Search Results (106)

Background/Objectives: Unlike other thoracic malignancies, seeding malignant cells along surgical tracts is a known complication of invasive diagnostic or therapeutic procedures for pleural mesothelioma (PM). We report the tract dissemination rate and risk factors in 308 consecutive patients treated over 9 years in a single institution who underwent pleurectomy decortication (PD). Methods: Clinical and outcome data were reviewed. Fisher’s exact test, Kaplan–Meier estimators, and log-rank tests were used to identify significant risk factors for surgical tract dissemination and to compare overall survival. Results: There were 233 males (75.6%), 187 right-sided operations (61%), 190 (61.7%) epithelioid histology cases, and the median age was 69 (29–84). During the study, malignant cell dissemination in resected surgical tracts was diagnosed in 69 (22.4%) patients. The dissemination rates in epithelioid, biphasic, and sarcomatoid tumors were 24.7%, 20.4%, and 0%, respectively. Disseminated malignant surgical tract was associated with advanced nodal status (p = 0.001), advanced staging by the American Joint Committee on Cancer (AJCC 8th edition, p = 0.03), female sex (0.02), side of surgery (p = 0.03), and the number of video-assisted thoracoscopic surgery (VATS) ports (p = 0.003). In epithelioid mesothelioma, the median survival from diagnosis was 19.7 months in patients with tract seeding versus 36.3 months in patients without seeding (hazard ratio, 1.9; p = 0.001). Conclusions: Procedure tract dissemination occurs in almost every fourth patient with pleural mesothelioma and is associated with shorter overall survival in the epithelioid subtype. Full article

Objectives: To evaluate outcomes of patients undergoing lung segmentectomy using open thoracotomy, Video-Assisted Thoracoscopic Surgery (VATS), or Robotic-Assisted Thoracoscopic Surgery (RATS) approaches. Methods: A total of 157 patients (mean age: 68.7 years; 58% male) who underwent lung segmentectomy from 2015 to 2024 at the Thoracic Surgery of Siena were retrospectively enrolled and divided into groups based on the surgical approach: thoracotomy (n = 60), VATS (n = 58), and RATS (n = 39). No significant differences were observed between groups in terms of age, gender, or tumor stage. Peri-operative outcomes, and, in patients with non-small cell lung cancer (NSCLC, n = 104), long-term outcomes, were analyzed. Group comparisons were conducted using Kruskal–Wallis, Dunn’s test, Chi-squared, or Fisher’s exact test and Kaplan–Meier analysis with log-rank test. Results: Conversion rate was 13% and 0% for VATS and RATS, respectively (p = 0.005). Pleural effusion on first post-operative day was lower in RATS than VATS (p = 0.0006) and open (p < 0.0001). The maximum Visual Analogue Scale (VAS) value recorded was lower in RATS than open (p = 0.016) and VATS (p = 0.013). Surgery time was longer for RATS than open (p = 0.001) and VATS (p = 0.013). No differences were found in hospital stay and post-operative complications. In patients with NSCLC, the median follow-up was 25 months. The 90-day mortality rate was 9.5% in thoracotomy, 0% in VATS and RATS (p = 0.05). The 1- and 2-year overall survival was higher in VATS and RATS groups than thoracotomy (p = 0.001 and p = 0.040, respectively). The number of harvested lymph nodes was larger in the open group (p = 0.010), while a higher number of stations were harvested in RATS and open than VATS (p = 0.001). No differences were found in local recurrence (p= 0.08). Conclusions: RATS segmentectomy ensures a lower conversion rate, less post-operative pain, reduced daily pleural effusion, and a greater number of harvested lymph node stations compared to VATS, providing comparable peri-operative outcomes. RATS and VATS segmentectomy offer an advantage over the open approach in short- and long-term survival. Full article

