Jean Marc Baste

Index of prolonged air leak score validation in case of video-assisted thoracoscopic surgery anatomical lung resection: results of a nationwide study based on the French national thoracic database, EPITHOR

OBJECTIVES The incidence rate of prolonged air leak (PAL) after lobectomy, defined as any air leak prolonged beyond 7 days, can be estimated to be in between 6 and 15%. In 2011, the Epithor group elaborated an accurate predictive score for PAL after open lung resections, so-called IPAL (index of prolonged air leak), from a nation-based surgical cohort constituted between 2004 and 2008. Since 2008, video-assisted thoracic surgery (VATS) has become popular in France among the thoracic surgical community, reaching almost 14% of lobectomies performed with this method in 2012. This minimally invasive approach was reported as a means to reduce the duration of chest tube drainage. The aim of our study was thus to validate the IPAL scoring system in patients having received VATS anatomical lung resections. METHODS We collected all anatomical VATS lung resections (lobectomy and segmentectomy) registered in the French national general thoracic surgery database (EPITHOR) between 2009 and 2012. The area under the receiver operating characteristic (ROC) curve estimated the discriminating value of the IPAL score. The slope value described the relation between the predicted and observed incidences of PALs. The Hosmer-Lemeshow test was also used to estimate the quality of adequacy between predicted and observed values. RESULTS A total of 1233 patients were included: 1037 (84%) lobectomies and 196 (16%) segmentectomies. In 1099 cases (89.1%), the resection was performed for a malignant disease. Ninety-six patients (7.7%) presented with a PAL. The IPAL score provided a satisfactory predictive value with an area under the ROC curve of 0.72 (0.67-0.77). The value of the slope, 1.25 (0.9-1.58), and the Hosmer-Lemeshow test (χ(2) = 11, P = 0.35) showed that predicted and observed values were adequate. CONCLUSION The IPAL score is valid for the estimation of the predictive risk of PAL after VATS lung resections. It may thus a priori be used to characterize any surgical population submitted to potential preventive measures.

Toxic plasma concentration of ropivacaine after a paravertebral block in a patient suffering from severe hypoalbuminemia

A case of systemic ropivacaine toxicity from a continuous thoracic paravertebral block in an adult patient who received a lobectomy is presented. The catheter was placed by the surgeon. Eleven hours after the start of the infusion, the patient experienced an arrhythmia leading to death. The total venous plasma concentration of ropivacaine was high (3.2 μg/mL). Furthermore, the patient had severe hypoalbuminemia (albumin 24 g/L), which resulted in the increase of the unbound ropivacaine plasma concentration that was responsible for the toxic side effects.

Comparative study for surgical management of thymectomy for non-thymomatous myasthenia gravis from the French national database EPITHOR

OBJECTIVES Thymectomy may be part of the therapeutic strategy in patients with myasthenia gravis (MG) without thymoma. Median sternotomy is still considered as the gold standard, but during the last 15 years, several groups have demonstrated the non-inferiority of cervicotomy with upper sternotomy and minimally invasive techniques. To date, there is no consensus on surgical procedure choice. The aim of our study was to compare the morbidity and mortality of three techniques [cervicotomy with upper sternotomy versus sternotomy versus video-assisted thoracic surgery (VATS)/robotic-assisted thoracic surgery (RATS)] from the national database EPITHOR and to analyse French epidemiology. METHODS From the national thoracic surgery database EPITHOR, we have extracted all the details regarding thymectomies performed for non-thymomatous MG. We have divided thymectomy into three groups: A-sternotomy; B-cervicotomy with upper sternotomy; C-VATS/RATS. We investigated the postoperative morbidity and mortality without analysis of the long-term evolution of the disease not available on EPITHOR. RESULTS From 2005 to 2013, 278 patients were included: 131 (47%) in Group A, 31 (11%) in Group B and 116 (42%) in Group C. The sex ratio F/M was 2.3. The mean age was, respectively, 42 ± 17, 42 ± 16, 35 ± 14 years old (P < 0.01). The number of patients without comorbidities was 63 (48%), 25 (81%) and 78 (65%), respectively (P < 0.01). The operative time was 94 ± 37, 79 ± 42 and 112 ± 59 min, respectively (P < 0.01). The number of patients who presented at least one postoperative complication was 12 (14%), 0 and 3 (9%) (P= 0.03), respectively. The postoperative lengths of stay were 7.7 ± 4.5, 5 ± 1.7 and 4.5 ± 2 days, respectively (P < 0.01). There was no death. CONCLUSIONS In our study, we were unable to prove the superiority of minimally invasive techniques due to the important differences between the groups. However, this study shows us major changes in French surgical procedures during the last decade with an increase in minimally invasive procedures such as VATS and RATS.

