Alessandro Pardolesi

Robotic Anatomic Segmentectomy of the Lung: Technical Aspects and Initial Results

BACKGROUND Robotic lobectomy with radical lymph node dissection is a new frontier of minimally invasive thoracic surgery. Series of sublobar anatomic resection for primary initial lung cancers or for metastasis using video-assisted thoracic surgery have been reported but no cases have been so far reported using the robot-assisted approach. We present the technique and surgical outcome of our initial experience. METHODS Clinical data of patients undergoing robotic lung anatomic segmentectomy were retrospectively reviewed. All cases were done using the DaVinci System. A 3- or 4-incision strategy with a 3-cm utility incision in the anterior fourth or fifth intercostal space was performed. Individual ligation and division of the hilar structures was performed using Hem-o-Lok (Teleflex Medical, Research Triangle Park, NC) or endoscopic staplers. The parenchyma was transected with endovascular staplers introduced by the bedside assistant mainly through the utility incision. Systematic mediastinal lymph node dissection or sampling was performed. RESULTS From 2008 to 2010, 17 patients underwent a robot-assisted lung anatomic segmentectomy in two centers. There were 10 women and 7 men with a mean age of 68.2 years (range, 32 to 82). Mean duration of surgery was 189 minutes. There were no major intraoperative complications. Conversion to open procedure was never required. Postoperative morbidity rate was 17.6% with pneumonia in 1 case and prolonged air leaks in 2 patients. Median postoperative stay was 5 days (range, 2 to 14), and postoperative mortality was 0%. Final pathology was non-small cell lung cancer in 8 patient, typical carcinoids in 2, and lung metastases in 7. CONCLUSIONS Robotic anatomic lung segmentectomy is feasible and safe procedure. Robotic system, by improving ergonomic, surgeon view and precise movements, may make minimally invasive segmentectomy easier to adopt and perform.

Diagnostic performance of low-dose computed tomography screening for lung cancer over five years.

Introduction: Low-dose computed tomography (LD-CT) screening can reduce lung cancer mortality; however, it is essential to improve nodule management protocols. We analyze the performance of the diagnostic protocol of the Continuous Observation of SMOking Subjects single-center screening study, after long-term follow-up. Methods: Between 2004 and 2005, 5203 asymptomatic high-risk individuals (≥20 pack-years, aged 50 years or older) were enrolled to undergo annual LD-CT for 5 years. Nodules 5 mm or smaller underwent repeat LD-CT a year later. Nodules larger than 5.0 mm and 8.0 mm or smaller received LD-CT 3 to 6 months later. Nodules larger than 8.0 mm or growing underwent CT-positron emission tomography. True positives were any stage prevalent lung cancer, progressing nodules diagnosed at stage 1, localized multifocal cancer, or new nodules diagnosed at any stage. False negatives were progressing nodules diagnosed at stage >1. False positives were benign nodules resected surgically. Results: Compliance was 79% over 5 years; 175 primary lung cancers were detected (0.76% per year), 136 (77.7%) were N0M0 and three were interval cancers. Eleven second primary lung cancers were diagnosed. Resectability was 87.4%; postoperative mortality 0.6%. Recall was 6.4% overall, 10.1% at baseline. False negatives were 14 of 175 (8%). Protocol sensitivity was 158 of 175 (90%); specificity 4994 of 5028 (99.4%); positive predictive value was 158 of 187 (84.5%); and negative predictive value was 4994 of 5016 (99.7%). Twenty-nine of 204 (14.2%) benign lesions were diagnosed surgically. Five-year overall and cancer-specific survival were 78% (95% confidence interval, 72–84) and 82% (95% confidence interval, 76%–88%) respectively. Conclusions: The performance of the CT protocol was satisfactory with an acceptable number of benign lesions biopsied surgically, low recall rate, and good oncological outcomes. However, interval and advanced cancers, and misdiagnoses, need to be reduced, perhaps by risk modeling and use of serum markers.

Composite chest wall reconstruction using titanium plates and mesh preserves chest wall function

