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Non-intubated video-assisted thoracoscopic surgery combines a minimally invasive technique with multimodal locoregional analgesia to enhance recovery. The mainstay sedation protocol involves propofol and fentanyl. Dexmedetomidine, given its opioid-sparing effect with minimal respiratory depression, facilitates sedation in non-intubated patients. This study aimed to evaluate the efficacy of dexmedetomidine during non-intubated video-assisted thoracoscopic surgery. A total of 114 patients who underwent non-intubated video-assisted thoracoscopic surgery between June 2015 and September 2017 were retrospectively evaluated. Of these, 34 were maintained with dexmedetomidine, propofol, and fentanyl, and 80 were maintained with propofol and fentanyl. After a 1:1 propensity score-matched analysis incorporating sex, body mass index, American Society of Anesthesiologists classification, pulmonary disease and hypertension, the clinical outcomes of 34 pairs of patients were assessed. The dexmedetomidine group showed a significantly lower opioid consumption [10.3 (5.7–15.1) vs. 18.8 (10.0–31.0) mg, median (interquartile range); P = 0.001] on postoperative day 0 and a significantly shorter postoperative length of stay [3 (2–4) vs. 4 (3–5) days, median (interquartile range), P = 0.006] than the control group. During operation, the proportion of vasopressor administration was significantly higher in the dexmedetomidine group [18 (53) vs. 7 (21), patient number (%), P = 0.01]. On the other hand, the difference of the hypotension and bradycardia incidence, short-term morbidity and mortality rates between each group were nonsignificant. Adding adjuvant dexmedetomidine to propofol and fentanyl is safe and feasible for non-intubated video-assisted thoracoscopic surgery. With its opioid-sparing effect and shorter postoperative length of stay, dexmedetomidine may enhance recovery after surgery. [Display omitted] [ABSTRACT FROM AUTHOR]

Atrial fibrillation is now a pandemic in our ageing community. Although James L. Cox devised a surgical procedure with near-universal curative success in 1987, catheter-based interventions have flourished. For persistent atrial fibrillation (AF), however, an isolated endocardial approach has limitations: procedural times are long, carry risk, and the outcomes are not durable. By combining left atrial endocardial and epicardial interventions with staged mapping, we optimise the benefits of both approaches. Our initial series of hybrid ablation for persistent atrial fibrillation reports excellent early outcomes, freedom from complications and excellent success at follow-up. [ABSTRACT FROM AUTHOR]

The Midwest Pediatric Surgery Consortium (MWPSC) suggested a simple aspiration of primary spontaneous pneumothorax (PSP) protocol, failing which, Video-Assisted Thoracoscopic Surgery (VATS) should be considered. We describe our outcomes using this suggested protocol. A single institution retrospective analysis was conducted on patients between 12 and 18 years who were diagnosed with PSP from 2016 to 2021. Initial management involved aspiration alone with a ≤12 F percutaneous thoracostomy tube followed by clamping of the tube and chest radiograph at 6 h. Success was defined as ≤2 cm distance between chest wall and lung at the apex and no air leak when the clamp was released. VATS followed if aspiration failed. Fifty-nine patients were included. Median age was 16.8 years (IQR 15.9, 17.3). Aspiration was successful in 33% (20), while 66% (39) required VATS. The median LOS with successful aspiration was 20.4 h (IQR 16.8, 34.8), while median LOS after VATS was 3.1 days (IQR 2.6, 4). In comparison, in the MWPSC study, the mean LOS for those managed with a chest tube after failed aspiration was 6.0 days (±5.5). Recurrence after successful aspiration was 45% (n = 9), while recurrence after VATS was 25% (n = 10). Median time to recurrence after successful aspiration was sooner than that of the VATS group [16.6 days (IQR 5.4, 19.2) vs. 389.5 days (IQR 94.1, 907.0) p = 0.01]. Simple aspiration is safe and effective initial management for children with PSP, although most will require VATS. However, early VATS reduces length of stay and morbidity. IV. Retrospective study. [ABSTRACT FROM AUTHOR]

The left upper lobe (LUL) has unique hilar anatomy, and LUL multi-segmentectomy (apical trisegmentectomy and lingulectomy) may result in different outcomes than both single anatomical segmentectomy and left upper lobectomy in the management of early-stage primary lung cancer; however no meta-analyses have been performed. The aim of this meta-analysis is to determine if LUL multi-segmentectomy is non-inferior to left upper lobectomy for long-term survival outcomes, or superior for in-hospital outcomes. Electronic databases searches were performed on PubMed, Embase, and the Cochrane Library to identify studies comparing outcomes in LUL multi-segmentectomy vs left upper lobectomy in early-stage lung cancer (clinical stage T2 N0 or less). Long-term postoperative overall and disease-free survival were assessed via reconstruction of Kaplan-Meier survival curves. In-hospital complications and length of stay, as well as long term recurrence were analysed via random effects models. Five relevant studies were identified, including 1,196 patients. Overall survival did not differ at 5 years (multi-segmentectomy 92.6% vs lobectomy 89.3%, P=0.188), but patients undergoing LUL multi-segmentectomy had better disease-free survival at 5 years (93.1% vs 88.4%, P=0.041). Patients undergoing LUL multi-segmentectomy had a shorter mean length of hospital stay (mean difference -0.26 days, 95% CI; -0.39 to 0.14, P<0.01, I2=0.00%). There was no difference in combined in-hospital complications (P=0.14), local recurrence (P=0.35), distant recurrence (P=0.23), or overall recurrence (P=0.39). LUL multi-segmentectomy is associated with reduced hospital length of stay, but no difference in long-term overall survival compared with left upper lobectomy in the management of early-stage primary lung cancer. [ABSTRACT FROM AUTHOR]

Although thoracoscopic surgery has become the routine surgical method for esophageal atresia/tracheoesophageal fistula (EA/TEF), thoracoscopic treatment for recurrent tracheoesophageal fistula (rTEF) is far from popularized. We aimed to explore the safety and efficacy of thoracoscopic treatment for rTEF with a large-cohort study. We retrospectively analyzed the clinical characteristics and outcomes of 103 consecutive patients who underwent thoracoscopic surgery for rTEF by one surgeon after EA/TEF repair at two different institutions in China from 2014 to 2021. One hundred and three pediatric patients (67 boys) were enrolled and the primary operations were performed via thoracoscopic (n = 75, 72.82%) or open surgery (n = 28, 27.18%). The median age at rTEF diagnosis was 5 (3, 10) months after the primary repair. Patients were diagnosed with recurrent fistula to the trachea (n = 97, 94.17%), bronchi (n = 4, 3.88%), and lung parenchyma (n = 2, 1.94%), and all of them underwent thoracoscopic surgery at a median age of 7 (5, 14) months with a median weight of 6200 (4870, 7650) g. After the repair of rTEF, the incidence of esophageal leakage, esophageal stricture, and TEF recurrence were 12.8%, 33.4%, and 10.8%, respectively. After the follow-up, 87 patients survived, 6 died, and 10 were lost to follow-up. The results of thoracoscopic surgery for rTEF were comparable with previously reported thoracotomy surgery. Owing to the clear field during the operation, rapid patient recovery and esthetic results, the thoracoscopic approach could be a better choice for experienced pediatric surgeons. LEVEL IV [ABSTRACT FROM AUTHOR]

