapse of the right lower lobe. Considering the likelihood that this patient\u27s multiple ribs fractures contributed to the hemothorax and trapped lung, the patient underwent surgical evacuation of the hemothorax followed by rib fixation of ribs three through six. The procedures were performed using both intra-thoracic and extra-thoracic video-assisted thoracoscopic surgery (VATS) and did not require the use of thoracotomy incision or open exposure of the thoracic cavity. This case report suggests that this operative technique is a viable option for delayed presentation of multiple rib fractures and complex sequela associated with this pathology

Diaphragmatic Pacing: Is There a Benefit?

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

Stapled Diaphragmatic Plication: Is It Better Than Suture Plication?

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

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

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

ICG for Intraoperative Thoracic Duct Lymphangiogram in VATS Thoracic Duct Ligation

Thoracic duct ligation is a proven, established procedure for chylothorax management refractory to medical management. However, intraoperative localization of the thoracic duct course or leakage is difficult, and there is a lack of consensus on the best intraoperative modality to visualize a thoracic duct. This video proposes that ICG can be used as the modality of choice for intraoperative localization of the thoracic duct. The Patient A forty-two-year-old man presented after sustaining bilateral pneumothoraces and multiple fractures. He was taken to the OR for VATS hemothorax evacuation and chest wall stabilization. His recovery was uneventful, and he was discharged on postoperative day six with no issues. The patient presented five days later with a large right pleural effusion. Thoracentesis drained four liters of chylous fluid consistent with chylothorax. The patient was started on medical management with NPO and Octreotide and subsequently underwent three talc pleurodeses to close the leak, but they were all unsuccessful and surgical management was indicated. The Surgery ICG is a water-soluble molecule with fluorescence in the near-infrared light spectrum. It is inexpensive to manufacture and nontoxic, even in large amounts. The near-infrared signal can be overlaid with the white light camera image to produce an image of real time fluorescence in the surgical field. In this procedure, ICG was administered immediately after intubation and about one hour was allowed for peak fluorescence to develop while the patient was prepped and draped. As the camera was advanced into the chest, the team observed an abundance of adhesions and plaques from the previous talc pleurodeses procedures. The adhesions were lysed, and the right lung was displaced to reveal a collection of serous fluid underneath it. That fluid was suctioned up and blunt dissection attempted to locate the leakage. SPY imaging was then turned on, and the fluorescent imaging was overlaid on top of the normal camera image. On the posterior of the right lung was a collection of fluorescent lymphatic fluid. This was the first time lymphatic fluid being ejected from the thoracic duct lesion into the chest was directly visualized. The SPY gain was then reduced to determine exactly where the fluid was coming from. With the SPY gain turned off, it was nearly impossible to distinguish the fluorescent lymphatic fluid, which became clear, from the serosanguinous fluid in the field. Next, the team began suturing the visceral pleura of the lung to the parietal pleura of the chest wall in an attempt to close the tissue on top of itself and prevent additional leakage. While it may have been standard procedure to perform an en masse ligation of the thoracic duct, it was not possible in this case because of fibrosis and inflammation secondary to the previous talc pleurodeses. As the final portion of the suture was tied down and cut, there was no additional leakage out of the thoracic duct opening. A layer of bioglue sealant was applied and talc pleurodesis was performed so fibrosis and inflammation would prevent additional leakage in the future. Compared to the large amounts of preoperative chylous drainage on medical management, there was minimal postoperative drainage on a low-fat diet. In conclusion, ICG can be considered a practical, safe, and reproducible method of intraoperative lymph angiography. Reference(s) 1. Arshava EV, Parekh KR. Thoracoscopic Thoracic Duct Ligation: How I Teach It. The Annals of Thoracic Surgery. 2020;109(5):1330-1334. doi:10.1016/j.athoracsur.2020.01.004 2. Meester R, QUEST MEDICAL IMAGING. Fluorescence Imaging Enters the Surgical Suite. Accessed January 15, 2023. https://www.photonics.com/Articles/Fluorescence_Imaging_Enters_the_Surgical_Suite/a61927 3. Chakedis J, Shirley LA, Terando AM, Skoracki R, Phay JE. Identification of the Thoracic Duct using Indocyanine Green During Cervical Lymphadenectomy. Ann Surg Oncol. 2018;25(12):3711-3717. doi:10.1245/s10434-018-6690-4 4. Kamiya K, Unno N, Konno H. Intraoperative indocyanine green fluorescence lymphography, a novel imaging technique to detect a chyle fistula after an esophagectomy: Report of a case. Surg Today. 2009;39(5):421-424. doi:10.1007/s00595-008-3852-1 5. Matsuura Y, Ichinose J, Nakao M, Okumura S, Mun M. Recent fluorescence imaging technology applications of indocyanine green in general thoracic surgery. Surg Today. 2020;50(11):1332-1342. doi:10.1007/s00595-019-01906-6 6. Morales-Conde S, Licardie E, Alarcón I, Balla A. Indocyanine green (ICG) fluorescence guide for the use and indications in general surgery: recommendations based on the descriptive review of the literature and the analysis of experience. Cirugía Española (English Edition). 2022;100(9):534-554. doi:10.1016/j.cireng.2022.06.023 7. Newton AD, Predina JD, Nie S, Low P, Singhal S. Intraoperative Fluorescence Imaging in Thoracic Surgery. J Surg Oncol. 2018;118(2):344-355. doi:10.1002/jso.25149 8. Okusanya OT, Hess NR, Luketich JD, Sarkaria IS. Infrared intraoperative fluorescence imaging using indocyanine green in thoracic surgery. European Journal of Cardio-Thoracic Surgery. 2018;53(3):512-518. doi:10.1093/ejcts/ezx352 9. Vecchiato M, Martino A, Sponza M, et al. Thoracic duct identification with indocyanine green fluorescence during minimally invasive esophagectomy with patient in prone position. Diseases of the Esophagus. 2020;33(12):doaa030. doi:10.1093/dote/doaa030</p