FIGURE 1. A, Left clavicle and first rib reconstruction; B, rib reconstruction with titanium plates and a dual-mesh patch. TECHNIQUE Surgical reconstruction was performed in 13 patients using a Titanium Fixation System (Synthes, West Chester, Pa); Figure 1, A, consisting of titanium plates and self-tapping unlock screws. All plates can be joined by U-shaped release pins, which allows quick and easy surgical access in case of reoperations. There were 3 patients groups (Table 1). In groups A and B, rib reconstruction was performed with titanium plates and a dual-mesh patch was placed and fixed to the plates to avoid direct contact between prosthesis and lung parenchyma (Figure 1, B). In group C, the first patient, in particular, received an en bloc sternectomy for sternum infection after cardiac surgery, and then 4 titanium plates were fixed to the clavicle and to both sides of the second, fourth, and fifth rib, respectively, successively covered with a titanium patch. In all cases of sternum resection, a bilateral pectoralis major muscle flap was carried out to cover the prosthesis. There was no postoperative mortality. A subcutaneous seroma occurred in 2 patients and atrial fibrillation and prolonged air leakage in 1 patient. A 3-day stay in the intensive care unit was required for hemodynamic instability in a patient with malignant mesothelioma having extrapleural pneumonectomy and chest resection. All the other patients were extubated immediately at the end of the surgical procedures. Preand postoperative data showed a good preservation of respiratory function even after lung resection if compared with predictive values (Table 1).

Robot-assisted Lung Anatomic Segmentectomy: Technical Aspects

Anatomic lung segmentectomy is a possible alternative to lobectomy for small (<2 cm) primary lung cancers. Interest in anatomic lung segmentectomy has increased further after the adoption of high-resolution computed tomography and the implementation of lung cancer screening studies, which are increasing the detection rate of small lung cancers. Robotic surgery seems well suited to the precise dissection required for anatomic segmentectomy. Initial experience of robotic anatomic segmentectomy in patients with a single primary or metastatic lung lesion is highly encouraging. The introduction of robotic staplers, aspirators, and 5-mm lung forceps will further increase precision.

Operative rigid bronchoscopy: indications, basic techniques and results

Palliative airway treatments are essential to improve quality and length of life in lung cancer patients with central airway obstruction. Rigid bronchoscopy has proved to be an excellent tool to provide airway access and control in this cohort of patients. The main indication for rigid bronchoscopy in adult bronchology remains central airway obstruction due to neoplastic or non-neoplastic disease. We routinely use negative pressure ventilation (NPV) under general anaesthesia to prevent intraoperative apnoea and respiratory acidosis. This procedure allows opioid sparing, a shorter recovery time and avoids manually assisted ventilation, thereby reducing the amount of oxygen needed, while maintaining optimal surgical conditions. The major indication for NPV rigid bronchoscopy at our institution has been airway obstruction by neoplastic tracheobronchial tissue, mainly treated by laser-assisted mechanical dissection. When strictly necessary, we use silicone stents for neoplastic or cicatricial strictures, reserving metal stents to cover tracheo-oesophageal fistulae. NPV rigid bronchoscopy is an excellent tool for the endoscopic treatment of locally advanced tumours of the lung, especially when patients have exhausted the conventional therapeutic resources. Laser-assisted mechanical resection and stent placement are the most effective procedures for preserving quality of life in patients with advanced stage cancer.

Endobronchial ultrasound for mediastinal staging in lung cancer patients

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has changed the way mediastinal staging is performed in lung cancer patients. EBUS-TBNA is probably the most important non-invasive procedure for mediastinal staging and the currently preferred approach in many reference cancer centres worldwide. EBUS-TBNA is a less invasive technique than mediastinoscopy with low morbidity and no mortality and can be performed in an outpatient setting with excellent results. This study describes the technical aspects of EBUS-TBNA and our personal experience with the procedure.

An overview of the use of artificial neural networks in lung cancer research

The artificial neural networks (ANNs) are statistical models where the mathematical structure reproduces the biological organisation of neural cells simulating the learning dynamics of the brain. Although definitions of the term ANN could vary, the term usually refers to a neural network used for non-linear statistical data modelling. The neural models applied today in various fields of medicine, such as oncology, do not aim to be biologically realistic in detail but just efficient models for nonlinear regression or classification. ANN inference has applications in tasks that require attention focusing. ANNs also have a niche to carve in clinical decision support, but their success depends crucially on better integration with clinical protocols, together with an awareness of the need to combine different paradigms to produce the simplest and most transparent overall reasoning structure, and the will to evaluate this in a real clinical environment. We have performed an assessment of the evidence for improvements in the use of ANN in lung cancer research. Our analysis showed that often the use of ANN in the medical literature had not been performed in an accurate manner. A strict cooperation between physician and biostatisticians could be helpful in determine and resolve these errors.