Infants with congenital pulmonary airway malformation (CPAM) are generally asymptomatic and the surgical treatment can be planned using a thoracoscopic technique. We report the case of a newborn with a large type 1 CPAM who presented with severe respiratory distress and was treated with percutaneous transthoracic drainage before open surgery. A full-term male patient was born via vaginal delivery. Antenatal imaging had raised suspicion of type 1 CPAM in the right lung. At birth, he was admitted to the neonatal intensive care unit (NICU) due to ventilatory insufficiency and oxygen dependence. A chest X-ray confirmed the antenatal diagnosis of a large type 1 CPAM. On the first days of life (DOL), we inserted a percutaneous transthoracic chest tube to drain the large cyst and initiated high-frequency oscillatory ventilation (HFOV). Although the patient initially showed clinical improvement, his condition subsequently deteriorated. Suspecting tube dislocation, on the seventh DOL a second drainage was placed in the cyst. On the tenth DOL, given the persistent clinical severity, a right upper lobectomy was performed. Postoperatively, the patient was supported by conventional ventilation with a reduced oxygen requirement. On the thirteenth DOL, the infant was successfully extubated. Histological analysis confirmed the diagnosis of type 1 CPAM. After nearly a month, the infant was transferred to the pediatric surgery ward and later discharged. During multidisciplinary follow-up, the patient maintained good general health with no signs of recurrence. In newborns with large, symptomatic type-1 CPAMs a percutaneous catheter drainage can be used as a temporizing measure before the definitive surgical resection. [ABSTRACT FROM AUTHOR]

Preoperative anxiety is a common preoperative psychological state in patients with cancer and associated with worsening perioperative outcomes. However, high-quality prospective studies on preoperative anxiety in patients undergoing lung surgery are scarce. We conducted a prospective cohort study, enrolling a total of 540 patients. Preoperative anxiety in patients undergoing thoracic surgery was measured using the Hospitalization Anxiety Scale. Patients were grouped according to the Hospitalization Anxiety Scale scores as follows: no anxiety (score <8) and anxiety (score ≥8). The association of preoperative anxiety with postoperative complications and non-complicated adverse events was determined by univariate regression and polynomial regression analyses. A total of 121 patients (22.4 %) experienced preoperative anxiety. The anxiety group had a longer average hospital stay (4.33 vs. 3.85 days). Postoperative complications were similar between groups, but the anxiety group reported worse sleep quality (measured by the Athens Insomnia Scale). Regarding postoperative pain, both groups had comparable rates of mild and severe pain on postoperative day 1. However, the anxiety group experienced significantly higher rates of severe pain on postoperative day 2 and mild pain on postoperative day 3. Additionally, the incidence of postoperative nausea and vomiting was significantly higher in the anxiety group on postoperative day 1. Preoperative anxiety may not increase the rates of postoperative complications in patients undergoing lung surgery. However, it may be associated with postoperative sleep disturbances, pain, nausea, and vomiting, as well as prolong the length of postoperative hospitalization. [ABSTRACT FROM AUTHOR]

Shape registration of patient-specific organ shapes to endoscopic camera images is expected to be a key to realizing image-guided surgery, and a variety of applications of machine learning methods have been considered. Because the number of training data available from clinical cases is limited, the use of synthetic images generated from a statistical deformation model has been attempted; however, the influence on estimation caused by the difference between synthetic images and real scenes is a problem. In this study, we propose a self-supervised offline learning framework for model-based registration using image features commonly obtained from synthetic images and real camera images. Because of the limited number of endoscopic images available for training, we use a synthetic image generated from the nonlinear deformation model that represents possible intraoperative pneumothorax deformations. In order to solve the difficulty in estimating deformed shapes and viewpoints from the common image features obtained from synthetic and real images, we attempted to improve the registration error by adding the shading and distance information that can be obtained as prior knowledge in the synthetic image. Shape registration with real camera images is performed by learning the task of predicting the differential model parameters between two synthetic images. The developed framework achieved registration accuracy with a mean absolute error of less than 10 mm and a mean distance of less than 5 mm in a thoracoscopic pulmonary cancer resection, confirming improved prediction accuracy compared with conventional methods. • 2D/3D model-based deformable registration for highly occluded endoscopic camera images. • Self-supervised offline learning using a data-driven pneumothorax deformation model. • Use of common image features to transfer the self-supervised model to real scenes. • Performance analysis and application to image-guided pulmonary resection. [ABSTRACT FROM AUTHOR]

This study aimed to determine the impact of surgical approach on postoperative recovery, quality of life, and satisfaction level in patients undergoing uniportal or multiportal video-assisted thoracoscopic surgery (VATS) or open thoracotomy. This prospective study included patients who underwent open thoracotomy, uniportal VATS, or multiportal VATS in a tertiary Hospital between January 1, 2019 and May 1, 2021. Recovery was evaluated at postoperative 24th, 48th, and 72nd hours, and 1 month using the Postoperative Recovery Index (PoRI); quality of life was evaluated using the Short Form 36 (SF-36) at postoperative 1 month; and patient satisfaction\was assessed with visual analog scale (VAS) at postoperative 72nd hours and at 1 month. Of 215 patients screened, 163 patients met the inclusion criteria. Women had higher PoRI values than men at postoperative 24th, 48th, and 72nd hours. Open thoracotomy was associated with higher PoRI values, lower SF-36 scores (except social functioning), and lower satisfaction at postoperative 72nd hours compared to VATS. Patients in the uniportal and multiportal VATS groups had similar postoperative recovery, satisfaction, and quality of life outcomes. Satisfaction was similar in all groups at 1 month. Both uniportal and multiportal VATS were superior to open thoracotomy in terms of postoperative recovery, quality of life, and patient satisfaction. Long-term studies with larger patient populations comparing uniport and multiport VATS are needed. [ABSTRACT FROM AUTHOR]

Objective: To show a case of severe intravascular leiomyomatosis with intracardiac extension treated by a multidisciplinary minimally invasive surgery.Design: Stepwise demonstration of the technique with a video.Setting: General Hospital.Patient(s): A 40-year-old woman with palpitation and dyspnea.Intervention(s): The patient was diagnosed with intravascular leiomyomatosis by computed tomography scan. She underwent a successful single-stage minimally invasive surgery with complete excision.Main Outcome Measure(s): The feasibility and safety of using this technique for intravascular leiomyomatosis with intracardiac extension.Result(s): A combined thoracoabdominal surgery was successfully performed. During the procedure, cardiopulmonary bypass was maintained for 72 minutes. The patient soon recovered and was discharged.Conclusion(s): Minimally invasive surgery is a possible choice for intravascular leiomyomatosis with intracardiac extension. [ABSTRACT FROM AUTHOR]

Purpose: We sought to evaluate the impact of thoracoscopic repair on perioperative outcomes in infants with esophageal atresia and tracheoesophageal fistula (EA/TEF). Methods: The American College of Surgeons National Surgical Quality Improvement Program pediatric database from 2014 to 2018 was queried for all neonates who underwent operative repair of EA/TEF. Operative approach based on intention to treat was correlated with perioperative outcomes, including 30-day postoperative adverse events, in logistic regression models. Results: Among 855 neonates, initial thoracoscopic repair was performed in 133 (15.6%) cases. Seventy (53%) of these cases were converted to open. Those who underwent thoracoscopic repair were more likely to be full-term (p = 0.03) when compared to those in the open repair group. There were no significant differences in perioperative outcome measures based on surgical approach except for operative time (thoracoscopic: 217 min vs. open: 180 min, p <0.001). A major cardiac comorbidity (OR 1.6, 95% CI 1.2–2.1; p = 0.003) and preoperative ventilator requirement (OR 1.4, 95% CI 1.0–1.9; p = 0.034) were the only risk factors associated with adverse events. Conclusions: Thoracoscopic neonatal repair of EA/TEF continues to be used sparingly, is associated with high conversion rates, and has similar perioperative outcomes when compared to open repair. Level of evidence : III [ABSTRACT FROM AUTHOR]