Background: Regional anaesthesia techniques allow postoperative pain control while reducing opioid consumption. Ketamine is another viable option for minimising perioperative opioid use. We evaluated the efficacy of a perioperative multimodal analgesia protocol incorporating paravertebral block (PVB) and ketamine infusion in patients undergoing video-assisted thoracic surgery (VATS). Methods: This retrospective single-centre study divided patients into two groups: the opioid-sparing (OS) group receiving PVB and ketamine (n = 41), and the control group (n = 21) treated with postoperative morphine infusion. The primary outcome was the need for rescue opioid therapy; secondary outcomes included postoperative pain scores assessed at multiple time points over 48 h using the numeric rating scale (NRS), prevalence of chronic postoperative pain at three months, perioperative haemodynamics, and hospital length of stay. Results: Rescue opioid administration was significantly lower in the OS group (19.5% vs. 47.6%, p = 0.021). Upon awakening, pain control was better in the OS group (1 [1–2] vs. 4 [3–4], p < 0.001); however, pain scores did not differ afterwards. Chronic postoperative pain was less common in the OS group (n = 10/41; 23.8% vs. n = 11/21, 52.4%; p = 0.028). No differences in haemodynamics were reported, nor were there any ketamine/PVB-related complications. No difference in length of hospital stay was observed between the groups. The ketamine starting dose and postoperative morphine requirements were inversely correlated (rho = −0.380; p = 0.002). Conclusions: A multimodal analgesia protocol integrating PVB and ketamine infusion in patients undergoing VATS may effectively reduce postoperative opioid consumption, improving analgesia in the initial postoperative period. Full article

The aim of this retrospective clinical study was to assess surgical duration and surgical and post-operative complications associated with Video-Assisted Thoracoscopic Surgery (VATS) and lung biopsy in horses with severe Equine Pasture Asthma (EPA) and paired control horses. Twelve horses (6 EPA-affected, 6 control) were sex, age and breed matched. Twenty-four thoracic surgeries were performed. Surgery of each matched pair (EPA-affected and healthy) was performed during asthma exacerbation (summer) and remission (winter). Surgical times were shorter with uncomplicated thoracoscopy (85 min) and significantly longer (p < 0.001) when intra-operative complications necessitated conversion to thoracotomy (156 min). The overall surgical time of EPA-affected horses during asthma exacerbation was significantly longer than control horses at any time point, predicted mean difference of 78 min (p < 0.05). When comparing EPA-affected horses to themselves during asthma exacerbation and remission, surgical times were significantly longer (p < 0.01) with a predicted mean difference of 98 min; this effect of seasonality did not occur amongst control horses. Intra-operative surgical complications (6/24) were evenly divided between EPA and control horses, however, only severe EPA horses in exacerbation were noted to have lung hyperinflation. Post-operative complications: fever, colic, hemothorax, pneumothorax, subcutaneous emphysema, surgical site infection, and/or laminitis occurred in 13/24 surgical procedures (54%). No fatalities resulted from these procedures. Full article

