Shun-Mao Yang

Image-guided thoracoscopic surgery with dye localization in a hybrid operating room

BACKGROUND The rate of detection of small pulmonary nodules (SPNs) has increased. Thoracoscopic resection following image-guided localization had been a reliable alternative in their treatment. We present our experience with image-guided dye localization using robotic C-arm computed tomography (CT) followed by immediate video-assisted thoracoscopic surgery (VATS) for SPNs in a hybrid operating room (OR). METHODS From July 2015 to July 2016, 25 consecutive patients with SPNs smaller than 2 cm underwent robotic C-arm CT-guided blue dye tattooing followed by immediate VATS in a hybrid OR. Their medical records were retrospectively reviewed to evaluate the feasibility and safety of this novel procedure. RESULTS Robotic C-arm CT-guided dye localization was successfully performed in 23 patients (92%). Wound extension was required for nodule identification in the remaining two patients. The median size of the nodules was 1.0 cm (range, 0.6-2.0 cm). The median needle localization time and surgery time were 46 and 109 min, respectively. All 25 patients had successful resection of their lesions. The pathological diagnoses were primary lung adenocarcinoma in 18 (72%), benign tumors in 5 (20%), and metastatic lesions in 2 (8%). There was no operative mortality. The median length of the postoperative stay was 3 days (range, 2-8 days). Complications were noted in two patients (8%). One patient had a penetrating injury of the diaphragm during needle localization. The other had pneumonia postoperatively. Both patients were managed conservatively. CONCLUSIONS Our experience showed that robotic C-arm CT-guided dye localization followed by immediate thoracoscopic surgery in a hybrid OR is safe and feasible. It may become an effective and attractive alternative in managing SPNs.

Robotic-assisted thoracoscopic sleeve lobectomy for locally advanced lung cancer

BACKGROUND The Da Vinci robotic system has been used to enhance the surgeons visualization and agility in lung cancer surgery, and thus facilitate refined dissection, knot tying and suturing. However, only a few case reports exist on performing a sleeve lobectomy with a robotic-assisted thoracoscopic surgery (RATS) technique. Here we describe our early experience performing RATS sleeve lobectomies. To our knowledge, this is the first study reporting a series of RATS sleeve lobectomies. METHODS The six consecutive NSCLC patients who underwent a RATS sleeve lobectomy between November 2013 and July 2015 at the National Taiwan University Hospital were enrolled in this study. The lobectomies were all performed by the same surgeon using a three-arm robotic system with an additional utility incision made for assistance and specimen retrieval. RESULTS Five patients were diagnosed with squamous cell carcinoma, while the sixth was diagnosed with a carcinoid tumor. The mean operation time was 436.7 [255-745] minutes. The mean postoperative intensive care unit (ICU) stay and hospital stay were 3.7 [1-11] and 11.3 [3-26] days, respectively. Two (33.3%; 2/6) morbidities were noted, including one pneumonia and one anastomosis stricture. There were no cases of mortality or of conversion to thoracotomy. CONCLUSIONS Our experience performing a RATS sleeve lobectomy in the six patients demonstrated the feasibility of RATS in complex lung cancer surgeries. The three-dimensional vision and articulated joint instruments made robotic-assisted bronchial anastomosis easier under the endoscopic setting. Our experience suggests that RATS offers specific advantages with regard to accuracy and safety when performing sleeve lobectomies.

Single-incision laparo-thoracoscopic minimally invasive oesophagectomy to treat oesophageal cancer†.

OBJECTIVES Single-incision thoracoscopic and laparoscopic procedures have been applied in treating various diseases. However, it is unknown whether such procedures are feasible in treating oesophageal cancer. METHODS Minimally invasive oesophagectomy (MIO) with a single-incision approach in the thoracoscopic and laparoscopic procedures was attempted in 16 patients with oesophageal cancer. RESULTS One patient was converted to laparotomy and a four-port thoracoscopic procedure due to bleeding. Of the patients successfully treated with a single-port MIO, 6 underwent a McKeown procedure and 9 an Ivor Lewis procedure, including 3 cases of total laryngopharyngo-oesophagectomy with cervical pharyngogastrostomy. The mean ventilator usage of the patients after surgery was 0.3 ± 0.6 days, the mean intensive care unit (ICU) stay was 3.8 ± 3.1 days and the mean number of dissected lymph nodes was 28.6 ± 14.6. One delayed anastomotic leakage occurred, and another patient developed a trachea-oesophageal fistula induced by surgical clip-related tissue erosion, both of which were successfully treated by the placement of an oesophageal stent. No pulmonary complications or surgical mortalities occurred in the study. Minor complications developed in 2 patients, 1 experiencing pneumothorax and 1 postoperative delirium. When compared with traditional MIO in our series (n = 315), no statistical difference was found among patients receiving single-port MIO in terms of ventilator usage, ICU stay and the number of dissected lymph nodes. CONCLUSIONS Single-port MIO seems to be a feasible option for treating patients with oesophageal cancer, which requires further evaluation and follow-up in the future.