Long-gap esophageal atresia remains a challenging condition. There are no standard guidelines on the optimal surgical approach or the optimal management strategy for the potential postoperative complications. We report a case of long-gap EA treated by staged thoracoscopic repair in which the chest drain caused a complication. A female with prenatal diagnosis of polyhydramnios and a small stomach suspicious for esophageal atresia was delivered by cesarean section at 33 weeks of gestation. The orogastric tube remained coiled in the upper esophagus, confirming the diagnosis of esophageal atresia. X-rays showed a gasless abdomen, suspicious for a lack of a distal tracheo-esophageal fistula. On the second day of life, the patient underwent a tracheoscopy, which confirmed the absence of a tracheo-esophageal fistula. A gastrostomy was done at the same time. At 1 month of age the patient underwent a fluoroscopic study, and the esophageal gap was found to be 3.5 vertebral bodies. At 2 months of age she underwent a thoracoscopic placement of internal traction sutures. Five days later she underwent a thoracoscopic esophageal anastomosis, which was under moderate tension. A chest tube was left in place. Seven days after the operation a routine esophagram showed that the chest tube had slipped into the esophagus through the anastomosis. We pulled the chest tube back under direct endoscopic vision. There was also a tight stenosis at the anastomosis. We placed a trans -anastomotic tube for feedings and a naso-esophageal tube to suction the secretions of the upper esophagus. Forty-for days later we repeated the esophagram and confirmed the persistence of the tight stenosis. The patient underwent serial dilations every 2 weeks for 3 months and a Nissen fundoplication, after which the stricture completely resolved. Although rare, the chest tubes used after the repair of an esophageal atresia can cause complication at the anastomotic site. [ABSTRACT FROM AUTHOR]

• Lung ultrasonography (LUS) is a simple and easy technique. • LUS has an acceptable predictability of pleural adhesion. • Patients with pleural adhesion in LUS consumed more opioids to control the postoperative pain. • LUS may provide useful information contributing to effective postoperative analgesia in VATS. Pleural adhesion makes video-assisted thoracoscopic surgery (VATS) an arduous procedure and can increase postoperative pain from accompanying adhesiolysis. For the present study, the feasibility of lung ultrasonography for the prediction of pleural adhesions and postoperative pain in VATS was investigated. Blinded, prospective, observational study. Tertiary teaching hospital, Seoul, South Korea. Sixty patients (American Society of Anesthesiologists physical status I to III) scheduled to undergo VATS were assessed for eligibility. After exclusions, 53 patients were enrolled and followed-up. None. Patients were evaluated with lung ultrasonography during deep spontaneous respiration before induction of anesthesia, and surgeons confirmed the presence of pleural adhesions during the surgery. Pain was evaluated using a numeric rating scale and by the amount of opioid consumption until 24 hours postoperatively. Lung ultrasonography showed acceptable predictability of pleural adhesions, with the area under the receiver operating characteristic curve (0.75, 95% confidence interval [CI] 0.67-0.83) and high specificity (0.97, 95% CI 0.91-0.99) but low sensitivity (0.53, 95% CI 0.38-0.68). The pain score was not different between sonographic adhesion (+) and (–) groups; however, the sonographic adhesion (+) group consumed more opioids until 24 hours postoperatively (fentanyl 675 [558-805] μg v 420 [356-476] μg; p < 0.001). Lung ultrasonography may help with planning postoperative pain management in VATS; however, it was a better tool for ruling out rather than detecting pleural adhesions. [ABSTRACT FROM AUTHOR]

Esophageal atresia (EA) is often associated with congenital heart disease (CHD). Repair of EA by the thoracoscopic approach places physiological stress on a newborn with CHD. This paper reviews the outcomes of infants with CHD who had undergone thoracoscopic EA repair, comparing their outcomes to those without CHD. This was a review of infants who underwent thoracoscopic EA repair from 2009 to 2017 at one institution. Operative time and outcomes were analyzed in relation to CHD status. Twenty five infants underwent thoracoscopic EA repair during the study period. Seventeen (68%) had associated anomalies of whom 9 (36%) had cardiac anomalies. The mean operative time was 217 min. There was no difference in operative time between CHD and non-CHD cases (estimate 20 min longer operative time in the presence of a cardiac anomaly [95% CI − 20 to 57]). Two cases were converted to open thoracotomy; both were non-CHD. There was no difference in the time to feeding, time in intensive care unit or time in hospital between CHD and non-CHD cases. Five patients developed an anastomotic leak (two CHD and three non-CHD) of which two were clinical; all were managed conservatively. There was no case of recurrent fistula. This pilot study did not find evidence that thoracoscopic EA repair compromised outcomes in children with congenital heart disease. A prospective multicenter study with long-term follow-up is recommended to confirm whether thoracoscopic repair in CHD is truly equivalent to the open operation. Therapeutic. Level III. [ABSTRACT FROM AUTHOR]

Study Objective: The study was to determine the analgesic effect of ultrasound-guided intercostal nerve block (ICNB) and single-injection erector spinae plane block (ESPB) in comparison with multiple-injection paravertebral block (PVB) after thoracoscopic surgery.Design: Randomized, controlled, double- blinded study.Setting: Operating room, postoperative recovery room and ward.Patients: Seventy-five patients, aged 18-75 years, ASA I-II and scheduled for elective thoracoscopic partial pulmonary resection surgery were enrolled in the study. Seventy-two patients were left for final analysis.Interventions: Patients were randomly assigned into the three groups (PVB group, ICNB group or ESPB group). After anesthesia induction, a single anesthesiologist performed PVB at T5-T7 levels or ICNB at T4-T9 levels or ESPB at T5 level under ultrasound guidance using 20 ml of 0.375% ropivacaine. Patients were connected to the patient-controlled morphine analgesia device after surgery.Measurements: Cumulative morphine consumption at 24 h postoperatively as primary outcome was compared. Visual analog scale pain scores at rest and while coughing at 0, 2, 4, 8, 24 and 48 h postoperatively, cumulative morphine consumption at other observed time and rescue analgesia requirement were also recorded.Main Results: There was a significant difference in median [interquartile range, IQR] morphine consumption at 24 h postoperatively among the three groups (PVB, 10.5 [9-15] mg; ICNB, 18 [13.5-22.1] mg; ESPB, 22 [15-25.1] mg; p = 0.000). This difference was statistically significant for PVB group vs ESPB group (median difference, -7.5; 95% confidence interval [CI], -12 to -4.5; p = 0.000) and PVB group vs ICNB group (median difference, -6; 95% CI, -9 to -3; p = 0.001), but not for ICNB vs ESPB (median difference, -3; 95% CI, -6 to 1.5; p = 0.192). PVB group had significantly lower VAS scores at rest and while coughing than ESPB group at 0, 2, 4, 8 h postoperatively and than ICNB group at 8 h postoperatively. There was no significant difference in the VAS scores between ICNB group and ESPB group at all time. Median VAS scores at rest and while coughing at all time were low (<4) in all groups. More rescue analgesia was needed in ESPB group during 48 postoperative hours (PVB vs ICNB vs ESPB; 13% vs 29% vs 46%; p < 0.05).Conclusions: Ultrasound-guided multiple-injection PVB provided superior analgesia to ICNB and single-injection ESPB, while ICNB and single-injection ESPB were equally effective in reducing pain after thoracoscopic surgery. [ABSTRACT FROM AUTHOR]

To assess the efficacy of computed tomography (CT)-guided localization with the injection of a low dose of patent blue dye (PBD) for the thoracoscopic resection of pulmonary nodules. Overall, 125 consecutive patients underwent CT-guided localization with injection of a lower dose of PBD between June 2015 and June 2016. The total injection dose relative to the distance between nodules and the visceral pleura was recorded. The clinical and radiological characteristics, technical details, pathological results and procedure-related complications were reviewed. A total of 137 indeterminate pulmonary nodules were identified. The mean nodule size was 9.5 (3.0–22.0) mm. The mean injection dose of PBD relative to the distance between nodules and the visceral pleura was classified as follows: 0.07 ml: <1 cm, 0.1 ml: 1–2 cm and 0.18 ml: >2 cm. The mean time of CT-guided localization was 16.5 (10–50) min. The mean time interval from localization to surgery was 188 (24–1440) min. Pneumothorax developed in 50 patients (40%), and focal parenchymal hemorrhage occurred in 16 patients (12.8%) after localization. No patient required chest tube placement or emergent resuscitation. The success rate of dye marking was 98.5% (135/137). Malignancies, including 82 lung cancers, were diagnosed in 97 nodules (70.8%). The injection of a lower dose PBD based on the distance to the visceral pleura can be successful with nodular localization and may facilitate thoracoscopic surgery, even in cases with a long interval from localization to surgery. • The injection of a lower dose PBD according to different nodular depths achieves a high success rate of nodular localization. • This setting may lead to less diffusion effect and avoid overresection of normal lung parenchyma. • It is a simple and efficient technique facilitating thoracoscopic surgery for impalpable nodules. • This procedure may allow for more flexibility in the surgical schedule because of the longer staining effect. [ABSTRACT FROM AUTHOR]