Malignant mediastinal tumors are a group representing some of the most demanding oncological challenges for early, multi-level, and successful management. The timely identification of any suspicious clinical symptomatology is urgent in achieving an accurate, staged histological diagnosis, in order to follow up with an equally detailed medical therapeutic plan (interventional or not) and determine the principal goals regarding efficient overall treatment in these patients. We report a case of a 24-year-old male patient with an incident-free prior medical history. An initial chest X-ray was performed after the patient reported short-term, consistent moderate chest pain symptomatology, early work fatigue, and shortness of breath. The following imaging procedures (chest CT, PET-CT) indicated the presence of an anterior mediastinal mass (meas. ~11 cm × 10 cm × 13 cm, SUV: 8.7), applying additional pressure upon both right heart chambers. The Alpha-Fetoprotein (aFP) blood levels had exceeded at least 50 times their normal range. Two consecutive diagnostic attempts with non-specific histological results, a negative-for-malignancy fine-needle aspiration biopsy (FNA-biopsy), and an additional tumor biopsy, performed via mini anterior (R) thoracotomy with “suspicious” cellular gatherings, were performed elsewhere. After admission to our department, an (R) Video-Assisted Thoracic Surgery (VATS) was performed, along with multiple tumor biopsies and moderate pleural effusion drainage. The tumor’s measurements had increased to DMax: 16 cm × 9 cm × 13 cm, with a severe degree of atelectasis of the Right Lower Lobe parenchyma (RLL) and a pressure-displacement effect upon the Superior Vena Cava (SVC) and the (R) heart sinus, based on data from the preoperative chest MRA. The histological report indicated elements of a combined, non-seminomatous germ-cell mediastinal tumor, posthuberal-type teratoma, and embryonal carcinoma. The imminent chemotherapeutic plan included a “BEP” (Bleomycin^®/Cisplatin^®/Etoposide^®) scheme, which needed to be modified to a “VIP” (Cisplatin^®/Etoposide^®/Ifosfamide^®) scheme, due to an acute pulmonary embolism incident. While the aFP blood levels declined, even reaching normal measurements, the tumor’s size continued to increase significantly (DMax: 28 cm × 25 cm × 13 cm), with severe localized pressure effects, rapid weight loss, and a progressively worsening clinical status. Thus, an emergency surgical intervention took place via median sternotomy, extended with a complementary “T-Shaped” mini anterior (R) thoracotomy. A large, approx. 4 Kg mediastinal tumor was extracted, with additional RML and RUL “en-bloc” segmentectomy and partial mediastinal pleura decortication. The following histological results, apart from verifying the already-known posthuberal-type teratoma, indicated additional scattered small lesions of combined high-grade rabdomyosarcoma, chondrosarcoma, and osteosarcoma, as well as numerous high-grade glioblastoma cellular gatherings. No visible findings of the previously discovered non-seminomatous germ-cell and embryonal carcinoma elements were found. The patient’s postoperative status progressively improved, allowing therapeutic management to continue with six “TIP” (Cisplatin^®/Paclitaxel^®/Ifosfamide^®) sessions, currently under his regular “follow-up” from the oncological team. This report underlines the importance of early, accurate histological identification, combined with any necessary surgical intervention, diagnostic or therapeutic, as well as the appliance of any subsequent multimodality management plan. The diversity of mediastinal tumors, especially for young patients, leaves no place for complacency. Such rare examples may manifest, with equivalent, unpredictable evolution, obliging clinical physicians to stay constantly alert and not take anything for granted. Full article

Objectives: Pericardial effusion is the accumulation of excess fluid in the pericardial sac. The etiology is multi-factorial and different techniques are used for management, including subxiphoid approaches, anterior and lateral thoracotomies, video-assisted thoracic surgery (VATS), and percutaneous pericardiocentesis. We evaluate the surgical management strategies for pericardial effusion and their outcomes in this systematic review. Methods: A systematic literature review was performed to identify studies on the surgical management of pericardial effusion from inception to February 2024 using PubMed, Cochrane, and Scopus. Articles were independently assessed by two reviewers, with discrepancies resolved by the senior author. Articles were considered for inclusion if they described different pericardial effusion surgical management techniques. Baseline patient characteristics and procedural and outcome variables were extracted. Results: A total of 27 studies comprising 2773 patients were evaluated. The median age was 56.2 years (interquartile range 47–62.2). The most common etiologies of pericardial effusion were malignancy (31.0%), post-cardiac surgery (18.7%), and idiopathic (15.4%). Other causes included uremia (9.6%), infection (9.6%), and autoimmune disease (4.2%). The subxiphoid pericardial window was the most common approach (82.6%), followed by anterior and lateral thoracotomy (12.0%), and median sternotomy (0.6%). At median follow-up of 24 months, the most frequent post-procedural complications were recurrence of effusion (10.5%), arrhythmias (2.7%), and pneumonia (0.7%). Conclusions: Subxiphoid pericardial window is the most common approach for draining pericardial effusions. Prognosis depends on both the underlying etiology and the chosen drainage strategy. Treatment should be tailored to individual patients, considering patient comorbidities and the specific etiology. Full article

