Although unexpected conversion during Video-Assisted Thoracic Surgery (VATS) lobectomy is up to 23%, the effects on postoperative outcomes remain debatable. This retrospective study aimed: (i) to ...identify potential preoperative risk factors of VATS conversion to standard thoracotomy; (ii) to assess the impact of surgical experience in VATS lobectomy on conversion rate and patient health-related quality of life.
We extracted detailed information on VATS lobectomy procedures performed consecutively (2014-2019). Predictors of conversion were assessed with univariable and multivariable logistic regressions. To assess the impact of VATS lobectomy experience, observations were divided according to surgeons' experiences with VATS lobectomy. The impact of VATS lobectomy experience on conversion and occurrence of postoperative complications was evaluated using logistic regressions. The impact of VATS lobectomy experience on EuroQoL-5D (EQ-5D) scores at discharge was assessed using Tobit regressions.
A total of 11,772 patients underwent planned VATS for non-small-cell lung cancer (NSCLC), with 1074 (9.1%) requiring conversion to thoracotomy. The independent predictors at multivariable analysis were: FEV1% (OR = 0.99; 95% CI: 0.98-0.99,
= 0.007), clinical nodal involvement (OR = 1.43; 95% CI: 1.08-1.90,
= 0.014). Experienced surgeons performed 4079 (34.7%) interventions. Experience in VATS lobectomy did not show a relevant impact on the risk of open surgery conversion (
= 0.13) and postoperative complications (
= 0.10), whereas it showed a significant positive impact (
= 0.012) on EQ-5D scores at discharge.
Clinical nodal involvement was confirmed as the most critical predictor of conversion. Greater experience in VATS lobectomy did not decrease conversion rate and postoperative complications but was positively associated with postoperative patient quality of life.
Abstract Background The aim of the study was to analyze the cost-effectiveness outcomes of video-assisted thoracic surgery (VATS) in the treatment of primary spontaneous pneumothorax (PSP), comparing ...the minimally invasive procedure with pleural drainage (PD). Methods Between July 2006 and October 2012, we treated 122 patients with a first episode of PSP by VATS (61 patients) or pleural drainage (61 patients). We established the relationship between costs and quality-adjusted life (QAL) for both techniques. Results The total cost per patient of minimally invasive procedure was more advantageous than that of chest tube (€2,422.96 vs €4,855.12). The QAL expectancy of VATS was longer than that of PD (57.00 vs 40.80 at 60 months). The QAL year of VATS (.32 at 1st year and .25 at 5th year) was better than that of PD. Incremental cost-effectiveness ratio of VATS versus PD was between €7,600.00 (1st year) and €10,045.00 (5th year), remaining well below the threshold of acceptability. Conclusion VATS as the first-line treatment for PSP allowed low morbidity, short hospitalization, and excellent quality of life.
The aim of this study was to evaluate the surgical procedures of osteosynthesis and the respective costs in isolated sternal fractures and manubriosternal dislocations.
Between January 2006 and July ...2011, we treated 47 patients with an isolated fracture and 18 patients with a dislocation of the sternum surgically. In case of sternal fracture, the titanium plate was used in 30 (64%), steel plate in 12 (25%), and steel wire in 5 patients (11%). The stabilization after traumatic luxation was obtained with steel wire in 4 patients (22%) and titanium plate associated with demineralized bone matrix in 14 patients (78%). The quality adjusted life years (QALYs) was analyzed, as well as the incremental cost-effectiveness ratio based on QALYs.
In the sternal fractures, titanium plate showed a decreased time of intervention (30 2 minutes), length of stay (3 1 days), and total cost ( 2,277.10) compared with steel plate ( 2,667.70) and steel wire ( 2,801.60) procedures, displaying an excellent difference in QALYs (0.825 and 1.615, respectively). In the sternal dislocation, steel wire technique highlighted a poor QALYs, although this approach was less expensive than titanium plate with demineralized bone matrix ( 3,553.60 vs. 6,047.80). Incremental cost-effectiveness ratio revealed that the titanium plate costs were 623.55 more than the steel wire per QALYs gained.
The rigid titanium plate application ensured a safe and easy management of traumatic sternal lesions with a good prognosis of patients, justified by the improved QALYs compared with other methods.
Therapeutic study, level IV; economic analysis, level IV.