The study objective was to provide a 5-year update on our tertiary-level institutional experience with computed tomography–guided platinum microcoil lung surgery. A retrospective cross-sectional study was conducted. All patients admitted to the Thoracic Service at Vancouver General Hospital to undergo computed tomography–guided microcoil lung surgery were included. Key primary outcome variables were successful nodule localization and severity of adverse events associated with placement. Secondary outcomes included nodule characteristics on preoperative computed tomography chest and nodule surgical pathology. Continuous variables were reported as mean (± standard deviation), and counts were reported as proportions n (%). A total of 97 lung nodules were resected in 92 patients. Mean age was 65.3 (±10.6) years, and 59 (61%) were female. All 97 nodules (100%) were successfully localized using video-assisted thoracic surgery wedge resection. There were 59 cases (60.8%) of placement-related events noted on computed tomography of the chest. All were minor and self-limited in nature and did not require treatment: pneumothorax 45 (46.4%), lung hematoma 18 (18.6%), dislodgement 4 (4.1%), and hemoptysis 2 (2.1%). Mean nodule diameter was 13.2 mm (±6.7). Density was nonsolid in 27 (27.8%) and semi-solid in 27 (27.8%). There was a single case of positive surgical margin, and 4 (4.1%) went on to completion lobectomy. Non–small lung cancer was identified in 66 nodules. Computed tomography–guided platinum microcoil lung surgery is safe with a favorable clinical adverse event profile and is suitable for poor-risk patients. The method is efficient, yielding 100% diagnostic localization in our 5-year update. It eliminates the need for thoracotomy and palpation to localize worrisome subpleural tiny nodules. It is ideal for the management of changing nodules concerning for early lung cancer and diagnosis of small indeterminate lung nodules or metastases. [ABSTRACT FROM AUTHOR]

• Bronchogenic cysts rarely arise from the diaphragm. • Non-specific imaging features sometimes make a preoperative diagnosis difficult. • An early diagnostic surgical excision is the most definitive method of management. • Posterior mediastinal bronchogenic cysts can be excised thoracoscopically. • Intraoperative prone positioning of the patient enhances the ease of this approach. Mediastinal bronchogenic cysts are encountered relatively often, but in many cases, diagnosis using imaging modalities, is difficult. Early surgical excision of bronchogenic cysts is recommended as a diagnostic and therapeutic measure. Here, we report the case of patient with a lower mediastinal bronchogenic cyst, who was treated using thoracoscopic surgery with prone positioning and include a review of literature on diagnosis and treatment of this condition. The patient was a 66-year-old woman with an asymptomatic cystic lesion in the posterior, lower mediastinum. The lesion was diagnosed as an esophageal cyst using preoperative imaging and was scheduled for thoracoscopic removal with the patient in the prone position. Intraoperatively, the lesion was found to have no continuity with the esophageal wall and was easily separated from it. Moreover, a cord extending to the lesion, appeared to arise from the crura of the diaphragm. On histopathological examination of the extracted mass, the lesion was diagnosed as a bronchogenic cyst. Postoperatively, the patient recovered uneventfully and was discharged after 7 days. Thoracoscopic mediastinal cystectomy with the patient in the prone position may be an optimal surgical strategy for the treatment of bronchogenic cysts in the posterior, lower mediastinum. [ABSTRACT FROM AUTHOR]

Introduction: The standard technique for Ivor Lewis minimally invasive esophagectomy involves a two-stage approach necessitating repositioning mid-procedure.Technique: We describe our technique for a one-stage hand-assisted minimally invasive esophagectomy that allows sequential access to the chest and abdomen within the same surgical field, eliminating the need for repositioning. The patient is positioned in a "corkscrew" configuration with the abdomen supine and the chest rotated to the left to allow access to the right chest. The abdomen and chest are prepped into a single operative field. This technique allows sequential access to the abdomen for gastric mobilization, chest for division of the esophagus, abdomen for construction of the gastric conduit, and chest for intrathoracic anastomosis.Conclusion: This approach enables extracorporeal construction of the conduit, which helps ensure a clear distal margin on the specimen and facilitates conduit length by placing the stomach on stretch during stapling. [ABSTRACT FROM AUTHOR]

Highlights • This is the first case of brachial plexus injury during thoracoscopic esophagectomy in the prone position. • This paralysis is due to excessive abduction and external rotation associated with the intraoperative position. • To avoid intraoperative brachial plexus injury in the prone position, thoughtful orientation of the head and right arm in a less loaded position is important. Abstract Introduction During prone esophagectomy, placement of a port in the third intercostal space for upper mediastinal dissection requires adequate axillary expansion. To facilitate this, the right arm is elevated cranially and simultaneously turned outward. Brachial plexus paralysis associated with esophagectomy in the prone position has not been documented. Presentation of case A 58-year-old man diagnosed with middle intrathoracic esophageal cancer was referred to our department. Thoracoscopic esophagectomy in the prone position was performed following neoadjuvant chemotherapy. After surgery, he complained of difficulty moving his right arm. Physical examination revealed perceptual dysfunction and movement disorder in the territory of cervical spinal nerve 6. Magnetic resonance imaging indicated the injury in the right posterior cord of the brachial plexus at the costoclavicular space. Therefore, we diagnosed the patient with right brachial plexus injury caused by the intraoperative position. The postoperative course was uneventful other than the brachial plexus paralysis, and he was discharged on postoperative day 23. He underwent continuous rehabilitation as an outpatient, and the right brachial plexus paralysis had completely disappeared by 2 months after surgery. Discussion This is the first case of brachial plexus injury during thoracoscopic esophagectomy in the prone position. In prone esophagectomy, managing the patient's position, especially the head and arm positions, is so important to avoid brachial plexus injury due to intraoperative positioning. Conclusion The clinicians should consider managing the patient's position with anatomical familiarity to avoid brachial plexus injury due to intraoperative positioning. [ABSTRACT FROM AUTHOR]

Highlights • Open surgery is usually performed for a perforating mediastinal mature teratoma. • Asymptomatic perforation involving a teratoma is very rare. • Complete thoracoscopic surgery was successfully used in this case. • Complete thoracoscopic surgery might be meaningful in cases of few or no symptoms. Abstract Introduction A perforating mediastinal mature teratoma can cause severe inflammation and adhesion; therefore, open surgery is usually performed. Asymptomatic perforation involving a teratoma is very rare. Complete thoracoscopic surgery is often difficult because of inflammation associated with perforation and the frequently large size of a mediastinal mature teratoma. We report a rare case of an asymptomatic perforating mediastinal mature teratoma successfully treated with complete thoracoscopic surgery. Presentation of case The patient was a 15-year-old girl with an abnormal shadow at the mediastinum seen on chest radiography at a health examination performed at her junior high school; an asymptomatic mediastinal tumour was suspected. Enhanced computed tomography revealed a 6.5 × 3.5-cm tumour associated with the right upper lobe. Thoracoscopic surgery was performed using 4 access ports. Although there were inflammatory changes, hemi-thymectomy and right upper lobectomy were achieved with complete thoracoscopic surgery. The tumour included the skin, sebaceous glands, hair, and pancreatic tissue and was diagnosed as a mature teratoma perforating the right upper lobe. Discussion There might be limited inflammatory changes if the patient has few or no symptoms, as in our case. In such cases, the tumour may be excised even if it is large. Conclusion We report a rare case of an asymptomatic perforating mediastinal mature teratoma that was successfully treated with complete thoracoscopic surgery. Although infection, inflammatory adhesion, large tumour size, and the need for radical cure are concerns, complete thoracoscopic surgery might be helpful. In cases of few or no symptoms, thoracoscopic surgery is worth challenging. [ABSTRACT FROM AUTHOR]