Background: Lung cancer represents a significant health concern, particularly among the elderly population. With global life expectancy increasing, the number of very elderly patients is rising. Robotic-assisted thoracic surgery (RATS) offers potential advantages over both traditional and video-assisted thoracoscopic surgery (VATS). This study aims to evaluate the feasibility and safety of RATS in very elderly patients (VEP) diagnosed with lung cancer. Methods: This retrospective study included patients who underwent major lung resections using RATS between 2015 and 2022 at two specialized centers. Patients were divided into very elderly patients (VEP, ≥80 years) and non-elderly patients (NEP, <80 years). Demographic, clinical, and surgical data were analyzed. Propensity score matching (PSM) at a 1:3 ratio was performed using clinically relevant variables that were significantly different at baseline to balance the two groups. Results: This study included 340 patients: 28 VEP and 312 NEP. Before PSM, VEP had higher ASA scores, more advanced disease stages, and increased comorbidities. Despite these differences, postoperative outcomes were comparable. Complications occurred in 42.9% of VEP and 29.8% of NEP (p = 0.16), but grade III complications were observed in 14.3% of VEP and 6.4% of NEP (p = 0.12), and grade IV complications were observed in 0% of VEP and 0.9% of NEP (p = not estimable). The mean hospital stay was 4 days in both groups (p = 0.99). Even after PSM (26 VEP vs. 71 NEP), complications, hospital stay, and 90-day mortality (3.9% in VEP, 0% in NEP) were similar. Multivariable analysis identified reduced FEV1 as a predictor of complications, while pathological stage I and lobectomy were associated with a decreased risk of complications, both before and after PSM. Conclusions: RATS is a safe and feasible option for selected very elderly patients with lung cancer, yielding outcomes comparable to younger patients. Full article

Background: The positive effects of oral nutritional supplements (ONS) on postoperative outcomes have been well recognized in several previous studies. However, to date, little data has been available with respect to determining the best immune modulating supplement to use and what its impact might be in thoracic surgery. The aim of this study was to evaluate the role of preoperative immune-nutritional supplement intake as predictor of postoperative cardiopulmonary complications (CPCs) in patients undergoing uniportal video-assisted thoracoscopic (uVATS) lung resection. Methods: This is a retrospective, observational study enrolling consecutive patients who underwent uVATS lung resections for cancer from January 2022 to December 2024 in the context of the Enhanced Pathway of Care (EPC) Program. All patients were evaluated by a nutritionist and dietetics team during the preoperative phase. The nutritional protocol consisted of 250 mL ONS rich in arginine, omega-3-fatty acids, and nucleotides to be taken twice a day for 5–7 days before surgery. Results: Four hundred ninety-one patients were enrolled: 277 patients underwent anatomic lung resection and 214 underwent wedge resection (WR). Utilizing the univariate analysis, we found that in patients undergoing anatomic lung resection, not-ONS-intake, high Body Mass Index (BMI), and arrythmia were correlated with a higher CPCs rate compared to the patients without nutritional supplementation (7.2% ONS vs. 15% not-ONS, p = 0.04; BMI 28.4 kg/m² vs. BMI 26.4 kg/m², p = 0.03; 31.2% arrythmia vs. 9.4% no-arrythmia, p < 0.01). These correlations, except for BMI, were confirmed after stepwise logistic regression. Alternately, in patients undergoing WR, hypertension and low-FEV1% were associated with a higher CPCs rate (5.1% hypertension vs. 0.4% no-hypertension, p = 0.02; FEV1% 79.7% vs. 95%, p = 0.01). Conclusions: Our results demonstrated that preoperative ONS after uVATS anatomic lung resection, in the context of an EPC program, influences the postoperative period, reducing the CPCs rate. Full article

