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The first video-assisted thoracic lobectomy in non-intubated patient in America was performed on 27th of September 2014 in Bogotá Colombia, The National Cancer Institute in Bogotá received Dr. Diego González-Rivas to make possible this kind of procedure in a 53-year-old man, with a history of papillary thyroid cancer treated with surgery and Iodine therapy, in whom two pulmonary nodules were found in the monitoring tomography. We resected the nodule located at the right upper lobe previously marked by scintigraphy, the other one required a lobectomy because it was a deep nodule with malignant radiologic appearance inside of the middle lobe. The procedure discoursed in a non-intubated patient without technical difficulties or complications, very short recovery time, minimum pain and a quiet and usual postoperative evolution. This procedure, the first reported in America was replicated after others with similar results in several countries thanks to the collaboration between surgeons, anesthesiologists, radiologists, nurses and therapists, because especially in such interventions teamwork is essential. We believe that given the benefits in terms of recovery for the patient and anesthetic time, we could go on replicating the experience in selected patients.

Introduction The rationale for oncologic surveillance following pulmonary lobectomy is to detect recurrent disease or a second primary lung cancer early enough so that an intervention can increase survival and/or improve quality of life. Therefore, we reviewed literature for international guidelines and reorganized these useful factors associated with non-small-cell lung cancer (NSCLC) recurrence as remedies in postoperative follow-up. Method The population of interest for this review was patients who had been treated with complete resection for primary NSCLC and were in follow-up. Result Guidelines on follow-up care for NSCLC vary internationally. Because of the production of progressive medical modalities, the current follow-up care should be corrected. Conclusion The specific follow-up schedule for computed tomography imaging may be more or less frequent, depending upon risk factors for recurrence. Many different predictors of postoperative recurrence may help to optimize the patient selection for specified surveillance guidelines and personalized adjuvant therapies to prevent possibly occult micrometastases and to get a better outcome.

Botryomycosis is a rare pyogranulomatous disease characterized by suppurative and often granulomatous bacterial infection of the skin, soft tissues and viscera. Only about 90 cases have been reported in world literature till date: 75% of them are cases of cutaneous botryomycosis. Of the 18 reported cases of primary pulmonary botryomycosis, only one had histologically proven botryomycosis in a lung cavity. We report here a case of primary pulmonary botryomycosis occurring in a lung cavity, which is to the best of our knowledge first such case from India. The index case was a 62 year old female who presented to us with recurrent episodes of non-massive streaky hemoptysis with CT chest revealing ‘Air Crescent’ sign with a probable fungal ball in a left upper lobe cavity. Left upper pulmonary lobectomy was done and histopathology of the cavitary tissue revealed Splendore-Hoeppli phenomenon and features suggestive of Botryomycosis. Tissue culture from the cavitary specimen grew Pseudomonas aeruginosa. Botryomycosis can mimic Aspergilloma radiologically as was seen in our case, but therapy is often a combination of both medical and surgical measures unlike Aspergilloma.

The objective of this study was to compare the air leak duration of two regulated chest tube modes following pulmonary lobectomy.This is a prospective randomized trial on 100 consecutive pulmonary lobectomies (2010-11) performed for lung cancer. A single 24-French chest tube was connected to an electronic system capable of maintaining the pleural pressure within preset values (regulated suction mode) or within a physiological range (regulated seal mode). Patients were randomized to two groups: Group 1, regulated individualized suction (range: -11 to -20 cmH2O, according to lobectomy type); Group 2, regulated seal (-2 cmH2O). The main endpoint was the duration of air leak (h) calculated from the end of the operation to a value consistently below 20 ml/min. Patients with prolonged air leak (168 h) were connected to a portable device before discharge. Their air leak duration was considered as 192 h. The sample size was calculated to detect 1-day difference in air leak duration with a statistical power of 80%.The two groups were well matched for several baseline and surgical characteristics. No crossovers occurred between groups. The average air leak duration (Group 1: 28 vs Group 2: 22.2, P = 0.6), and the number of patients with prolonged air leak (Group 1: 5 vs Group 2: 4, P = 0.7) and with other complications (Group 1: 6 patients vs Group 2: 7 patients, P = 0.9) were similar between the groups. Sixteen patients of Group 1 and 21 of Group 2 had an air leak present immediately after extubation. Among them, patients of Group 2 (regulated seal) had an air leak lasting 34.5 h less than those of Group 1 (regulated suction) (52.9 vs 87.4, P = 0.07).Regulated seal is as effective and safe as regulated suction in managing chest tubes following lobectomy. This information demonstrates with objective data the non-superiority of regulated suction vs regulated seal and may assist in future investigations on regulated pleural pressure.