Uniportal video-assisted thoracic surgery thymectomy

A 47-year-old gentleman presented with an incidental discovery of a 2.5-cm anterior mediastinal mass. Following radiological review, the diagnosis of likely thymoma is made and the patient is referred for surgical resection. The patient is currently self-employed and working as a carpenter. He is very concerned about the possibility of having a sternotomy as it would impact on his recovery and return to work. A single port, muscle sparing technique seems the best option for this gentleman. He undergoes surgery and is discharged 2 days later. He is back at work in 2 weeks. Over the past 10 years, video-assisted thoracic surgery (VATS) has replaced median sternotomy for the resection of anterior mediastinal masses, including thymoma. In 1993, the thoracoscopic approach to thymectomy was first reported by Sugarbaker from Boston, as well as a Belgian group (1,2). To date, the VATS approach has become the preferred and standard operation for the treatment of thymic disease. Numerous studies confirmed that, compared to standard sternotomy, VATS thymectomy results in less post-operative pain, better preserved pulmonary function, improved cosmesis (which can be particularly important to many young female myasthenia gravis patients) and is oncologically feasible for noninvasive thymomas as long as en bloc resection of the tumor is achieved (3-5). Most published reports regarding this procedure have focused on the right-sided approach, which has been adopted by most surgeons as the space in the right chest cavity is relatively large, with little interference from the heart, and the superior vena cava acts as an anatomical landmark. The current trend is to reduce the number of ports and minimize the length of incisions to further decrease postoperative pain, chest wall paresthesia, and length of hospitalization. Single-port thoracoscopy for mediastinal mass resection is not new. In our early experience with uniportal VATS thymectomy, we adopted the use of a singular access device (SILS port, Covidien) that permits the insertion of three or four instruments, together with CO2 insufflation, through a right-sided single 3-cm incision, without rib spreading.

Bronchovascular Reconstruction for Lung Cancer: Does Induction Chemotherapy Influence the Outcomes?

BACKGROUND Bronchoangioplastic interventions (BAIs) for lung cancer are challenging procedures associated with a high risk of postoperative morbidity and mortality. The role of induction chemotherapy (IC) in these patients is debated. METHODS We reviewed clinical records of patients who underwent a BAI between 1998 and 2009 using a prospective clinical and operative database. RESULTS Among 47 patients (39 men; mean age, 66 years) who underwent BAI, 26 (55.3%) received IC for N2 disease or for locally advanced lung cancer. We performed 35 pulmonary artery (PA) sleeve resections (31 partial and 4 circumferential), 10 PA reconstructions with a pericardial patch (8 autologous, and 2 heterologous), and 2 PA reconstructions using heterologous conduit. The 30-day mortality rate was 4.2% (n=2). Morbidity occurred in 19 (40.4%) patients; 5 patients (10.6%) had major complications (3 [6.4%] patients with fatal bronchovascular fistulas and 1 patient each with cardiac dislocation and acute respiratory distress syndrome) (2.2%). Fourteen patients (29.8%) had minor complications: 6 (12.7%) cardiac, 7 (14.9%) pulmonary, and 1 (2.2%) stroke. IC did not influence the complication rate. Overall 5-year survival and disease-free survival was 39.2% and 36.9%, respectively. Early pathologic stage and the absence of nodal involvement significantly influenced survival (p=0.005 and p=0.002, respectively). Patients receiving IC had a better prognosis (62.7% versus 10.7%; p=0.0003). At multivariate analysis, IC influenced long-term survival (p=0.003 [95% CI, 2.92-8.56]). CONCLUSIONS BAIs are feasible and effective surgical procedures with acceptable morbidity and mortality. IC does not influence morbidity and allows good long-term outcomes.

Bronchopleural Fistula After Pneumonectomy: Risk Factors and Management, Focusing on Open-Window Thoracostomy

We evaluated principal risk factors and different therapeutic approaches for post-pneumonectomy bronchopleural fistula (BPF), focusing on open-window thoracostomy (OWT). We retrospectively reviewed all patients treated by pneumonectomy for lung cancer from 1999 to 2014; we evaluated preoperative, operative, and postoperative data; time between operation; and fistula formation, size, treatment, and predicting factors of BPF. Cumulative incidence curves for the development of BPF were drawn according to the Kaplan-Meier method. Differences between groups were assessed with the log rank test. Multivariable Cox proportional hazards regression analysis was used to assess the independent risk factors for BPF. P values <0.05 were considered significant. BPF occurred in 60 of 733 patients (8.2%). Bronchial suture with Stapler (EndoGia) (P = 0.02), right side (P = 0.003), and low preoperative albumin levels (< 3.5 g/dL) (P = 0.02) were independent predicting factors of fistula. Early BPF was treated by thoracotomic (12) or thoracoscopic (2) debridement of necrotic tissue and BPF surgical repair. Late BPF was treated by bronchoscopic application of fibrin glue (3) or endobronchial stent (1), chest tube and cavity irrigation by povidone-iodine (15). OWT was performed in 27 patients, followed by muscle flap interposition in 7 of these 27. The survival time of patients after the treatment of BPF was 29.0 months. The overall survival of patients treated by OWT was 50% at 2 years and 27 (8%) at 4 years. Correct management of BPF depends on several factors. In case of failure of different initial therapeutic approaches, we could consider OWT, followed by myoplasty.