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Concept: Video-assisted thoracoscopic surgery

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Surgical resection is currently the gold standard in operable patients with early-stage lung cancer. Video-assisted thoracoscopic surgery (VATS) lobectomy is a technique that has technically evolved and grown increasingly popular over the past two decades. This article presents the evolution, definition, current application, and some of the controversies surrounding VATS lobectomy.

Concepts: Medicine, Cancer, Lung cancer, Cancer staging, Surgery, Thoracic surgery, VATS lobectomy, Video-assisted thoracoscopic surgery

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BACKGROUND: We compared the surgical outcomes in patients with clinical N0 and pathologic N2 (cN0-pN2) non-small cell lung cancer (NSCLC) who underwent video-assisted thoracoscopic surgery (VATS) lobectomy and open thoracotomy to evaluate the role of VATS lobectomy for cN0-pN2 disease. METHODS: Between March 2006 and August 2011, 1,456 patients with clinical N0 NSCLC disease underwent lobectomy with systematic node dissection (SND) at Shanghai Chest Hospital. Of those patients, 157 were shown to have cN0-pN2 NSCLC. Of those, 67 patients underwent VATS lobectomy, and 90 patients underwent open lobectomy. SND was performed in all 157 patients. Clinicopathologic factors, local recurrence rates, and survival rates were compared. RESULTS: The two groups were similar in age, sex, and pulmonary function. The VATS approach was associated with significantly shorter chest tube duration and postoperative stay than was the thoracotomy approach. Operative mortality, morbidity, and recurrence did not differ between the two groups. There was no significant difference between the two types of operation in numbers of total lymph nodes removed (17.4 ± 6.1 in the VATS group vs 18.1 ± 7.2 in the open group, p = 0.78) and mediastinal lymph nodes removed (11.7 ± 5.6 in the VATS group vs 12.0 ± 5.1 in the open group, p = 0.84). Similarly, the two groups were not significantly different with regard to stations of total lymph nodes removed (7.6 ± 1.9 in the VATS group vs 7.8 ± 2.3 in the open group, p = 0.81) and mediastinal lymph nodes removed (4.5 ± 1.1 in the VATS group vs 4.7 ± 1.3 in the open group, p = 0.71). The rates of overall survival and disease-free 5-year survival were not significantly different between the two groups. CONCLUSIONS: The clinical outcomes of thoracoscopic lobectomy were comparable to those of thoracotomy for patients with cN0-pN2 NSCLC. Single-station N2 is a good prognostic factor for disease-free survival in these patients.

Concepts: Cancer, Disease, Lung cancer, Non-small cell lung carcinoma, Lymph node, Thoracic surgery, VATS lobectomy, Video-assisted thoracoscopic surgery

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A case of high-frequency jet ventilation (HFJV) during video-assisted thoracoscopicsurgery (VATS) in a patient with previous contralateral pneumonectomy is presented. A 77yearold man with a right pneumothorax was scheduled for bullectomy by VATS. He had undergone left pneumonectomy due to lung cancer 6 years earlier.Anesthesia was induced and maintained with propofol and fentanyl. The patient was intubated with a normal, single-lumen endotracheal tube (ETT).HFJV was applied through the ETT during the VATS procedure. Although PaCO(2) gradually increased from 51.9 mmHg to 80.0 mmHg, appropriate surgical conditions were provided, PaO(2) was well preserved, and blood pressure and heart rate were stable throughout the VATS procedure.

Concepts: Cancer, Lung cancer, Endotracheal tube, Intubation, Pneumothorax, Thoracic surgery, VATS lobectomy, Video-assisted thoracoscopic surgery

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PURPOSE: Nonspecific esophageal motility disorder (NEMD) is a vague category that includes patients with poorly defined contraction abnormalities observed during esophageal manometry. This study investigated the therapeutic effects of the video-assisted thoracoscopic surgery (VATS) approach using long myotomy and fundopexy for NEMD. METHODS: The VATS approach using myotomy and fundopexy was performed for 4 patients of NEMD between 2005 and 2008. A total of 4 patients with NEMD that underwent treatment at our institution were analyzed retrospectively. RESULTS: The patients included 2 males and 2 females with a median age of 48 years (range 21-74 years). The median duration of NEMD symptoms was 58 months (range 4-108 months). Dysphagia was a primary symptom in all patients. Chest pain was a primary symptom in 3 of 4 patients (75 %). Treatment with medication was attempted before the operation. The median operative time was 344.5 min (range 210-476 min). The median time before starting oral feeding was 2.5 days (range 2-22 days). All patients achieved a significant improvement of their previous condition. CONCLUSIONS: The VATS approach using myotomy and fundopexy for NEMD is a good treatment in cases resistant to medication and balloon dilation.

Concepts: Surgery, Gastroesophageal reflux disease, Achalasia, VATS lobectomy, Video-assisted thoracoscopic surgery, Nutcracker esophagus, Esophageal motility study, Esophageal motility disorder