BACKGROUND AND STUDY AIMS: Thoracoscopic pulmonary lobectomy is being performed in an increasing number of patients. The aims of the current study were to assess natural orifice transluminal endoscopic surgery (NOTES) as an alternative to transthoracic endoscopic surgery, and to test the feasibility of peroral transesophageal right upper pulmonary lobectomy with the assistance of a single transthoracic trocar. METHODS: In 10 acute and 4 survival pigs, right upper pulmonary lobectomy was performed using a forward-viewing double-channel gastroscope and an operative thoracoscope with a 5-mm working channel inserted through a single transthoracic 12-mm) port. Time, safety, and feasibility of the following steps were recorded in all animals: esophagotomy, hilar dissection, individual ligation of the hilum elements, pulmonary lobectomy, and specimen retrieval. In the survival experiments, esophagotomy was closed using a reticulated laparoscopy suture device and an esophageal stent was placed. These animals were kept alive and monitored for 2 weeks. RESULTS: Esophagotomy was performed safely in all animals (mean procedure duration 5.4 ± 1.7 minutes). Dissection of the right upper lobe hilum elements (bronchus, arteries, and veins) was carried out without adverse events. Individual ligation of the hilum elements was performed in all but two cases (time for dissection and ligation 44.2 ± 14.8 minutes). Lobectomy and specimen retrieval were completed in all animals (9.5 ± 3.1 minutes). Esophagotomy closure and stent placement were carried out in 20.0 ± 2.8 minutes in the survival animals. These animals fed normally and gained weight postoperatively without signs of disease. Endoscopic examination before necropsy revealed a pseudo-diverticulum in one animal, and wound dehiscence with confined collection/recess in the remaining animals. CONCLUSIONS: Transesophageal right upper pulmonary lobectomy using single transthoracic trocar assistance is feasible and may represent a step towards scar-free pulmonary lobectomy., This project was funded by the FCT Grants project PTDC/SAUOSM/105578/2008.

Background Atrial fibrillation (AF) after thoracic surgery is a continuing source of morbidity and mortality. The effect of postoperative AF on long-term survival however has not been studied. Our aim was to evaluate the impact of AF on early outcome and on survival > 5 years after pulmonary lobectomy for lung cancer. Methods From 1996 to June 2009, 454 consecutive patients undergoing lobectomy for lung cancer were enrolled and followed-up until death or study end (October 2010). Patients with postoperative AF were identified; AF was investigated with reference to its predictors and to short- and long-term survival (> 5 years). Results Hospital mortality accounted for 7 patients (1.5%), while postoperative AF occurred in 45 (9.9%). Independent AF predictors were: preoperative paroxysmal AF (odds ratio [OR] 5.91; 95%CI 2.07 to 16.88), postoperative blood transfusion (OR 3.61; 95%CI 1.67 to 7.82) and postoperative fibro-bronchoscopy (OR 3.39; 95%CI 1.48 to 7.79). Patients with AF experienced higher hospital mortality (6.7% vs. 1.0%, p = 0.024), longer hospitalization (15.3 ± 10.1 vs. 12.2 ± 5.2 days, p = 0.001) and higher intensive care unit admission rate (13.3% vs. 3.9%, p = 0.015). The median follow-up was 36 months (maximum: 179 months). Among the 445 discharged subjects with complete follow-up, postoperative AF was not an independent predictor of mortality; however, among the 151 5-year survivors, postoperative AF independently predicted poorer long-term survival (HR 3.75; 95%CI 1.44 to 9.08). Conclusion AF after pulmonary lobectomy for lung cancer, in addition to causing higher hospital morbidity and mortality, predicts poorer long-term outcome in 5-year survivors.