Highlights • ILS is a rare congenital malformation, and is supplied by an aberrant systemic artery. • Planning surgical treatment strategy for bilateral ILS is important for preserving respiratory function. • Limited resection using VATS for bilateral ILS can be safe and useful as minimally invasive surgery. Abstract Introduction Intralobar pulmonary sequestration (ILS) is a rare congenital malformation, and is supplied by an aberrant systemic artery. The conventional surgical resection for ILS is lobectomy through an open thoracotomy. However, lobectomy might lead to a significantly compromised pulmonary function. There have been some reports on the feasibility or advantages of the VATS approach in recent years. We report a rare case where we performed a two staged segmentectomy and wedge resection of the affected lesions using a VATS approach for bilateral ILS, and achieved a successful outcome. Case presentation A 30-year-old woman was diagnosed with pneumonia. Chest CT showed multiple cystic masses containing fluid, in the posterobasal segment of the right lung and a hyper infiltrated area in the identical segment of the left lung. 3D CT angiography showed that the area of the right sided lesion received its blood supply from the left gastric artery and the area of the left sided lesion from the proximal celiac artery. The patient was diagnosed with bilateral ILS, and a staged, sequential lung resection was planned using the VATS approach. Anatomical basilar segmentectomy with VATS minithoracotomy for the right ILS, and resection of only the sequestrated lung by VATS for the left ILS were performed. Conclusions It is important to plan the surgical treatment strategy for bilateral ILS for the preservation of respiratory function. Limited resection using the VATS approach for bilateral ILS can be performed safely and might be useful as a minimally invasive surgery. [ABSTRACT FROM AUTHOR]

PMNGCT is an independent predictor of poor prognosis despite advances in multidisciplinary management. Multidrug chemotherapy followed by aggressive surgical resection remains the mainstay of treatment. Although associated with significant morbidity, an open surgical approach is traditionally used. We describe the first reported case, to our knowledge, of a patient who underwent resection of a PMNGCT via a minimally invasive approach following induction chemotherapy. [ABSTRACT FROM AUTHOR]

Purpose There is no consensus in the pediatric surgical community about when to recommend video-assisted thoracoscopic surgery (VATS) for patients with primary spontaneous pneumothorax (PSP). We aimed to identify factors that predict the likelihood of requiring VATS, and to compare recurrence rates and healthcare utilization among different management approaches to PSP. Methods A retrospective chart review and a telephone survey were conducted on all patients 12–21 years who were diagnosed with PSP from 2007 to 2015. Data were extracted on patient demographics, initial management, hospital length of stay (LOS), and subsequent admissions, procedures, and recurrences. Results A total of 46 patients were included with a mean age of 16.1 years (+/− 1.2). Most patients were male (41, 89%) and white (16, 44%). Initial management comprised chest tube drainage alone in 28 (61%), no intervention in 8 (17%), and VATS in 10 (22%). Total LOS was 6 days (IQR 4–7) and was longer in patients who underwent VATS (p < 0.001). Recurrence occurred in 17 patients (37%). However, recurrence and healthcare utilization were not significantly associated with initial management approach. Among those who had initial chest tube drainage, 14 (50%) underwent VATS on that admission, and 8 (28%) had subsequent surgery. Significant predictors of ultimately requiring VATS were presence of an air leak and partial lung expansion. Conclusion Most patients with PSP currently undergo chest tube placement as initial management, although most eventually require VATS. Presence of an air leak and partial lung expansion on chest radiograph within the first 48 h of management should prompt earlier surgical intervention. Type of study Retrospective. Level of evidence III [ABSTRACT FROM AUTHOR]

Background: Left atrial appendage (LAA) closure can be an alternative to oral anticoagulation to prevent cardiogenic thromboembolisms in patients with nonvalvular atrial fibrillation.Objective: The purpose of this study was to retrospectively evaluate the safety, completeness, and mid-term prevention of our thoracoscopic stapler-and-loop technique for LAA closure.Methods: Patients operated on between October 2008 and February 2017 were reviewed. Endoscopic stapler and ligation loops were used. Patients received 1 month of anticoagulation before discontinuation. Hospital death and procedure-related major complications (thromboembolism, hemorrhagic events, phrenic palsy) were the primary composite endpoint for safety, and cardiogenic thromboembolisms were the endpoint for prevention. Brain magnetic resonance imaging investigated new thromboembolic spots 1 year after surgery.Results: There were 201 patients (118 men, 83 women) with a mean age of 74 years (range 68-94) years, mean CHA2DS2-VASc score (± SD) 4.1 ±1.4, and mean HAS-BLED score 2.9 ± 1.0. Mean operation time was 28 minutes. All LAAs were removed, and intraoperative transesophageal echocardiography confirmed completeness of the closure in each patient. No hospital deaths or major procedure-related complications occurred. Follow-up results for 198 patients (98%) over a mean period of 48 months (range 12-110) revealed that 2 patients developed cardiogenic thromboembolisms (0.25 event per 100 patient-years). Magnetic resonance imaging of 51 patients with a mean CHA2DS2-VASc score of 4.7 ± 1.6 revealed 1 new small spot in each of 2 patients (3.9%; 3.9 spots per 100 patient-years).Conclusion: Our thoracoscopic stapler-and-loop technique swiftly, safely, and completely closed LAAs in patients with nonvalvular atrial fibrillation and provided acceptable mid-term prevention without anticoagulation. [ABSTRACT FROM AUTHOR]

Objective We evaluated health-related quality of life at 12 months after thoracoscopic surgical ablation in patients enrolled in the Atrial Fibrillation Ablation and Autonomic Modulation via Thoracoscopic Surgery study. The Atrial Fibrillation Ablation and Autonomic Modulation via Thoracoscopic Surgery study assessed the efficacy and safety of ganglion plexus ablation in patients with symptomatic advanced atrial fibrillation undergoing thoracoscopic surgical ablation. Methods Patients (n = 240) underwent thoracoscopic pulmonary vein isolation with additional ablation lines in patients with persistent atrial fibrillation. Subjects were randomized to additional ganglion plexus ablation or control. Short Form 36 quality of life questionnaires were collected at baseline and at 6 and 12 months of follow-up. Results A total of 201 patients were eligible for quality of life analysis (age 59 ± 8 years, 72% were men, 68% had an enlarged left atrium, 57% had persistent atrial fibrillation). Patients improved in physical and mental health at 6 months (both P < .01) and 12 months (both P < .01) relative to baseline, with no difference between the ganglion plexus (n = 101) and control (n = 100) groups. Short Form 36 subscores in patients with 1 or no atrial fibrillation recurrences were similar to those in the general Dutch population after 12 months. Patients with multiple atrial fibrillation recurrences (30%) improved in mental ( P < .01), but not physical health, and 6 of 8 Short Form 36 subscales remained below those of the general Dutch population. Patients with irreversible, but not with reversible procedural complications had persistently diminished quality of life scores at 12 months. Conclusions Thoracoscopic surgery for advanced atrial fibrillation results in improvement in quality of life, regardless of additional ganglion plexus ablation. Quality of life in patients with no or 1 atrial fibrillation recurrence increased to the level of the general Dutch population, whereas in patients with multiple atrial fibrillation recurrences quality of life remained lower. Irreversible but not reversible procedural complications were associated with persistently lower quality of life. [ABSTRACT FROM AUTHOR]

