Davide Di Natale

Reasons for conversion during VATS lobectomy: what happens with increased experience

Although controlled studies have demonstrated the benefits of a minimally invasive approach for pulmonary lobectomy over thoracotomy, reports have also documented that significant complications can occur during thoracoscopic lobectomy and sometimes require planned or emergent conversion to open surgery. Several authors have identified and reported causes and implications of intraoperative conversion to thoracotomy using different types of classification. The aim of this single centre retrospective review is to evaluate how the reasons for conversion change with increased experience, dividing patients who were converted to thoracotomy during video-assisted thoracic surgery (VATS) lobectomy, between 2011 and 2017, in two groups: those treated during learning curve (LC group) and those treated after learning curve (ALC group). Our research suggests that the conversion rate, with increased skills, decreases but a variety of reasons for conversion persist. Of these, calcified, benign or malignant hilar adenopathy is the most frequent and represents the leading cause of conversion to open surgery due to complicated vascular dissection or vessel injury. Its strongly recommended, with increased confidence in performing VATS lobectomies, also to develop management strategies and techniques to prevent and control possible intraoperative adverse events.

Endoscopic management of critical neoplastic central airway obstruction

Background: To evaluate morbidity, mortality, and survival of interventional bronchoscopy for management of critical neoplastic central airway obstruction. Methods: This is a retrospective single-center study included all consecutive patients with neoplastic central airway obstruction undergoing interventional bronchoscopy. Characteristics of obstruction, endoscopic strategy, adjuvant treatments, morbidity, mortality, and survival were recorded and then statistically analysed. Results: Our study population counted 37 patients (mean age 67±15 years old). The trachea was involved in 6 (16%), the carina in 5 (14%), and the main bronchus in 26 (70%) patients. Restore of airway patency was obtained in 33 (89%) patients. A stent was inserted in 21 (57%) patients. Adjuvant therapy was carried out in 13/37 (35%) patients. The median overall survival was 17 months. The re-opening of airway (P Conclusions: Interventional bronchoscopy is a life-saving procedure in non-surgical patients with central airway obstruction. Recanalization of airway and the administration of adjuvant therapy remain the only significant survival prognostic factors.

Hybrid robotic thoracic surgery for excision of large mediastinal masses

Between April 2016 and October 2017, we retrospectively reviewed all patients undergoing excision of large mediastinal masses using a hybrid robotic thoracic approach at the Unit of Thoracic Surgery of Monaldi Hospital in Naples. The inclusion criteria for this approach were: evident unilateral predominance of the mass; absence of invasion to surrounding structures. Planned conversion to sternotomy was necessary in one patient for tenacious adhesions between the mediastinal goiter and the left innominate vein. In all cases the postoperative course was uneventful. The hybrid robotic approach, adopted in our Unit, consists of a thoracic procedure performed completely with articulated surgical instruments under three-dimensional vision and followed by final extension of a port-site incision to retrieve the voluminous specimen. This approach uses all the advantages of robotic technology that enables to perform a fine dissection in the small space of the anterior mediastinum and at the same time, through the simple extension of a minimally invasive access, avoids the painful sequelae of thoracotomy. In selected cases, with increased experience in robotic surgery, it can be proposed for excision of large mediastinal masses, although a longer follow-up period is necessary to validate our findings.

Antero mediastinal retrosternal goiter: surgical excision by combined cervical and hybrid robot-assisted approach

Most intrathoracic goiters are located in the anterior mediastinum. Surgical resection is usually recommended in case of morbidity associated with the goiters mass effect or for suspicion of malignancy difficult to diagnose without resection. Intrathoracic goiters are usually resected through a cervical approach, with sternotomy needed in selected cases. We report a case of antero mediastinal retrosternal goiter in old age patient undergoing surgical excision by combined cervical and hybrid robot-assisted approach. All steps of the thoracic procedure were completely performed using the da Vinci robot system with final extension of a port-site incision to extract the specimen. This approach provides more advantages than sternotomy regarding post operative clinical benefits and allows a more accurate surgical resection in the antero-superior mediastinum than conventional thoracoscopy.

Morgagni hernia repair in adult obese patient by hybrid robotic thoracic surgery

Morgagni hernia is a relatively uncommon congenital diaphragmatic hernia in which abdominal contents protrude into the chest through the foramen of Morgagni. It usually occurs on the right side of the chest but may occur on the left side or in the midline. In adults, it commonly presents with non-specific symptoms such as dyspnea, cough, gastroesophageal reflux disease and other. Surgical repair should be always performed to prevent the risk of hernia incarceration. Transthoracic approach has been proposed especially in cases with indeterminate, anterior pericardial masses. We believe that in adult obese patients with Morgagni hernia and voluminous hernial sac containing only omentum, the transthoracic approach can represent a valid alternative to transabdominal approach. The use of hybrid robotic thoracic surgery can be strongly recommended because it allows, through robotic instruments, to perform delicate surgical maneuvers in difficult to reach anatomical areas and, with the final extension of a port-site incision, to remove voluminous specimens from the thoracic cavity, avoiding the chest wall discomfort that follow the thoracotomy access.