There are only a few reports in the veterinary literature describing the use of stapling equipment and techniques for pulmonary surgery. These reports indicate that complications associated with these procedures are minimal. Although pulmonary lobectomy procedures originally described independent isolation and ligation of the hilar vessels, it became apparent that, with the use of the smaller staples, especially the ones designed for vascular use, this was unnecessary. Therefore, en bloc hilar stapling is the procedure of choice. This makes the surgical procedure extremely quick to perform. Similarly, there is no indication to routinely oversew staple lines when performing a partial lobectomy. This is a tedious procedure and may actually increase the chance of air leakage. If point areas of leakage do occur, these can be independently occluded either with sutures or individual vascular clips. Selecting the correct size of TA stapler and staples to create the correct length of staple line is critical. It is important that all the tissue to be ligated lie comfortably within the staple line. It is better to use a stapler that is too long and collect the extra staples on a sponge than to use one that is too short that results in leakage from nonstapled tissue. In general, the 4.8-mm staples should not be used for pulmonary surgery in the dog and cat. They do not compress the tissue enough to prevent leakage. For most complete lobectomies, where the hilus of the lung can be adequately isolated, the TA 30 V3 is the stapler of choice. When performing a partial lobectomy, a longer stapler is often required. If a TA 55 or TA 90 is necessary, it should be used with 3.5-mm staples. Even though stapling techniques have made pulmonary surgical procedures safe, easy, and quick to perform, they are not totally free of problems and complications. Experience in the use of the equipment is essential, as is good surgical judgment as to when to use or not to use these techniques. The absence of reported clinical complications, either short- or long-term, attests to the success of these techniques.

Objective: Lobectomy with pulmonary artery resection and reconstruction is seldom performed in order to avoid pneumonectomy in selected cases. The aim of this study is to determine how safe and effective the graft reconstruction of the pulmonary artery is, using autologous tissue taken from the pulmonary vein. Methods: Eight patients with diagnosed non-small-cell lung cancer were treated by lobectomy with pulmonary artery reconstruction with curative intent. All patients could have tolerated pneumonectomy. Patch or conduit angioplasty was performed by usingatailoredgraft,harvestedfromtheautologouspulmonaryveinoftheresectedlobe.Patientswerefollowedupandtheclinicalrecordswere analyzed retrospectively. Long-term patency of the reconstructed pulmonary artery was investigated by computed tomographic pulmonary angiogram. Results: No procedure-related complications and no perioperative mortality were observed. No blood transfusion was required. Follow-up varied from 10 to 64 months. No local recurrences were found next to the angioplasty. Ideal long-term patency of the pulmonary artery was demonstrated in all cases. Two patients are alive with evidence of extrathoracic metastatic disease and four patients are apparently healthy. Two patients died of progressive disease. Conclusions: The use of pulmonary vein tissue as a graft to repair the pulmonary artery is feasible, reproducible, and seems to be oncologically correct. Pulmonary vein tissue can be easily harvested during surgery and offers a high-quality vascular tissue for pulmonary angioplasty. # 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

BACKGROUND--This report describes a preliminary experience with six patients undergoing video imaged thoracoscopic pulmonary lobectomy. METHODS--Three left upper lobectomies, and one each of right upper, right lower and left lower lobectomy were undertaken. The resections were performed as orthodox dissectional lobectomy procedures but were carried out under videothoracoscopic imaging with instruments introduced through two stab incisions. The entire resected lobe was delivered through a 7 cm submammary intercostal incision. RESULTS--There were no operative deaths or complications attributable to the technique. In three other patients conversion to an open thoracotomy was required because of bleeding (two cases) or obscure anatomy (one case). Post-operative pain in those undergoing thoracoscopic resection was less than that encountered with standard thoracotomy and early clinic review showed the patients to be pain free with excellent shoulder movement. CONCLUSIONS--Major pulmonary resection according to standard cancer practices is feasible with videothoracoscopic techniques. This approach is likely to offer considerable functional benefit to patients. Specimen delivery through the submammary incision imposes a 5 cm primary lesion size limitation. Detailed mediastinal assessment is necessary to exclude N2 status before undertaking thoracoscopic surgery.