Background/Objectives: The use of goal-directed fluid therapy (GDFT) guided by stroke volume (SV) variation during thoracic surgery, particularly with one-lung ventilation (OLV) and protective ventilation strategies, is not well established. This study aimed to determine whether maximizing stroke volume (SV) before initiating one-lung ventilation (OLV) reduces the incidence of intraoperative hypotension requiring vasoactive agents during video-assisted thoracoscopic surgery (VATS). Methods: Sixty patients undergoing VATS were randomly assigned to an SVM group (n = 30) or a control group (n = 30). The SVM group received 6% hydroxyethyl starch before OLV to achieve and maintain an SV increase of less than 10%. The control group received no active fluid therapy before OLV positioning. Both groups received Ringer’s lactate solution intraoperatively based on baseline (control) or maximized (SVM) SV goals. The primary outcome was the use of vasoactive agents for hypotension. Results: Patients in the SVM group received significantly less Ringer’s lactate solution than controls (4.2 ± 2.4 vs. 6.1 ± 2.8 mL/kg/h, p = 0.005). While fewer patients in the SVM group required vasoactive agents (20% vs. 40%), the difference was not statistically significant (p = 0.091). IL-6 levels were significantly lower during OLV in the SVM group. Conclusions: Pre-OLV SVM was associated with reduced intraoperative crystalloid administration and attenuation of inflammatory response, with a non-significant trend toward lower vasopressor use. These findings suggest a potential benefit of SVM in thoracic surgery, though larger multicenter trials are needed to confirm clinical efficacy. Full article

Video-assisted thoracoscopic surgery (VATS) is a minimally invasive diagnostic and therapeutic procedure utilized in various thoracic conditions. VATS has grown in popularity with ever-expanding knowledge of enhanced recovery after surgery (ERAS) protocols and its benefits regarding patient care and outcomes. Pain control following VATS is of utmost importance to minimize the complication risk. Options for pain control following VATS have traditionally included systemic IV analgesia but have evolved to include loco-regional analgesia as well. The serratus anterior plane block (SAPB) is one form of loco-regional analgesia utilized in VATS that has been shown to provide effective pain control of the anterolateral chest wall. Patients who received SAPB compared to control methods of anesthesia demonstrated significant decreases in postoperative pain and postoperative opioid consumption. SAPB is effective and offers a promising safety profile as the block is typically more superficial than other types of loco-regional analgesia. This review outlines the recent literature surrounding the use of SAPB for pain control in VATS. Full article

Lung cancer is the leading cause of cancer-related mortality among both men and women worldwide, underscoring the need for an effective treatment strategy. For early-stage non-small cell lung cancer [NSCLC], surgical resection is the standard treatment. Robotic-assisted thoracic surgery [RATS] and video-assisted thoracic surgery [VATS] are better than open thoracotomy because they are less invasive. Recent lung cancer screening programs are detecting NSCLC at earlier stages, which is expected to result in an increase in the number of NSCLC surgeries as early-stage cases are diagnosed. A limited number of randomized controlled trials have compared RATS and VATS in operable NSCLC. We conducted a literature review to summarize the available evidence on these two surgical techniques. The purpose of this study is to compare the intraoperative and postoperative outcomes of RATS and VATS in early-stage NSCLC patients. RATS shows lower conversion rates to thoracotomy (6.3% vs. 13.1% p < 0.01) and more thorough lymph node dissection than VATS (e.g., 7.5 vs. 5.6 stations, p < 0.001). However, RATS is linked to considerably higher costs (USD 22,582 vs. USD 17,874, p < 0.05) and longer operative times (median 241.7 vs. 214.4 min, p = 0.06). The two techniques exhibited minimal differences in postoperative complications and pain, while RATS patients experienced shortened hospital stays (4–5 vs. 5–6 days, p < 0.006). While the accuracy of staging and treatment planning is improved by the improved lymph node retrieval in RATS, the long-term survival rate is still uncertain. Full article

Background: An erector spinae plane block (ESPB) has gained popularity due to its effectiveness and simplicity for pain relief. However, it is uncertain whether an ESPB provides superior analgesia after a VATS or thoracotomy compared to other regional and systemic analgesic techniques. Methods: A retrospective cohort study was conducted from January to June 2023 comparing an ESPB with intravenous combination analgesia (IV–CA) in VATS patients and with thoracic epidural analgesia (TEA) in thoracotomy patients. The primary endpoint was the opioid demand during the first two hours in the post-anesthesia care unit (PACU). The secondary outcomes included the pain scores and adverse events. Results: A total of 61.2% of the 165 included VATS patients and 56.9% of the 72 thoracotomy patients were treated with an ESPB. Following a VATS, an ESPB decreased the median piritramide demand (7.5 [3.0 to 12.0] vs. 10.5 [6.5 to 15.5] mg, p < 0.01). However, after a thoracotomy, an ESPB increased the median piritramide demand (12.0 [6.0 to 15.0] vs. 3.0 [0.0 to 9.0] mg, p < 0.01). The pain scores and adverse events were similar between the groups. Conclusions: An ESPB reduces the piritramide demand in VATS patients compared with IV–CA, providing similar pain relief. However, in thoracotomy patients, an ESPB is associated with an increased piritramide demand compared to TEA. An ESPB is an attractive add-on to IV–CA after a VATS, while TEA remains the gold standard after a thoracotomy. Full article