Long-term outcome after bilateral lung transplantation - a retrospective study from a low-volume center experience.

BackgroundThe aim of this study is to review the long-term outcomes of bilateral lung transplantation (BLTx) in our institution and examine the potential issues that may influence outcomes in a low-volume center.MethodsA retrospective review of BLTx performed in our institution between July 2006 and December 2012 was conducted. Standardized donor selection, procurement, and preservation protocols for brain-dead donors were applied. Measured outcomes were in-hospital mortality and actuarial survival using the Kaplan-Meier method.ResultsTwenty-five consecutive patients (13 male, 12 female) underwent BLTx with a mean age of 41.8 ± 13.5 years. Before LTx, the mean body mass index was 18.3 ± 3.1 kg/m2. Seven of these patients (28%) required oxygen supplementation at rest before LTx, while the remaining patients (72%) required noninvasive mechanical ventilation (n = 6, 24%), invasive mechanical ventilation (n = 9, 36%) or extracorporeal membrane oxygenation (ECMO) (n = 3, 12%). The lung grafts were procured from brain-dead donors with the mean age of 26.8 ± 11.4 year and the best PaO2 / FiO2 ratio of 513 ± 77 before procurement. All cross match results between same-race donors and recipients were negative. The percentage of same-sex matching and CMV mismatching were 64% and 4%, respectively. The mean time listed on the transplant list was 308 ± 261 days. The mean ischemic time for the first and second grafts were 222 ± 62 and 361 ± 67 minutes. During transplantation, 22 (88%) patients depended on ECMO and one (4%) on cardiopulmonary bypass support. All but two patients (82%) were discharged home in good condition; two (8%) patients died within 3 months after BLTx. The cumulative survival rates at 1-, 2-, 3-, and 5-years were 88%, 83%, 72%, and 72%, respectively.ConclusionsAlthough the comparatively few annual LTx performed is consistent with the low donation rate, our single-center growing experience demonstrates that good post-lung transplant outcomes can be achieved at a low-volume LTx center.

Incision for Uniportal VATS: Above the Rib or Intercostal Space?

Congratulations to Vermeijden and coworkers for this valuable study [1]. The authors investigated the contribution of cell-saving devices and filtration of the salvaged blood to transfusion requirements. They conducted this study in 6 different centers and concluded that the “use of cell-saving devices, with or without a filter, does not reduce the total number of allogeneic blood products, but reduces the percentage of patients who need blood products during cardiac surgery.” We have some concerns about the study design that we think may directly affect the results of the study. The authors conducted this study by using a cellsaving device in 1 group and a leukocyte-depleting filter in the other. Because this study was carried on at different medical institutions, we should know the exact brand name and the technical information about the cell-saving device that each institution used. There are several cell-saving devices in use with different characteristics. If all of the institutions used the same type of the device that is fine. However, the devices on the market have different pore sizes, variable wash speeds, different pump and centrifuge speeds, and so on. Therefore the use of different machines may produce different results. We think that the authors should inform the reader about this issue.

Handmade Guiding Tip Using a Nélaton Tube for Endostapler Application to Pulmonary Vessels

Pulmonary vessel stapling is the most important but challenging part of thoracoscopic pulmonary lobar and segmental resection. Many thoracoscopy specialists guide the stapler with an introducer to apply staples. Since the introduction of the modified stapler with a curved and angular anvil tip, more surgeons have come to prefer stapling pulmonary vessels without guidance. However, many problems remain with the use of this new product in current clinical practice. Here we propose an easy method with an additional handmade Nélaton tube applied at the anvil tip of the stapler. Through this safe and low-cost modification, pulmonary vessels can be stapled without the aid of an introducer, reducing the possibility of vascular injury during the looping and dividing of the pulmonary vessels by the stapler.

