Robotic Right Upper Lobe Sleeve Lobectomy

<p><strong>Clinical Summary</strong></p><p>A 52-year-old male light smoker was under regular annual checks following a previous ocular melanoma, which was treated in 2013 with brachytherapy. During one of the follow-up visits, a lesion was found in the upper right lobe (RUL), close to the right main bronchus without hilar or mediastinal adenopathy. Flexible bronchoscopy showed, in the right-side airways, a tumor occluding almost the entire right upper bronchus and involving the proximal main bronchus. A biopsy confirmed a typical carcinoid tumor, and the patient was scheduled to undergo a robotic upper lobe sleeve-lobectomy (daVinci Surgical System, Intuitive Surgical, Mountain View, CA, USA). </p><p><strong>Surgical Technique</strong></p><p>Under general anesthesia, the patient was positioned into a left lateral decubitus position. The port-mapping implied 4 ports: an 8 mm camera port in the sixth intercostal space below the scapula tip; two ports at the sixth intercostal space posteriorly, following the same space with a distance between them of about 5 cm; and a final port placed anteriorly at the 6th intercostal space, just above the diaphragm. The camera was maintained in the same position for the entire procedure. The first step was to open the mediastinal pleura below the azygos vein to identify the tumor arising from the right upper bronchus. This was followed by the exposure of the Boyden branch and the upper vein. All lobar vessels were individually dissected and encircled with a vessel loop. To complete the posterior fissure and all the vessel transections, a 45 mm robotic stapler (Intuitive Surgical, Mountain View, CA, USA) was used. At this point, a 45 mm endostapler (Covidien Endo GIA™) was used to complete the fissures.</p><p>The right main bronchus and the upper lobe bronchus were dissected and cleared using the robotic scissors. The bronchial resection started from the anterior wall of the right main bronchus. Once the tumor was visualized, the resection was extended to the intermediate bronchus under bronchoscopic control. The specimen was removed and the inferior pulmonary ligament was released to allow a decrease in tension on the anastomosis. The anastomosis was performed through two running V-lock™ (Covidien) sutures using a 3-0 nonabsorbable autolocking suture. The suture was started from the caudal corner of the pars cartilaginea to the pars membranacea, toward the anterior bronchial wall. The tension of the suture was assessed at each step. The continuity of the suture was guaranteed by tying the two sutures through a double knot. The pars membranacea was left as a final step. Once concluded, the integrity of the anastomosis was checked endoscopically and through irrigation. A single 24 Fr chest tube was placed through the camera port. The patient had an uneventful clinical course and was discharged on the fifth postoperative day. Pathological analysis confirmed typical carcinoid with bronchial involvement, with no bronchial margins and no lymph node malignancy. The follow-up through bronchoscopy showed a good caliber anastomosis [1-2].</p> <p><strong>References</strong></p><p>1) Schmid T, Augustin F, Kainz G, Pratschke J, Bodner J. Hybrid video-assisted thoracic surgery-robotic minimally invasive right upper lobe sleeve lobectomy. <em><a href="https://doi.org/10.1016/j.athoracsur.2010.08.079">Ann Thorac Surg. 2011;91(6): 1961-1965</a></em>.<br>2) Cerfolio RJ. Robotic sleeve lobectomy: technical details and early results. <em><a href="https://doi.org/10.3978/j.issn.2072-1439.2016.01.70">J Thorac Dis. 2016;8(suppl 2): S223-S226</a></em>.</p