For over two decades, robotic-assisted thoracic surgery (RATS) has revolutionized thoracic oncology. With enhanced visualization, dexterity, and precision, RATS has reduced blood loss, shortened hospital stays, and sped up recovery compared to traditional surgery or video-assisted thoracoscopic surgery (VATS). The use of 3D high-definition imaging and articulated instruments allows for complex resections and advanced lymph node assessment. RATS delivers oncological outcomes similar to open surgery and VATS, with high rates of complete (R0) resections and acceptable complication rates. Its minimally invasive nature promotes quicker recovery. Advances in imaging software and augmented reality further enhance surgical accuracy and reduce intraoperative risks. However, RATS has some limitations, including high costs and a lack of tactile feedback, and certain complex procedures, such as extended resections and intrapericardial interventions, remain challenging. With growing experience and technological advances, RATS shows promise in reducing morbidity, improving quality of life, and expanding access to advanced oncologic care. This article reviews the evolution, benefits, and limitations of RATS in NSCLC treatment, highlighting its emerging role in managing complex cases. Full article

Spontaneous ventilation lung surgery (SVLS) without intubation is aimed at avoiding adverse effects of mechanical ventilation lung surgery (MVLS) entailing one-lung mechanical ventilation through a double-lumen tracheal tube. This innovative strategy has evolved following the publication of a small randomized study of thoracoscopic pulmonary wedge resection carried out under spontaneous ventilation without tracheal intubation in fully awake patients. It now entails target-controlled sedation, the use of a laryngeal mask, and thoracic analgesia by intercostal or paravertebral blocks and has shown promise both in unicenter and multicenter studies, resulting in optimal feasibility and safety and highly satisfactory results, particularly in patients undergoing lung cancer resection and metastasectomy, lung biopsy for undetermined interstitial lung disease, lung volume reduction surgery for end-stage emphysema, and bullectomy for primary and secondary spontaneous pneumothorax. However, concerns and unresolved issues still exist regarding the advantages and disadvantages of SVLS as well as the identification of optimal indications. This perspective is aimed at providing a critical overview of the current knowledge about SVLS with emphasis on recent data comparing the results with those of MVLS published in the last 10 years. Full article

Background and Objectives: Non-intubated uniportal video-assisted thoracoscopic surgery (NI-UniVATS) is a minimally invasive technique performed using a single port, allowing the entire surgical procedure to be completed with spontaneous breathing without the need for general anesthesia. Materials and Methods: This retrospective study included 51 patients who underwent NI-UniVATS between 2020 and 2023. The intraoperative and postoperative data of patients who underwent NI-UniVATS were evaluated. Results: Among the cases, 37 (72.5%) were male, and 14 (46.6%) were female, with a mean age of 47.73 ± 20.43 years (range: 18–78 years). The mean operative time was 25.92 ± 7.31 min. No perioperative complications were observed in any patient. The mean postoperative hospital stay was 4.17 ± 1.76 days (range: 2–9 days). A right hemithoracic approach was performed in 28 patients (54.9%), whereas a left hemithoracic approach was used in 23 patients (45.1%). The procedures performed included wedge resection in 27 patients (52.9%), biopsy in 22 patients (43.1%), pericardial window creation in one patient (2%), and intrathoracic foreign body removal in one patient (2%). Conclusions: NI-UniVATS allows for safer surgery by preventing the adverse effects and complications associated with general anesthesia. NI-UniVATS can be recommended as a safe and feasible approach for both minor and major thoracic procedures. Full article