A 51 year-old man was admitted to the hospital with fever and general fatigue. He was diagnosed as acute lymphoblastic leukemia after examination showed the existence of lymphoblasts in the bone marrow.Remission induction therapy caused severe suppression of the bone marrow. He suddenly complained of left chest pain, and a chest X-ray showed an abnormal shadow in the left upper lobe. Pulmonary fungal infection was suspected and intravenous amphotericin B was administered. The abnormal shadow on the chest X-ray improved but remained. Lobectomy of the left upper lobe was then performed. Histology of the resected lobe showed non-septate hyphae, and mucormycosis was diagnosed. Anti-leukemic chemotherapy was again bigun, but no relapse of mucormycosis was seen.

Practical risk models stratifying the risk of prolonged air leak after pulmonary lobectomy have been developed and discussed. These scores may assist during preoperative patients' counseling, to identify patients at higher risk for prolonged air leak, who may benefit from the use of prophylactic measures such as the use of sealants, buttressed staple lines, or pleural tents. Furthermore, they may be used as standardized inclusion criteria for future randomized clinical trials testing the efficacy of these new technologies, and in doing so make the interpretation of results across different centers and studies more comparable. The clinical use of digital chest drainage units that permit quantitative measurement and recording of air leak flow and intrapleural pressure appears to add to the prediction and management of air leak after pulmonary resection. The use of risk scores based on these digital measures may set the stage for future investigations of active pleural management aimed at treating air leak by tailoring the level of intrapleural pressure to the needs of individual patients.

Using robotic technology to perform pulmonary surgery is of great current interest to the thoracic surgical community. With the advent of video-assisted thoracic surgery in the early 1990s, we have provided major benefit to our patients undergoing all types of surgical procedures from videoassisted thoracoscopic surgery (VATS) pleural biopsy to what is now becoming more routine, VATS lobectomy. No question exists that increasing data have shown that perioperative recovery, complication rates, quality of life, and cost to the system all favor a VATS approach over an open approach (thoracotomy) for pulmonary lobectomy. For the most important outcome variable, that of cancer-related survival, the data have continued to suggest at least an equivalence between VATS lobectomy and thoracotomy and lobectomy, with a hint of improved survival using the VATS approach. In the Society of Thoracic Surgeons database, VATS lobectomy has increased to more than 30% of all lobectomies performed. This operation is now quite standardized, with an approach to the hilar vessels, bronchus, and lymph nodes similar to that of the open approach. Training programs have incorporated this operation into the standard armamentarium of the thoracic resident, and simulations courses and fellowships are available to help provide learning opportunities to surgeons who are out in practice. With this background, robotic lobectomies have been performed on a limited basis, with the advocates suggesting that the visualization and dissection are superior compared with a VATS approach. Robotic technology does have a certain appeal. The arms have a wrist-like movement and the magnification and depth of field of the robotic camera are superior to the standard VATS camera. However, it is not clear that these are significant advantages compared with VATS in the realm of cancer surgery. They might be useful for cardiac or urologic procedures; however, in thoracic arena, where the field is wide and the operation is primarily one

Endostaplers are widely used in pulmonary lobectomy procedures performed through video-assisted thoracoscopic surgery (VATS). Using them to approach fused pulmonary fissures during VATS lobectomy procedures is safer and quicker than manual techniques. However, the direction of endostaplers is sometimes limited by the location of the working ports, which may result in difficulties in positioning the endostaplers or even traction or laceration of peripheral lung tissue. We describe here a useful surgical technique that uses a Penrose drain tube as a guide for the endostapler, making its use to divide fused pulmonary fissures during VATS lobectomy easier and safer.