PITAC: Pressurized Intrathoracic Aerosol Chemotherapy

Pressurized intrathoracic aerosol chemotherapy (PITAC) is a novel and promising treatment for malignant pleural effusion, allowing surgeons to achieve an effective pleurodesis together with a potential anti-neoplastic effect. The treatment delivers chemotherapeutic agents via a nebulizer into the thoracic cavity, where a therapeutic aerosol is formed. PITAC rationale is based on physical properties such as the homogeneous distribution of a gas within a closed space and creating a pressure gradient to overcome the tumor interstitial fluid pressure, which enhances in-tissue drug penetration. This procedure is performed using VATS, incorporating all the advantages of a minimally invasive approach. In addition, a low dose of chemotherapeutic drugs is administered with no systemic toxicity.Given these advantages, PITAC may soon represent a pioneering treatment in the field of loco-regional therapy for pleural carcinomatosis. This video presents a demonstration of the procedure.First, the patient was laid in the lateral decubitus position under general anesthesia. Two 12 mm balloon trocars were positioned in the chest wall, one in the seventh intercostal space (ICS) in the mid-axillary line and one in the fifth ICS in the anterior axillary line. The camera was inserted through the trocar at the seventh ICS. A standard thoracoscopy was then performed with a careful exploration of the entire thoracic cavity. Balloon trocars were required to create a closed system and avoid pressurized aerosol dispersal outside the thoracic cavity. After MPE removal and lysis of eventual pleural adhesions, multiple parietal pleural biopsies were sampled as common practice. In patients without a preoperative diagnosis of pleural carcinomatosis, pathologic confirmation should be obtained by intraoperative frozen section.A dedicated checklist containing all safety aspects of the PITAC procedure was double checked before administration of chemotherapy drugs. CO2 was used to pressurize the pleural space and the gas was inflated into thoracic cavity by the trocar at the fifth ICS. The dedicated CE-certified nebulizer in surgical stainless steel was then inserted through the trocar at the fifth ICS and connected to a high pressure injector. Cytostatic solutions were prepared according to the patient’s body surface area (BSA), calculated with the Boyd formula, and were then drawn into the injector syringe. Before starting the nebulization, the patient was covered with a sterile drape to minimize operating room air contamination with aerosol chemotherapeutic agents.Next, all the staff left the operating room (OR) to prevent eventual exposure to chemotherapy. Using a remote control, cisplatin (10.5 mg/m2 in 150 mL NaCl 0.9 percent) and doxorubicin (2.1 mg/m2 in 50 mL NaCl 0.9 percent) were aerosolized into the pleural cavity at 0.7 mL/s flow with a maximal upstream pressure of 220 PSI. This closed system was left in a steady state for 30 minutes at 37 °C under a constant intrathoracic pressure of 12 mmHg CO2 to increase drug penetration into the neoplastic tissue. Cisplatin and doxorubicin were selected for both direct cytotoxic and sclerosing effects on pleural layers.Vital signs and the nebulization procedure were remote controlled by both surgeons and anesthesiologists from outside the OR, even though there is no significant inhalation risk. At the end of 30 minutes of nebulization, the staff entered the OR to remove the remaining toxic aerosol using a closed surgical smoke evacuation system with two microparticle filters to capture residual molecules. Next, the pleural space was carefully explored to check hemostasis. The trocar ballons were then deflated and retracted under vision control. Finally, two chest drains were placed and the lung was ventilated.To conclude, PITAC is a safe, feasible, and effective technique to control malignant pleural effusion recurrence. Further investigations should also assess its oncological role. PITAC might represent a pioneering treatment in the field of locoregional therapy for pleural carcinomatosis.Reference(s)1) Clive AOJ, Bhatnagar R, Preston NJ, et al. Interventions for the management of malignant pleural effusions: a network meta-analysis. Cochrane Database Syst Rev 2016;5:CD010529.2) Bibby AC, Dorn P, Psallidas I, Porcel JM, Janssen J, Froudarakis M et al. ERS/EACTS statement on the management of malignant pleural effusions. Eur J Cardiothorac Surg 2018; doi:10.1093/ejcts/ezy258.3) Solass W, Hetzel A, Nadiradze G, Sagynaliev E, Reymond MA. Description of a novel approach for intraperitoneal drug delivery and the related device. Surg Endosc 2012;26(7):1849–55.4) Solass W, Giger-Pabst U, Zieren J, Reymond MA. Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC): occupational health and safety aspects. Ann Surg Oncol 2013;20(11):3504–11.5) Solass W, Kerb R, Murdter T, et al. Intraperitoneal chemotherapy of peritoneal carcinomatosis using pressurized aerosol as an alternative to liquid solution: first evidence for efficacy. Ann Surg Oncol 2014; 21(2):553–9.6) B. Tempfer, G. Winnekendonk, W. Solass et al. Pressurized intraperitoneal aerosol chemotherapy in women with recurrent ovarian cancer: a phase2 study. Gynecologic Oncology, vol. 137, no. 2, pp. 223–228, 2015.7) Kuchen N, Cereser T, Hailemariam S and Schoeb O. Safety and efficacy of pressurized intraperitoneal/intrathoracic aerosol chemotherapy (PIPAC/PITAC) in patients with peritoneal and/or pleural carcinomatosis: A preliminary experience. J Med Therap. 2018; 2(1): 1-6.8) Drevet G, Maury JM, Bakrin N, Tronc F. Technique of pressurized intrathoracic aerosol chemotherapy (PITAC) for malignant pleural effusion. Pleura Peritoneum. 2020 Nov 9;5(4):20200129.9) Tempfer CB, Giger-Pabst U, Seebacher V, Petersen M, Dogan A, Rezniczek GA. A phase I, single-arm, open-label, dose escalation study of intraperitoneal cisplatin and doxorubicin in patients with recurrent ovarian cancer and peritoneal carcinomatosis. Gynecol Oncol 2018; 150: 23–30.10) Mazumdar M, Smith A, Schwartz LH. A statistical simulation study finds discordance between WHO criteria and RECIST guideline. J Clin Epidemiol. 2004 Apr;57(4):358-65.</p