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STUDY DESIGN:: Retrospective study. OBJECTIVE:: The authors evaluated the surgical technique and learning curve for video-assisted thoracoscopic surgery (VATS) for treating thoracolumbar burst fractures and bony tumors by examining surgical data and outcome for the first 30 VATS procedures performed by a single surgeon at a training institution. SUMMARY OF BACKGROUND DATA:: VATS is commonly used in the treatment of early-stage lung cancer. The widespread use of this technique among neurosurgeons is limited by the lack of cases and the steep learning curve. METHODS:: This study was a retrospective case series of the first 30 T12 and L1 thoracoscopic vertebrectomies from 2003 to 2008. The sample was limited to one surgeon and one region of the spine to minimize the potential variation so that a learning curve could be assessed. Surgical data and outcomes were analyzed. Estimated blood loss and operation time were analyzed using a linear generalized estimating equation model with a first-order autoregression correlation structure. RESULTS:: The average operative time for thoracoscopic corpectomy was 270±65 minutes (range 160-416 min). Operating room time decreased significantly after the first 3 operations. The authors observed a stable linear decrease in operating time over the course of the study. The average blood loss during the thoracoscopic procedure was 433±330 mL (range 100-1500 mL) and did not change as the series progressed. Complications and conversions to open procedures occurred in 2 patients and were evenly distributed throughout the series. CONCLUSIONS:: Thoracoscopic vertebrectomy at the thoracolumbar junction has a relatively long learning curve. In this series, operating room time improved dramatically after the first 3 cases but continued to improve subsequently. The learning curve can be accomplished without an increase in blood loss, complications, rate of conversion to open procedures, or frequency of misplaced instrumentation.

Concepts: Cancer, Surgery, Physician, Surgeon, Learning curve, Thoracic surgery, VATS lobectomy, Video-assisted thoracoscopic surgery

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Pulmonary glomus tumors are extremely rare, with only 19 cases having been reported worldwide. The glomus body is considered to be related to the regulation of body temperature, but the reported cases were not associated with hyperpyrexia. Here, we describe a 28-year-old man with hyperpyrexia and anemia complicated with a coin lesion of the right lung. After resection of the upper lobe of the right lung by video-assisted thoracoscopic surgery, all of the patient’s symptoms disappeared. The pathologic analysis reported a rare pulmonary glomus tumor. The disease had not recurred by 1 year after operation.

Concepts: Cancer, Oncology, Lung, Medical signs, Video-assisted thoracoscopic surgery, Glomus tumor

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This is a case report on a 26-year-old woman with metastatic mandibular osteosarcoma to the lung. A video-assisted thorascopic surgery (VATS) completion left upper lobe lobectomy was attempted, but was converted to a thoracotomy when anomalous pulmonary vein drainage (APVD) was identified. There were no other anomalies found and the lobectomy was completed as planned. To our knowledge, this is the first reported case of an attempted VATS lobectomy for patients with APVD. This case demonstrates that APVD tends not to be associated with any other anatomic abnormalities in the lung and should not be a contraindication for VATS lobectomy.

Concepts: Cancer, Lung, Lung cancer, Heart, Surgery, Vein, VATS lobectomy, Video-assisted thoracoscopic surgery

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Respiratory deficits are common following curative intent lung cancer surgery and may reduce the patient’s ability to be physically active. We evaluated the influence of surgery on pulmonary function, respiratory muscle strength and physical performance after lung resection. Pulmonary function, respiratory muscle strength (maximal inspiratory/expiratory pressure) and 6-min walk test (6MWT) were assessed pre-operatively, 2 weeks post-operatively and 6 months post-operatively in 80 patients (age 68±9 years). Video-assisted thoracoscopic surgery was performed in 58% of cases. Two weeks post-operatively, we found a significant decline in pulmonary function (forced vital capacity -0.6±0.6 L and forced expiratory volume in 1 s -0.43±0.4 L; both p<0.0001), 6MWT (-37.6±74.8 m; p<0.0001) and oxygenation (-2.9±4.7 units; p<0.001), while maximal inspiratory and maximal expiratory pressure were unaffected. At 6 months post-operatively, pulmonary function and oxygenation remained significantly decreased (p<0.001), whereas 6MWT was recovered. We conclude that lung resection has a significant short- and long-term impact on pulmonary function and oxygenation, but not on respiratory muscle strength. Future research should focus on mechanisms negatively influencing post-operative pulmonary function other than impaired respiratory muscle strength.

Concepts: Pulmonology, Lung cancer, Heart, Respiratory physiology, VATS lobectomy, Video-assisted thoracoscopic surgery, Vital capacity, Lung cancer surgery

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We compared video-assisted thoracoscopic surgery (VATS) lobectomy and stereotactic body radiation therapy (SABR) to explore clinical outcomes in the treatment of patients with early stage NSCLC.

Concepts: Medicine, Cancer, Lung cancer, Non-small cell lung carcinoma, Surgery, Thoracic surgery, VATS lobectomy, Video-assisted thoracoscopic surgery

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BackgroundVideo-assisted thoracoscopic surgery (VATS) lobectomy and stereotactic ablative radiotherapy (SABR) are both used for early-stage non-small-cell lung cancer. We carried out a propensity score-matched analysis to compare locoregional control (LRC).Patients and methodsVATS lobectomy data from six hospitals were retrospectively accessed; SABR data were obtained from a single institution database. Patients were matched using propensity scores based on cTNM stage, age, gender, Charlson comorbidity score, lung function and performance score. Eighty-six VATS and 527 SABR patients were matched blinded to outcome (1:1 ratio, caliper distance 0.025). Locoregional failure was defined as recurrence in/adjacent to the planning target volume/surgical margins, ipsilateral hilum or mediastinum. Recurrences were either biopsy-confirmed or had to be PET-positive and reviewed by a tumor board.ResultsThe matched cohort consisted of 64 SABR and 64 VATS patients with the median follow-up of 30 and 16 months, respectively. Post-SABR LRC rates were superior at 1 and 3 years (96.8% and 93.3% versus 86.9% and 82.6%, respectively, P = 0.04). Distant recurrences and overall survival (OS) were not significantly different.ConclusionThis retrospective analysis found a superior LRC after SABR compared with VATS lobectomy, but OS did not differ. Our findings support the need to compare both treatments in a randomized, controlled trial.

Concepts: Cancer, Lung cancer, Cancer staging, Surgery, Comorbidity, Thoracic surgery, VATS lobectomy, Video-assisted thoracoscopic surgery