Introduction: Many recently published studies describe the efficacy and the safety of LigaSure™ Vessel Sealing System in thoracic surgery for pulmonary atypical resections or fissure separations in human and for pulmonary major vessel division in experimental animal models. Materials and Methods: We report a case of a pulmonary lobectomy successfully performed on a 55 years-old caucasic woman with NSCLC using a bipolar thermal vessel sealer (LigaSure™ Vessel Sealing System). Results: We realized an upper right lobectomy, by a posterior- lateral thoracotomic approach, using LigaSure™ Vessel Sealing System to: enter the pleura space, seal segmental branches of the right pulmonary artery and of the right superior pulmonary vein, divide incomplete interlobar fissures, incise the mediastinal pleura in order to achieve systematic limphadenectomy and for haemostasis. Operative time was of 120 minutes; we couldn’t observe any intra-operative bleeding; post-operative course was uneventful without prolonged air leaks. One year follow-up reveals no procedure-related complications and absence of neoplasm relapse. Conclusion: In our opinion, LigaSure™ Vessel Sealing System could actually find application in anatomical resections for NSCLC early stages. In the future we hope to achieve larger series of patients in order to gain more data about this useful device.

The financial impact of employing minimally invasive techniques for lobectomy compared with traditional open thoracotomy was assessed. A retrospective review was conducted using ICD9 codes for thoracotomy, video-assisted thoracic surgery (VATS), and robotic VATS lobectomy to determine total average costs associated with the resultant hospital stay. The difference in total average costs was calculated for each group. Robotic VATS lobectomy had higher associated costs than VATS only, primarily attributed to increased costs of the first hospital day, but was still less costly than thoracotomy. The average cost of VATS is substantially less than thoracotomy primarily because of a decreased length of stay. The cost of robotic assistance for VATS is still less than thoracotomy, but greater than VATS alone.

The overall incidence of postoperative alveolar air leakage (AAL) remains high; however, the mechanism regarding how to adequately heal such postoperative AAL remains to be elucidated. The aim of this study was to determine any correlations between the activity of the fibrinolytic and coagulation system in the postoperative pleural effusion and appearance or disappearance of postoperative AAL.This study prospectively investigated 25 patients who underwent a pulmonary lobectomy from July 2005 to March 2006. Pleural effusion was collected through the chest tube. Alpha 2 plasmin inhibitor-plasmin complex (PIC), as a fibrinolytic marker, and thrombin-antithrombin complex (TAT), as a coagulation marker, were measured.The activity of the coagulation system was higher than that of the fibrinolytic system. The concentration of TAT tended to increase (3rd vs 4th postoperative day [POD], P = 0.0907). The mean time of appearance and disappearance of postoperative AAL was 1.4 days and 3.2 days, respectively. The patients with postoperative AAL had a TAT level significantly below the average on the 3rd POD in comparison to the patients without postoperative AAL (P = 0.0163). Moreover, the concentration of TAT in patients with postoperative AAL was significantly lower than that in patients without postoperative AAL (1824.0 +/- 137.3 ng/ml vs 3444.0 +/- 287.6 ng/ml, P = 0.0113) on the 3rd POD. On the 4th POD, the concentration of TAT was almost same and there was no significance (P = 0.6759).This study demonstrated for the first time the course of the fibrinolytic and coagulation activity in the pleural effusion after a pulmonary lobectomy, and showed that the delayed activity of the coagulation system is associated with the appearance of the postoperative AAL.

肺癌にて胸部硬膜外麻酔を併用した全身麻酔下に肺葉切除術を受けた患者で,リンパ球サブセットの変動について検討した.CD4は術中より,CD3・CD8やCD16は術直後に有意な低下を示した.術後はまずCD4,次にCD8,そしてCD16の順で増加回復し始めたが,すべてのサブセットの有意な低下は第7病日においても持続し,術後1ヵ月まで術前値に回復しなかった.したがって,他の手術では3日～1週間といわれているが,肺葉切除術ではそれより長期に術後1週間以上は免疫が抑制されていると考えられる.また,術中～第3病日に手術による障害の大きさに関連すると思われるnull cellの有意な増加がみられた.