A competing round-robin prediction model for histologic subtype prediction of lung adenocarcinomas based on thoracic computed tomography

Adenocarcinomas (ADC) is the major subtype of non-small cell lung cancers. Currently, surgery is used as the main approach for the treatment of the early-stage ADCs. However, different histological subtypes of ADC classified by the IASLC/ATS/ERS system may potentially impact on the surgical management, which subsequently influence the prognosis of the surgery. Thus, preoperative determination of ADC subtypes is essential and highly desirable. Nevertheless, the histological subtypes of ADCs may be either unknown or incompletely determined by biopsy before the surgery. Alternatively, the histological subtypes of ADCs may be predicted from the pulmonary computed tomographic (CT) images. However, previous studies showed limitations on the prediction results due to the complex composition of ADC subtypes. One possible reason is the radiomic descriptors used to differentiate different subtypes could be very different. The conventional approaches based on the same set of descriptors to distinguish all subtypes are inherently infeasible. Another possible reason is the complex composition of multiple subtypes in a lung nodule may hinder the extraction of effective radiomic descriptors to characterize each subtype. To overcome these challenges, a competing round-robin prediction model was proposed to predict the histological subtypes of ADCs, which was composed of three key ideas, namely, pair-specific radiomic descriptors for differentiation of every pair of subtypes, inter-regional descriptors for characterization of complex composition of subtypes in a nodule, and a multi-level round-robin classifier. Based on 70 ADCs patients, the proposed model achieved an accuracy of 86.3% in predicting five histological subtypes of adenocarcinomas.

Ultrasound-guided percutaneous dilatational tracheostomy using a saline-filled endotracheal tube cuff as an ultrasonographic puncture target: A feasibility study

Purpose: The saline‐filled endotracheal tube (ETT) cuff can be easily identified under cervical ultrasound and can serve as an ideal puncture target during percutaneous dilatational tracheostomy (PDT). The authors present their initial experience with this novel technique. Materials and methods: The records of 38 consecutive critically ill patients who underwent saline‐filled cuff puncture PDT between October 2016 and December 2017 were retrospectively reviewed. The saline‐filled ETT cuff was easily identified using ultrasound. Ultrasound‐guided puncture into the cuff, followed by an inward‐push of the ETT through the tube exchanger, facilitated accurate passage of the guidewire through the needle tip into the tracheal lumen. Results: Of 38 consecutive procedures, 37 (97.4%) were performed successfully, with only one converted to surgical tracheostomy due to guidewire displacement. The median procedure time was 8 min. There were no complications, such as accidental extubation, major bleeding, or posterior tracheal wall laceration or pneumothorax, and no procedure‐related mortalities. Conclusions: PDT performed using a saline‐filled cuff as the ultrasound‐guided puncture target and an endotracheal tube exchanger is feasible, and appeared to be easier to perform than standard PDT. Larger studies are required to confirm the safety and benefits of this technique.

Combined virtual-assisted lung mapping (VAL-MAP) with CT-guided localization in thoracoscopic pulmonary segmentectomy

BACKGROUND/OBJECTIVE Virtual assisted lung mapping (VAL-MAP) is a bronchoscopic lung marking technique developed to assist in navigational lung resection. It can be used for nodule localization and segmental identification. This article presents our initial experience of thoracoscopic pulmonary segmentectomy using combined VAL-MAP and computed tomography (CT)-guided localization. MATERIAL AND METHODS Markings with India Ink were made bronchoscopically, before surgery, using a virtual bronchoscopy system (LungPoint® Planner) without fluoroscopy guidance. Post VAL-MAP CT scans localized the actual markings. All data on patients, markings, and outcomes were retrospectively collected, and the contribution of VAL-MAP to the operation was graded by the surgeon. RESULTS From March 2017 to September 2017, 24 consecutive patients received the VAL-MAP marking procedure before thoracoscopic segmentectomy. Nineteen patients also received pre-operative CT-guided percutaneous localization after VAL-MAP; fifteen patients received CT-guided localization with dye (patent blue V) and microcoil, and four patients received with dye only. Of the 101 marking attempts made in all the patients, 71 (70.3%) were identified as contributing to the surgery. No clinically evident complications were associated with the procedure. A total of 24 segmentectomies were thoracoscopically conducted for 18 cases of lung cancer and six cases of benign diseases. CONCLUSION The combination of VAL-MAP and CT-guided percutaneous localization contribute to precise thoracoscopic pulmonary segmentectomy.

Nonintubated video-assisted thoracic surgery lobectomy for lung cancer

Nonintubated video-assisted thoracic surgery (VATS) is now well established and is performed in different institutions as a safe and versatile procedure in selected patients. To share the surgical and anesthetic techniques for nonintubated VATS, we present a 56-year-old female patient who underwent nonintubated VATS left upper lobectomy for primary non-small cell lung cancer. Our patient was sedated in a spontaneous breathing status using a target-controlled infusion of propofol. Additionally, regional anesthesia using intercostal block and left-sided intrathoracic vagal block enabled us to do left upper lobectomy and mediastinal lymph node dissection without difficulty. After an uneventful postoperative recovery, our patient was discharged to her home on postoperative day 3. The final pathology showed a well-differentiated adenocarcinoma without any involvement of mediastinal lymph node, measuring 27 mm in its maximal dimension. Nonintubated VATS lobectomy can be a safe and effective procedure providing satisfactory clinical outcomes in the patient.