Mediastinal Bronchogenic Cyst With Acute Cardiac Dysfunction: Two-Stage Surgical Approach

We describe a two-stage surgical approach in a patient with cardiac dysfunction and hemodynamic compromise resulting from a massive and compressive mediastinal bronchogenic cyst. To drain this cyst, video-assisted mediastinoscopy was performed as an emergency procedure, which immediately improved the patients cardiac function. Five days later and under video thoracoscopy, resection of the cyst margins was impossible because the cyst was tightly adherent to the left atrium. We performed deroofing of this cyst through a right thoracotomy. The patient had an uncomplicated postoperative recovery, and no recurrence was observed at the long-term follow-up visit.

All things are created twice, but the surgeon only gets one chance: bronchoscopy marking may help the surgeon to perform sublobar resection

We would like to thank Professor Sato for his interest and positive comments regarding our work. In an era of minimally invasive thoracic surgery [video-assisted thoracoscopic surgery (VATS) or robotic-assisted thoracoscopic surgery (RATS)], minimally invasive sublobar resection (SLR) represents a serious challenge especially for small peripheral nodules (SPNs) or ground glass opacities (GGOs).

Development of a precision multimodal surgical navigation system for lung robotic segmentectomy

Minimally invasive sublobar anatomical resection is becoming more and more popular to manage early lung lesions. Robotic-assisted thoracic surgery (RATS) is unique in comparison with other minimally invasive techniques. Indeed, RATS is able to better integrate multiple streams of information including advanced imaging techniques, in an immersive experience at the level of the robotic console. Our aim was to describe three-dimensional (3D) imaging throughout the surgical procedure from preoperative planning to intraoperative assistance and complementary investigations such as radial endobronchial ultrasound (R-EBUS) and virtual bronchoscopy for pleural dye marking. All cases were operated using the DaVinci SystemTM. Modelisation was provided by Visible Patient™ (Strasbourg, France). Image integration in the operative field was achieved using the Tile Pro multi display input of the DaVinci console. Our experience was based on 114 robotic segmentectomies performed between January 2012 and October 2017. The clinical value of 3D imaging integration was evaluated in 2014 in a pilot study. Progressively, we have reached the conclusion that the use of such an anatomic model improves the safety and reliability of procedures. The multimodal system including 3D imaging has been used in more than 40 patients so far and demonstrated a perfect operative anatomic accuracy. Currently, we are developing an original virtual reality experience by exploring 3D imaging models at the robotic console level. The act of operating is being transformed and the surgeon now oversees a complex system that improves decision making.

Pleural dye marking using radial endobronchial ultrasound combined with virtual bronchoscopy before minimal invasive sublobar lung resection

Introduction: Surgical resection of pulmonary nodules with minimally invasive techniques is challenging as the procedures have decreased the ability to palpate the lung in comparison with open thoracotomy. The objective of this study was to evaluate the feasibility of pleural dye marking using radial-EBUS (r-EBUS) combined with virtual bronchoscopy (VB) to help minimally invasive resection of small peripheral lung nodule (SPLN) or ground glass opacities (GGOs). Methods: Both bronchial path to nodule (LungPoint Software®) and sub-pleural methylene blue deposition were performed in the operating room immediately before minimally invasive surgery. A 4 mm fiberscope with a 2mm working channel, 1.4 mm r-EBUS probe and guide sheath were used under general anesthesia without fluoroscopy guidance, in a patient on operating position. One ml of methylene blue was inserted into the guide sheath at the end of the procedure. RESULTS: 15 sublobar nodule resections were performed in 13 patients including 4 GGOs. Median nodule’s greatest diameter was 8 mm (4 to 15 mm, 14 nodules Conclusion: r-EBUS combined with VB allows dye localization of SPLN before minimally invasive resection.

Video-assisted thoracic surgery for left upper lobectomy for complex lesions: how to extend the indication with optimal safety?

Abstract The feasibility of extending the VATS approach to locally advanced NSCLC has been described with good clinical outcome. These complex resections are still technically challenging and patient safety must remain the highest priority. In this article, we describe our routine VATS approach for left upper lobectomy in proximal, locally advanced lesions. Both surgical and anaesthesiology teams are trained during simulation sessions to respond rapidly in case of urgent thoracotomy. Encircling arterial and venous vessels allow control of inadvertent bleeding during difficult dissection. Also, whenever needed the double vessel control technique is a time saver waiting for conversion to thoracotomy.

Challenging posterior mediastinal mass resection via a minimally invasive approach with neurological monitoring

We report a novel surgical strategy for the resection of a rare type of posterior mediastinal tumour in a young patient. A melanotic schwannoma arose from the left thoracic sympathetic chain, adjacent to the origin of the artery of Adamkiewicz. Successful excision of this tumour via a minimally invasive approach without arterial or spinal cord injury was possible with the aid of neurological monitoring using spinal-evoked potentials.