The diaphragm is the primary muscle of respiration. Bilateral paralysis of the diaphragm due to phrenic nerve palsy causes severe dyspnoea and is life threatening. Diaphragmatic Plication has shown great promise in treating diaphragm paralysis and has evolved as operative treatment from an open thoracotomy to multiport and robotic video assisted thoracoscopic surgery. Here we present a case of idiopathic bilateral diaphragm paralysis resulting significant deterioration in lung function tests, supplemental oxygen, and ventilator dependence. The patient was treated with a 2-stage operative plication of each hemidiaphragm through a 2.5 cm single incision thoracoscopic technique, which resulted in normalization of lung function tests, elimination of oxygen dependence and negligible analgesia requirements. This is the first case reported in the literature of a single port VATS plication of the diaphragm for the treatment of bilateral phrenic nerve palsy. Surgery, specifically diaphragm plication, is indicated for patients with significant symptoms and persistent paralysis. Video-assisted thoracoscopic surgery (VATS) has evolved from open operations to smaller incisions, offering improved lung function, postoperative pain, hospital stay, morbidity, and mortality. Single port diaphragmatic plication is a novel approach to the treatment of bilateral phrenic nerve palsy. We make the case for indication of the technique for treatment of diaphragmatic paralysis. • Bilateral diaphragm paralysis due to phrenic nerve palsy is life-threatening. • Diaphragmatic plication has evolved from open thoracotomy to multiport and robotic video-assisted thoracoscopic surgery. • Case of idiopathic bilateral diaphragm paralysis resulted in significant lung function deterioration and ventilator dependence. • Treatment involved bilateral operative plication using a 2.5 cm single-incision thoracoscopic technique. • Outcome: normalization of lung function tests, elimination of oxygen dependence, and minimal analgesia requirements. • First case using a single-port technique for bilateral phrenic nerve palsy treatment. • Literature review and case made for indicating the technique in diaphragmatic paralysis treatment. [ABSTRACT FROM AUTHOR]

There is a risk for high-output congestive heart failure to be associated with an extra-lobar pulmonary sequestration (ELS) when there is left-to-left shunting caused by a large systemic arterial supply to a sequestration and venous drainage via the pulmonary veins into the left atrium. We present a 2-year-old boy who underwent thoracoscopic resection of an unusually hypervascular right ELS with a high output left-to-left shunt between the aorta and the left atrium via a pulmonary vein. This case is of particular interest because computed tomographic angiography identified a hypervascular nidus with indistinct borders between arterial and venous vessels suggestive of an arteriovenous malformation. [ABSTRACT FROM AUTHOR]

Abstract Descending necrotizing mediastinitis (DNM) is caused by a cervical or odontogenic infection that spreads downward to the mediastinum through anatomical cervical spaces. Its mortality rate is high, and its early diagnosis is important for successful treatment. Here, we report about a 14-month-old girl with DNM and pyothorax who was admitted to our hospital. She underwent thoracoscopic surgery (TS) for drainage of the mediastinum and was administrated with antibiotics. Her postoperative course was uneventful. Common fever in children, even in those without past history, can acutely progress to DNM with pyothorax. TS was effective in performing mediastinal drainage. [ABSTRACT FROM AUTHOR]

Introduction When considering treatment for pulmonary cancer complicated by interstitial pneumonia, the greatest problem is acute exacerbation. We report two cases of pulmonary cancer complicated by interstitial pneumonia in which multiple intrapulmonary lymph nodes were noted. Case presentations Cases 1 and 2 were 76- and 62-year-old males, respectively. Both cases were diagnosed as pulmonary cancer complicated by interstitial pneumonia, and upon chest CT, it was noted that, in addition to the primary lesions, there were multiple nodule shadows under the pleura in the lung lobe, which required identification in order to rule out lung metastasis. In Case 1, the pulmonary nodules were first resected during surgery and a swift diagnosis was made, determining them to be intrapulmonary lymph nodes, which were then operated on curatively. In Case 2, the patient underwent thoracoscopic observation during surgery, the shadows were diagnosed visually as intrapulmonary lymph nodes, and curative surgery was implemented. Discussion and conclusions The greatest problem in treating pulmonary cancer complicated with interstitial pneumonia is acute exacerbation, wherein, in the absence of any surgical indications, alternative treatment is limited. Thus, contra-indicating surgery for a patient due to a diagnosis of metastasis within the lungs, based only on nodule images, should be avoided. If nodules are noted in the area of the pleura, the possibility exists that these could be intrapulmonary lymph nodes, along with metastasis within the lung, and thoracoscopic surgery should be implemented proactively while keeping these in mind. [ABSTRACT FROM AUTHOR]

Study Objective: Although combined thoracic paravertebral blockade (TPVB)-general anesthesia (GA) could improve pain control compared to GA alone after thoracoscopic lung cancer surgery, it has not been established whether this improvement in pain control could reduce associated adverse outcomes. Thus, this study aimed to explore the association between TPVB usage and adverse outcomes after thoracoscopic lung cancer surgery.Design: Retrospective cohort study from a prospective database.Setting: A high-volume thoracic center in China.Patients: 13966 consecutive patients who received thoracoscopic lung cancer surgery from January 2016 to December 2018 in Shanghai Chest Hospital were enrolled.Measurements: With a 1:1 propensity score matching (PSM) analysis, adverse outcomes between GA alone and GA-TPVB were investigated. Multivariate and multiple linear regression analysis were used to identify factors and calculate odds radio (OR) for adverse outcomes.Results: The rate of TPVB usage was 14.8% (2070 out of 13,966). TPVB combined with GA was associated with lower rates of postoperative pulmonary complications (PPCs) (30.4% vs 33.5%, P = 0.005) and postoperative atrial fibrillation (POAF) (2.1% vs 2.9%, P = 0.041), and shorter length of hospital stay (LOS) (Median [IQR]; 5[4-5] vs 5[4-6]) days, P < 0.001) compared to GA alone. After a 1:1 PSM analysis, we investigated adverse outcomes in 2640 (1320 pairs) patients with or without TPVB usage, and this association remained existed, namely, the rates of PPCs (29.8% vs 34.2%, P = 0.014) and POAF (2.2% vs 3.6%, P = 0.028) were lower and LOS was shorter (5[4-5] vs 5[4-6] days, P < 0.001) in the GA-TPVB group. In multivariate analysis, the combination of GA plus TPVB was independent predictor for PPCs (OR = 0.879, 95%CI, 0.793-0.974, P = 0.014) and POAF (OR = 0.714, 95%CI, 0.516-0.988, P = 0.042), respectively. However, in multiple linear analysis, lower rates of PPCs and POAF associated with TPVB usage, rather than TPVB usage, were responsible for the reduced LOS.Conclusions: The usage of TPVB may be a feasible and adjustable approach to reduce the rates of PPCs and POAF and associated LOS in thoracoscopic lung cancer surgery. [ABSTRACT FROM AUTHOR]

A congenital bronchoesophageal fistula with pulmonary sequestration is rare in adults. Here, we report the case of an adult woman having congenital bronchoesophageal fistula with intralobar pulmonary sequestration who successfully underwent thoracoscopic resection and showed a good postoperative course. [ABSTRACT FROM AUTHOR]