A five classes (A-E) aggregate risk score predicting 90-day mortality after video-assisted thoracoscopic lobectomy for lung cancer, including as independent factors male sex (3 points), DLCO <60% (1 ...point) and operative time >150 minutes (1 point), has been recently published. This study aims to assess the effectiveness and reliability of this risk model in a large, independent cohort of patients, to confirm its generalizability. From the Italian VATS Group Database, we selected 2,209 patients 60% males; median age 69 years (IQR:63-74) who underwent video-assisted thoracoscopic lobectomy for non-small cell lung cancer. We calculated the aggregate risk score and the corresponding class of 90-day mortality risk for each patient. The correlation between risk classes and mortality rates was tested by Spearman's r-test. Model calibration was evaluated by Hosmer-Lemeshow goodness-of-fit test. Class A-E 90-day mortality rates were 0.33%, 0.51%, 1.39%, 1.31% and 2.56%, respectively. A strong uphill correlation was identified between risk classes and 90-day mortality (r=0.90; p=0.037), showing a positive correlation between increased mortality rate and class A to E. Hosmer-Lemeshow chi-squared value was 67.47 (p<0.001) with overall, Class D and E significantly lower 90-day mortality in our cohort than in the original one 1.04% vs 2.5% (p=0.018), 1.31% vs 5.65% (p=0.005) and 2.56% vs 18.75% (p=0.007), respectively. Despite our data show a positive correlation between 90-day mortality and risk classes from A to E with modest discriminatory performance, the poor calibration suggests the need for model recalibration using local data to better manage and counsel lung cancer patients eligible for video-assisted thoracoscopic lobectomy.
Background: The treatment of lung cancer depends on histological and/or cytological evaluation of the mediastinal lymph nodes. Endobronchial ultrasound/transbronchial needle aspiration-biopsy ...(EBUS/TBNA-TBNB) is the only minimally invasive technique for a diagnostic exploration of the mediastinum. The aim of this study is to analyze the reliability of EBUS in the preoperative staging of non-small cell lung cancer (NSCLC). Methods: A prospective study was conducted from December 2019 to December 2022 on 217 NSCLC patients, who underwent preoperative mediastinal staging using EBUS/TBNA-TBNB according to the ACCP and ESTS guidelines. The following variables were analyzed in order to define the performance of the endoscopic technique—comparing the final staging of lung cancer after pulmonary resection with the operative histological findings: clinical characteristics, lymph nodes examined, number of samples, and likelihood ratio for positive and negative outcomes. Results: No morbidity or mortality was noted. All patients were discharged from hospital on day one. In 201 patients (92.6%), the preoperative staging using EBUS and the definitive staging deriving from the evaluation of the operative specimen after lung resection were the same; the same number of patients were detected in downstaging and upstaging (8 and 8, 7.4%). The sensitivity, specificity, positive and negative predictive value, and diagnostic accuracy were 90%, 90%, 82%, 94%, and 90%, respectively. The likelihood ratio for positive and negative results was 9 and 0.9, respectively, confirming cancer when present and excluding it when absent. Conclusions: EBUS is the only low-invasive and easy procedure for mediastinal staging. The possibility to check the method in each of its phases—through direct visualization of the vessels regardless of their location in relation to the lymph nodes—makes it safe both for the endoscopist and for the patient. Certainly, the cytologist/histologist and/or operator must have adequate expertise in order not to negatively affect the outcome of the method, although three procedures appear to reduce the impact of the individual professional involved on performance.
Sternal resection and anterior chest wall reconstruction techniques for malignant processes are not always standardized. We report an innovative method of sternal osteosynthesis in two patients, ...65-year-old and 41-year-old women, with Ewing's sarcoma, and infiltrating thymoma, respectively. The first case manifested itself as a voluminous palpable mass while the second case was characterized for a paramediastinal mass widely extended to the anterior chest wall. Reconstruction with titanium mesh allowed the quick restoration of parietal stability, facilitating respiratory dynamic and recovery of patients.
•Oligometastatic NSCLC represents a category without a standard therapeutic approach.•In selected oligometastatic NSCLC, radical surgery seems to offer a good prognosis.•Treatment of selected ...synchronous oligometastatic NSCLC could be conducted safely.
Oligometastatic Non-Small Cell Lung Cancer (NSCLC) patients represent a category without a standard therapeutic approach. However, in selected oligometastatic NSCLC, radical surgery seems to offer a good prognosis. This retrospective study aimed to analyse the long-term outcomes of synchronous oligometastatic patients treated with curative intent and identify the factors associated with better results and the proposal of a risk stratification system for classifying the synchronous oligometastatic NSCLC.