Objectives To compare the cost of materials and hospitalization for standard techniques (suturing, stapling and electrocautery) for sealing the lung after pulmonary resection with those for a fleece-bound sealing procedure. Methods This cost comparison analysis uses as its basis a prospective randomised clinical trial involving 152 patients with pulmonary lobectomy/segmentectomy (standard technique group: 77 patients; fleece-bound sealing group: 75 patients). The cost comparison was performed from the economic perspective of Austrian and German hospitals, taking into consideration the cost of materials for the two alternatives as well as the mean time to hospital discharge. Results The clinical study found significantly smaller postoperative air leaks in the fleece-bound sealing group. The mean times to chest drain removal and to hospital discharge were also significantly reduced after application of fleece-bound sealing [5.1 vs. 6.3 days (P=0.022) and 6.2 vs. 7.7 days (P=0.01), respectively]. The cost of materials for sealing air leaks amounted to euro47 per patient in the standard technique group and euro410 per patient in the fleece-bound sealing group. The 1.5-day reduction in the length of hospital stay associated with fleece-bound sealing represents a saving of euro462 per patient. Conclusions There was an overall saving of euro99 for the fleece-bound sealing procedure compared to standard techniques for sealing the lung following pulmonary resection.

Postoperative patients who were readmitted to a hospital other than the one where they had had their surgery were significantly more likely to die than were those who returned to the same hospital, a new study has found. The US study, published online in JAMA Surgery , was led by Thomas C Tsai of Harvard School of Public Health in Boston, Massachusetts.1 Tsai and colleagues used Medicare claims data from 1 January 2009 to 30 November 2011 to identify patients aged 65 and older who had undergone coronary artery bypass grafting, pulmonary lobectomy, endovascular …

Background The objective of the present study was to compare in a prospective randomized fashion two different management schemes for chest tubes after lobectomy: water seal versus alternate suction (suction overnight and water seal during the day). Methods Ninety-four patients with air leak on the morning of the first postoperative day were randomly assigned to two groups: group 1 (water seal alone), 47 patients; or group 2 (alternate suction), 47 patients. The groups were then compared in terms of preoperative, operative, and postoperative variables. Results Alternate suction patients showed a reduced incidence of air leak longer than 4 days (p = 0.04) and longer than 7 days (p = 0.02), a shorter duration of chest tubes in place (p = 0.002), and a shorter postoperative hospital stay (p = 0.004). Conclusions Alternate suction was superior to water seal alone in reducing the incidence of prolonged air leak and postoperative hospital stay after lobectomy. As suction was applied only overnight, this modality has the same advantage of water seal in terms of early mobilization of patients.

To the Editor: We read with great interest the paper by Barbagallo et al on prophylactic use of helmet CPAP after pulmonary lobectomy: a randomized control trial.[1][1] Noninvasive ventilation (NIV) is a type of ventilation that does not require placement of an artificial airway. Selection of

Torsion of a lung or a lobe (LT) is a severe, sometimes life-threatening event that may occur spontaneously, after trauma, or after cardiac or thoracic surgery. The authors report on 2 prematurely born neonates who had LT after cardiac surgery. Both patients successfully underwent pulmonary lobectomy, which seems to be the best surgical approach. Given that careful anatomic unfolding of the lung and its reinflation under vision at the end of a cardiac or thoracic operation is deemed crucial to avoid LT, the authors suggest that, in case of a complete pulmonary fissure and/or free long bronchovascular pedicle, lobe fixation should be accomplished, too. Because of its rarity, we could find only 6 well-documented reports of LT diagnosed in children, whereas another 3 cases were quoted without clinical details. The pediatric literature is reviewed.

Assessment of possible cardiac sources of cerebral embolism is a frequent indication for transesophageal echocardiography. We report the case of a patient with a previous left upper pulmonary lobe resection who presented with an ischemic stroke suggestive of cardioembolic origin. A dense spontaneous echo contrast was found in the left upper pulmonary vein stump, which, in the absence of other potential causes of stroke, was considered to be related to the embolic event. We discuss the clinical significance of this finding as a possibly underappreciated source of systemic embolization.