Endoscopic treatment with fibrin glue of post-intubation tracheal laceration

Post-intubation tracheal laceration (PITL) is a rare and potential life-threatening condition requiring prompt diagnosis and treatment. A conservative treatment is indicated in patients with laceration <2 cm in length while surgery is the treatment of choice for laceration >4 cm. For laceration between 2-4 cm, the best treatment is debate; some authors recommend surgery while others do not definitely exclude endoscopic treatment. Herein, we reported the endoscopic treatment with fibrin glue of PITL. The procedure is performed using a standard video-bronchoscopy in operating room; the patient is in spontaneous breathing and deep sedation. After identification of tracheal laceration, the fibrin glue is injected through a dedicated double lumen catheter into the lesion. After mixing both components of fibrin glue, polymerization of fibrin occurs resulting in an elastic and opaque clot that closes the lesion. The key success of the procedure is based on accurate patient selection. Patients are eligible if (I) they are clinically stable and in spontaneous respiration; (II) with a small and superficial tracheal laceration (≤4 cm in length and without oesophageal injury); (III) localized at level of the upper or middle trachea; and (IV) without clinical and/or radiological signs of mediastinal collection, of emphysema or pneumomediastinum progression, and of infection.

In the era of ultrasound technology, could conventional trans-bronchial needle aspiration still play a role in lung cancer mediastinal staging?

BACKGROUND To evaluate the feasibility of a combined strategy including conventional-trans-bronchial needle aspiration biopsy (C-TBNA) and endobronchial ultrasounds transbronchial needle aspiration (EBUS-TBNA) for sampling mediastinal adenopathies in patients with lung cancer in order to determinate whether in the era of ultrasound technology C-TBNA could still play a role in mediastinal staging. METHODS It was a retrospective multicenter study including all consecutive patients with lung cancer and radiological mediastinal adenopathies undergoing TBNA for mediastinal staging (January 2014 - July 2016). C-TBNA was performed as first diagnostic procedure. All negative C-TBNA results were corroborated by EBUS-TBNA, and, if EBUS-TBNA was negative, by mediastinoscopy or surgery. The diagnostic yield of C-TBNA were then calculated. RESULTS A total of 175 patients were included in the study for a total of 197 mediastinal adenopathies sampled. C-TBNA was positive in 125 cases and negative in 72 cases who underwent EBUS-TBNA. It was positive in 58 cases and negative in 14 patients. After surgical exploration (n=12) and mediastinoscopy (n=2), 11 patients did not present metastases (true negative) while 3 presented mediastinal involvement (false negative). Thus, C-TBNA had a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of 67.2%, 100%, 100%, 15.3% and 69.0%, respectively. The sensitivity increased for sampling paratracheal versus subcarinal stations (80% versus 49%; P<0.001); and large adenopathies (≥15 mm) versus small adenopathies (<15 mm) (83% versus 43%; P<0.001). In all re-staging patients (n=4), Conventional-TBNA results were false negative. CONCLUSIONS The combined use of C-TBNA and EBUS-TBNA as the most cost-effective strategy in the setting of mediastinal staging. C-TBNA performed before EBUS-TBNA is indicated for sampling large mediastinal adenopathies near to carina while EBUS-TBNA remains the first choice for puncturing small adenopathies far from carina and for re-staging after induction therapy.

Three-dimensional virtual bronchoscopy using a tablet computer to guide real-time transbronchial needle aspiration.

Objectives We proposed a new virtual bronchoscopy tool to improve the accuracy of traditional transbronchial needle aspiration for mediastinal staging. Methods Chest-computed tomographic images (1 mm thickness) were reconstructed with Osirix software to produce a virtual bronchoscopic simulation. The target adenopathy was identified by measuring its distance from the carina on multiplanar reconstruction images. The static images were uploaded in iMovie Software, which produced a virtual bronchoscopic movie from the images; the movie was then transferred to a tablet computer to provide real-time guidance during a biopsy. To test the validity of our tool, we divided all consecutive patients undergoing transbronchial needle aspiration retrospectively in two groups based on whether the biopsy was guided by virtual bronchoscopy (virtual bronchoscopy group) or not (traditional group). The intergroup diagnostic yields were statistically compared. Results Our analysis included 53 patients in the traditional and 53 in the virtual bronchoscopy group. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy for the traditional group were 66.6%, 100%, 100%, 10.53% and 67.92%, respectively, and for the virtual bronchoscopy group were 84.31%, 100%, 100%, 20% and 84.91%, respectively. The sensitivity ( P  = 0.011) and diagnostic accuracy ( P  = 0.011) of sampling the paratracheal station were better for the virtual bronchoscopy group than for the traditional group; no significant differences were found for the subcarinal lymph node. Conclusions Our tool is simple, economic and available in all centres. It guided in real time the needle insertion, thereby improving the accuracy of traditional transbronchial needle aspiration, especially when target lesions are located in a difficult site like the paratracheal station.