Background In patients with atrial fibrillation (AF), the autonomic nervous system is supposed to play an role in triggering AF; however, little is known of the effect on atrial conduction characteristics. Objective The purpose of this study was to study the effect of ganglionic plexus (GP) stimulation during sinus rhythm on atrial and pulmonary vein conduction in patients during thoracoscopic surgery for AF Methods In 25 patients, the anterior right ganglionic plexus (ARGP) was stimulated (16 Hz, at 1, 2, and 5 mA). Epicardial electrograms were recorded using a 48-electrode map from the right pulmonary vein (RPV) or right atrial (RA). Intra-atrial activation time (IAT), local activation time (LAT), and inhomogeneity of conduction (IIC) were determined. ECG parameters (P-P, P-R interval) were measured. Results P-P interval was 956 ± 157 ms (range 768–1368 ms), and P-R interval was 203 ± 37 ms (range 136–280 ms). After ARGP stimulation, a short-lasting increase of P-P interval was observed, more prominent at higher output (1 mA = 82 ms, 2 mA = 180 ms, 5 mA = 268 ms, all P <.01 vs baseline). P-R interval remained unchanged. IAT was 34.4 ms (range 5.6–50.3 ms) at the RA and 105.8 ms (range 79.7–163.3 ms) at the RPV. After 1-mA stimulation IAT increased, in patients taking beta-blockers ( P = .001), or it decreased, and this change persisted after subsequent stimulation at higher current (1 mA, P = .001; 2 mA, P = .401; 5 mA, P = .593). Similar changes were observed for LAT and IIC. Conclusion ARGP stimulation results in a short-lasting, output-dependent decrease in sinus node frequency due to a parasympathetic response. Stimulation of the ARGP induced a prolonged increase or decrease in conduction characteristics in patients with AF, consistent with a persistent differential parasympathetic and/or sympathetic response. [ABSTRACT FROM AUTHOR]

A 38-year-old non-smoking female patient was evaluated at our hospital for an increasing mass in the right lower lung field at 24 weeks of gestation. Computed tomography revealed an approximately 7.5-cm diameter mass in the right lower lung lobe. After assessing the benefits to the patient and risks to the fetus, we performed a lobectomy with mediastinal lymph node dissection using video-assisted thoracoscopy. Three months postoperatively, the patient delivered a healthy male baby. The patient is alive 10 months following the lobectomy, and no evidence of recurrence and distant metastasis is noted. The 6-month-old infant is also doing well postpartum. [ABSTRACT FROM AUTHOR]

Objectives This study was designed to determine the incidence and risk factors associated with ipsilateral shoulder pain (ISP) after thoracic surgery and to investigate characteristics, locations, and severity of ISP. Design A prospective observational study. Setting University hospital. Participants Two hundred five patients who underwent thoracic surgery. Interventions None. Measurements and Main Results Pain at the incisional site and shoulder pain were assessed separately using the numeric rating scale (NRS) during the patients' stay in the postanesthesia care unit. The overall incidence of ISP was 47.3%. The incidence of ISP in thoracotomy patients (58.7%) was substantially higher than in video-assisted thoracoscopic surgery patients (20.9%). ISP was described most often as a dull aching pain (87%). In approximately half of the patients, ISP was located at the posterior side of the shoulder. The severity of ISP was classified as moderate to severe in 67% of patients. The potential risk factors associated with ISP were surgery using the thoracotomy approach (risk ratio: 2.12, 95% confidence interval: 1.16-3.86, p = 0.014) and surgical duration>120 minutes (risk ratio: 1.61, 95% confidence interval: 1.07-2.44, p = 0.023). Conclusions The incidence of ISP after thoracic surgery was high and the severity of pain was significant. The thoracotomy approach and the long duration of surgery are potential risk factors for ISP. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Patients with atrial fibrillation (AF) with enlarged atria or previous pulmonary vein isolation (PVI) are challenging patients for catheter ablation. Thoracoscopic surgery is an effective treatment for these patients but comes at the cost of an increase in adverse events. Recently, electrophysiological (EP) guided approaches to thoracoscopic surgery have been described which consist of EP guidance by measurement of conduction block across ablation lines. In this study we describe the efficacy and safety of EP-guided thoracoscopic surgery for AF in patients with enlarged atria and/or prior failed catheter ablation. Methods & results: A total of 72 patients were included. Two different approaches to EP-guided thoracoscopic surgery were implemented: epicardial or endocardial EP-guidance at the time of surgery. Residual intraoperative conduction requiring additional ablation was detected with epicardial or endocardial mapping techniques in 50% and 11%, respectively. Additional epicardial or endocardial ablation was performed until bidirectional block was confirmed. Follow-up consisted of an ECG and a 24h Holter at 3, 6 and 12months after the procedure. A total of 57 patients (79%) had freedom of AF and were off anti-arrhythmic drugs at one year follow-up (30 paroxysmal (83%), 27 persistent AF (75%)). Adverse events occurred in 13 patients (6 major). None of our patients died and all events were reversible. Conclusion: EP-guidance of thoracoscopic surgery can be safely performed both epicardially and endocardially and is associated with a high rate of long-term maintenance of sinus rhythm in patients with enlarged atria and/or a previously failed ablation. [Copyright &y& Elsevier]

Abstract: Pediatric patients with large extraovarian teratomas with a significant solid component are usually treated using open surgery because the size of the intracorporeal cavity does not facilitate the manipulation of large tumors. Here, we describe the cases of 3 children who underwent minimally invasive surgery for large extraovarian teratomas (diameter > 10 cm), including 2 cases of retroperitoneal teratoma and 1 case of a thoracic teratoma. All tumors had a large amount of sebaceous material that displaced other surrounding organs. Tumor volumes were reduced by intraoperative needle aspiration using a SAND balloon catheter with a double balloon that is designed to minimize the risk of spillage. Intraoperative needle aspiration of cystic content can provide sufficient working space and facilitates safe separation of the major vessels from the tumor. Treatment of large extraovarian teratomas by minimally invasive surgery involving skin incisions that result in a less noticeable scar, such as a Pfannenstiel incision or axillary incision, can achieve improved cosmetic outcomes. [Copyright &y& Elsevier]

Summary: Thoracoscopic surgery is now an integral part of paediatric practice. The evolution of instrumentation, optics and haemostatic devices have enabled even the most complex procedures to be carried out thoracoscopically. Although randomised studies are limited in children, thoracoscopic surgery appears to offer outcomes at least equivalent to that of open operations with less post-operative pain, less scarring and a more rapid recovery. Furthermore many of the long term musculo-skeletal deformities associated with a thoracotomy are avoided. There are however several surgical and anaesthetic challenges that make the widespread application of these techniques beyond that of specialised centres difficult. [ABSTRACT FROM AUTHOR]

In lung cancer, mediastinum lymphatic spread occurs. We review our technique and experience of thoracoscopic mediastinal lymphnode dissection (MLND). Between 1997 and 2011, 992 patients with primary lung cancer underwent thoracoscopic major pulmonary resection with MLND. Initially we used a combination of electrocautery and clips to divide blood vessels and lymphatic channels; our current technique relies on a vessel sealing system (VSS) which is expeditious and leads to less lymphorrhea. Furthermore, dissection of station 7 nodes is performed after each main bronchus or right intermediate bronchus is taped with a 0 silk suture, which is then brought out of the thorax through the access incision for antero-lateral retraction of the tracheal carina. We dissect between 3 and 4 N2 lymph node stations and a total of approximately 20 N2 lymph nodes. Postoperative complications related to MLND occurred in 35 of 992 patients (3.5%), 15 (1.5%) for recurrent laryngeal nerve injury, 3 (0.3%) for bilateral vagal injury, 14 (1.4%) for chylothorax and 3 (0.3%) for airway injury. However, none were lethal. Thoracoscopic mediastinal dissection is safe and feasible in treating lung cancer. We believe our technique and VSS are very useful for thoracoscopic MLND. [ABSTRACT FROM AUTHOR]