The medical records of patients from 18 centres with pathologically diagnosed synchronous oligometastatic NSCLC were retrospectively reviewed. The inclusion criteria were synchronous oligometastatic NSCLC, radical surgical treatment of the primary tumour with or without neoadjuvant/adjuvant therapy and radical treatment of all metastatic sites. The Kaplan – Meier method estimated survivals. A stratified backward stepwise Cox regression model was assessed for multivariable survival analyses.
281 patients were included. The most common site of metastasis was the brain, in 50.89 % patients. Median overall survival was 40 months (95 % CI: 29–53). Age ≤65 years (HR = 1.02, 95 % CI: 1.00–1.05; p = 0.019), single metastasis (HR = 0.71, 95 % CI: 0.45–1.13; p = 0.15) and presence of contralateral lung metastases (HR = 0.30, 95 % CI: 0.15 – 0.62; p = 0.001) were associated with a good prognosis. The presence of pathological N2 metastases negatively affected survival (HR = 2.00, 95 % CI: 1.21–3.32; p = 0.0065). These prognostic factors were used to build a simple risk classification scheme.
Treatment of selected synchronous oligometastatic NSCLC with curative purpose could be conducted safely and at acceptable 5-year survival levels, especially in younger patients with pN0 disease.
Non-Intubated Thoracic Surgery (NITS) is becoming increasingly adopted all over the world. Although it is mainly used for pleural operations,, non-intubated parenchymal lung surgery has been less ...frequently reported. Recently, NITS utilization seems to be increased also in Italy, albeit there are no multi-center studies confirming this finding. The objective of this survey is to assess quantitatively and qualitatively the performance of NITS in Italy.
In 2018 a web-based national survey on Non-Intubated management including both thoracic surgeons and anesthesiologists was carried out. Reference centers have been asked to answer 32 questions. Replies were collected from June 26 to November 31, 2019.
We raised feedbacks from 95% (55/58) of Italian centers. Seventy-eight percent of the respondents perform NITS but only 38% of them used this strategy for parenchymal surgery. These procedures are more frequently carried out in patients with severe comorbidities and/or with poor lung function. Several issues as obesity, previous non-invasive ventilation and/or oxygen therapy are considered contraindications to NITS. The regional anesthesia technique most used to provide intra- and postoperative analgesia was the paravertebral block (37%). Conversion to general anesthesia is not anecdotal (31% of answerers). More than half of the centers believed that NITS may reduce postoperative intensive care unit admissions. Approximately a quarter of the centers are conducting trials on NITS and, three quarters of the respondent suppose that the number of these procedures will increase in the future.
There is a growing interest in Italy for NITS and this survey provides a clear view of the national management framework of these procedures.
Several materials and techniques have been described for the procedure of chest wall reconstruction: the choice of using a technique or a material over another relies mainly on the surgeon's ...experience as well as thoracic defect localization and dimension, local availability of materials, and costs. From a technical point of view, autologous and alloplastic reconstruction are available, and, in both cases, rigid and non-rigid prostheses are found. Each material has its peculiarities, with advantages and disadvantages; thus, it is mandatory to be confident when planning the intervention to foresee possible complications and minimize them. We have reviewed the literature on chest wall reconstruction in chest wall tumors (both malignant and non malignant) with non-rigid prosthetic materials, focusing on safety outcomes.
Abstract
Purposes
We compared two different surgical methods evaluating the effectiveness of procedures and the quality of life (QoL) of patients.
Methods
From January 2010 to November 2017 we ...carried out 476 biportal video-assisted thoracoscopic surgery (VATS) approaches of sympathetic chain in 238 patients. One hundred and twenty-nine (54%) patients underwent conventional sympathectomy (CS) while 109 (46%) patients underwent sympathicotomy associated with the division of the rami communicantes (MWT). Quality of Life (QoL) was classified as follows: from 20 to 35 excellent; from 36 to 51 very good; from 52 to 68 good; from 69 to 84 poor; and > 84 very poor.
Results
We noticed statistical significant reduction of complications comparing CS with MWT approaches (chest pain from 36.4 to 4.5%; paresthesias from 8.5 to 3.6%; bradycardia from 28.6 to 10%, respectively). The preoperative and postoperative QoL index evaluation revealed a statistically significant improvement after surgery (CS: 86 ± 2 versus 35 ± 1,
p
= 0.00001; MWT: 85 ± 1 versus 33 ± 2,
p
= 0.00001), with general satisfaction of the two techniques.
Conclusion
Modified Wittmoser method seems to be a valid alternative to conventional sympathectomy, minimizing the percentage rate of complications and showing significant effectiveness in the quality of life improvement.
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