Background: This retrospective study evaluated the surgical learning curve and outcomes of thoracolaparoscopic esophagectomy.Patients and Methods: The study group comprised a series of 92 patients with preoperatively diagnosed resectable thoracic esophageal cancer. Additionally, the surgical outcomes in 79 esophageal cancer patients receiving open esophagectomies were compared. All patients underwent thoracolaparoscopic esophagectomy in the lateral decubitus position. The short- and long-term outcomes were evaluated, and the surgical learning curve was assessed.Results: The total operation time was 477.8 ± 102.2 min, the thoracoscopic time was 157.9 ± 61.3 min, the total blood loss was 554.4 ± 280.5 ml, and the number of retrieved lymph nodes was 34.3 ± 14.3. Postoperative morbidity was observed in 23 patients. After the surgeon's first 40 cases, the surgical technique and short-term outcomes were stable. The 5-year disease-specific survival was 66.6% and the 5-year overall survival was 64.6% in patients receiving R0 thoracolaparoscopic esophagectomy. Comparison of 5-year disease-specific survival rate according to tumor-node-metastasis stage between patients receiving R0 thoracolaparoscopic esophagectomy and conventional open esophagectomy showed that there were no significant differences in survival in any stage between the two groups. Loco-regional recurrence was observed in 6 patients, distant recurrence in seven, and combined recurrence in nine after R0 thoracolaparoscopic esophagectomy. There was no significant difference in the pattern of recurrence between the two groups.Conclusions: Thoracolaparoscopic esophagectomy for esophageal cancer was technically feasible and oncologically satisfactory, according to the surgical learning curve. [ABSTRACT FROM AUTHOR]

Abstract: Background: A recent series detailing thoracoscopic repair of esophageal atresia with tracheoesophageal fistula (EA/TEF) reported lower complication rates compared with historic controls. This study provides a contemporary cohort of patients repaired via thoracotomy for comparison with the recent large multi-institutional thoracoscopic series. Methods: Records of patients with EA/TEF between 1993 and 2008 were reviewed. Attention was focused on demographics and complications including anastomotic leak, recurrent fistulae, stricture formation, and need for fundoplication. Results: Seventy-two patients underwent repair of EA/TEF via thoracotomy. Complication rates in the current series compared with the thoracoscopic series were anastomotic leak, 2.7% versus 7.6%; recurrent fistulae, 2.7% versus 1.9%; stricture, 5.5% versus 3.8%; and need for fundoplication, 12% versus 24%. Differences in complication rates did not reach statistical significance. Two children in this cohort developed mild scoliosis attributed to congenital vertebral anomalies, neither of whom required intervention. Conclusions: Thoracoscopic repair of EA/TEF yielded complication rates similar to this contemporary series; however, trends toward increased anastomotic leaks and greater need for fundoplication were noted. No musculoskeletal sequelae were directly attributable to thoracotomy. [Copyright &y& Elsevier]

The ectopic parathyroid adenoma is an important cause of refractory and recurrent hyperparathyroidism. The mediastinal location of ectopic parathyroid tissue is reported in up to 20% of cases of ectopic parathyroid adenomas. In around 2% of cases where cervical approach is unfeasible, the mediastinal route imposes a surgical challenge. We describe a case of a twenty-five-year-old male patient with manifestations of hyperparathyroidism. Computed tomography of the chest showed an anterior mediastinal mass. Nuclear scintigraphy detected a functioning parathyroid tissue in the mediastinum. The mass was excised en block with the surrounding adipose tissue using a three-port video-assisted thoracoscopic surgery. The patient showed a full symptomatic and laboratory recovery. Mediastinal parathyroid glands comprise a unique surgical entity with diagnostic and management difficulties. Mediastinal parathyroid gland is a rare yet important cause of refractory hypercalcemia. The current localization tools improve the thoracoscopic management of MPAs. VATS can provide access and exposure to ectopic parathyroid adenoma with low morbidity. • Ectopic mediastinal parathyroid glands are rare yet challenging cause of refractory or recurrent hypercalcemia. • Most mediastinal parathyroids are approachable through a neck incision. • Larger, deeper or totally mediastinal glands require thoracic access. • Historically, in challenging cases, sternotomy or thoracotomy is performed with associated high morbidity in some cohorts. • The video-assisted thoracoscopic surgery (VATS) allows surgeons to retrieve these glands guided with localization tools. [ABSTRACT FROM AUTHOR]

Objective: The hypothesis was tested that preoperative multiple-injection thoracic paravertebral blocks reduce opioid requirements and promote early ambulation after video-assisted thoracic surgery procedures. Design: Prospective, randomized, controlled, blinded study. Setting: Single-university hospital. Participants: Fifty consenting patients undergoing video-assisted thoracic surgery. Interventions: Patients were randomly assigned to receive preoperative multiple-injection thoracic paravertebral blocks (PVB group, n = 25) or preoperative multiple subcutaneous saline injections at the same site as in the PVB group (control group, n = 25). Measurements and Main Results: Intraoperative fentanyl consumption was lower in the PVB group (p < 0.01). The time to first analgesic requirement was longer, and pain score at this time was lower in the PVB group (p < 0.05 and p < 0.01, respectively). Postoperative pain scores both at rest and coughing were lower during the first 4 hours in the PVB group than those in the control group (p < 0.01 for 0 hours and p < 0.05 for 1, 2, and 4 hours). Cumulative morphine consumption was significantly less in the PVB group at all time points (p < 0.05 for 12 hours and p < 0.01 for all other time points), but there were no significant differences in sedation scores between the 2 groups. There were no complications because of the blocks. Patient satisfaction with the analgesia was significantly greater (p < 0.05), and first mobilization and hospital discharge were quicker (p < 0.01 and p < 0.05, respectively) in the PVB group. Conclusion: Perioperative multiple-injection thoracic paravertebral blocks with bupivacaine containing epinephrine provided effective pain relief and a significant reduction in opioid requirements. This approach may also contribute to earlier postoperative ambulation after video-assisted thoracic surgery. [Copyright &y& Elsevier]

Abstract: In order to detect and track the small magnet embedded in the vicinity of a target tumor during surgical operation, a magnetic navigation system based on the three-dimensional measurement with micro-fluxgate magnetic sensors was developed. In this paper, we present an image overlay method for superimposing the magnet marker embedded through bronchoscope. To evaluate the performance of the proposed system and its applicability in clinical use, we set up an in vivo experiment, in which the surgeons used the system to perform a thoracoscopic surgery on a pig with transbronchial marking with oblique-viewing. As a result, the surgeons could operate the partial resection of the target area, which corresponded to the tumor lesions, of the pig lung easily and safely under the guidance of the magnetic navigation system. [Copyright &y& Elsevier]

Background.: Video-assisted thoracoscopic surgery (VATS) is commonly employed to achieve pleurodesis in patients suffering malignant pleural effusion (MPE). Aims.: To evaluate the utility and outcome of VATS pleurodesis in management of MPE. Methods.: Two hundred and two consecutive VATS pleurodesis for MPE were evaluated. Data was derived from a prospectively maintained database and hospital records. Pleurodesis was deemed unsuccessful if a significant effusion occurred within 30 days of surgery. Results.: VATS pleurodesis was successful in 88% of patients (failure 12%) while recurrence of effusion occurred in 18%. Post-operative air space, air leak, empyema and prolonged intercostal catheter drainage (>14 days) were all significantly associated with a failed procedure. Mean length of stay was 10.4 days and 42% of patients were discharged within 7 days of surgery. Morbidity was 20% with no operative deaths and median survival was 94 days. Inpatient mortality was 5%. High ASA (≥4) was significantly associated with increased risk of inpatient death (p <0.001) and poorer long-term survival (43 days versus 133 days, p =0.05). Conclusions.: VATS pleurodesis offers reasonable palliation of MPE with low morbidity and rapid recovery. Patients with an ASA score of ≥4 have a poor overall outcome and warrant less invasive palliative measures. [Copyright &y& Elsevier]

This article describes a diagnostic approach to the management of subcentimeter pulmonary nodules and delineates the contribution the chest surgeon brings to clinical decision making. This includes clinical experience and knowledge of nodule accessibility to thoracoscopic excisional biopsy based on the anticipated localization technique to be used. Characteristics of the ideal localization technique are discussed. Different localization techniques are then described, and their respective advantages and disadvantages are discussed. These techniques include intraoperative finger and instrument localization, preoperative radiologically placed hooks and coils, intraoperative ultrasonography, and preoperative placement of radiotracer markers. [Copyright &y& Elsevier]