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Purpose: To investigate regional disparities in lung cancer surgery in Japan., Methods: The annual incidence of lung cancer, lung cancer surgery, and the number of board-certified thoracic surgeons in Japan during 2014-2019 were investigated using a national open database. Lung cancer surgeries were categorized by procedure (wedge resection, segmentectomy, lobectomy, pneumonectomy) and approach (open, thoracoscopic). Disparities in 47 prefectures and urban-rural disparities during 2017-2019 were evaluated using the Gini coefficient and an unpaired t-test. Correlation was assessed using Pearson's correlation method., Results: The national annual average incidences of lung cancer and lung cancer surgery were 121,106 and 50,959, respectively, in 2014-2019. The use of the thoracoscopic approach increased over time in all procedures, except pneumonectomies. The Gini coefficients of lung cancer, thoracoscopic surgery, and board-certified thoracic surgeons indicated low inequality across prefectures; however, those of open surgery indicated high inequality. Open surgery was more common in urban areas than in rural areas. The number of thoracoscopic surgeries and board-certified thoracic surgeons by prefecture were moderately correlated., Conclusion: The thoracoscopic approach is becoming more common in lung cancer surgery, with little inter-prefectural regional disparity in the incidence of lung cancer, thoracoscopic surgeries, or the number of board-certified thoracic surgeons., Competing Interests: Declarations. Conflict of interests: The authors declare no conflicts of interest in association with the present study. Ethical approval: This study did not require institutional board approval or informed consent because of its retrospective nature and use of anonymized public data., (© 2024. The Author(s) under exclusive licence to Springer Nature Singapore Pte Ltd.)

Introduction: Rib fractures are among the most frequent injuries in trauma. This study aims to assess the current nationwide trends in operative rib fixation and identify predictors of surgical stabilization of rib fractures (SSRFs)., Methods: A 5-y (2017-2021) retrospective analysis of the Trauma Quality Improvement Program database was performed. Adult trauma patients who had at least one rib fracture were included. We analyzed data regarding type of SSRF including open and thoracoscopic approaches and its trends., Results: A total of 780,275 patients were identified, of which 15,339 patients (1.9%) were managed with SSRF. Trends of both open and endoscopic approaches were increasing during the study period. Patients with ≤2 rib fractures had a decreasing rate of SSRF. Flail chest (odds ratio = 13.42, P < 0.001) was the strongest predictor of SSRF., Conclusions: SSRF is gaining popularity in the management of chest trauma. The presence of a flail segment and multiplicity of rib fractures is among the predictors of SSRF., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The aim of this work is to assess the quality of observational studies and to make direct and indirect comparisons of robotic surgery with other approaches., Method: We searched various databases between 2014 and 2024 for observational studies comparing robotic-assisted surgery to thoracoscopy or thoracotomy., Results: Eighteen studies were included in the meta-analysis. Risk of confounding bias was present in 90% of studies, while risk of classification bias appeared in 80%. Robotic-assisted surgery reduced the risk of conversion to thoracotomy compared with thoracoscopy with an odds ratio of 0.21 (95% confidence interval: 0.06-0.65), with high heterogeneity between studies (I 2 =80%). Robotic-assisted surgery did not significantly reduce postoperative complications or 30-day mortality compared with thoracotomy or thoracoscopy. For 5-year overall survival, comparisons of robotic-assisted surgery to thoracoscopy or thoracotomy were non-significant with I 2 of 55%., Conclusion: This work demonstrates the need for a randomized controlled trial to validate robotic surgery for the treatment of bronchial cancer., (Copyright © 2024 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Objectives: The goal of this study was to assess the safety and quality of recovery (QOR) after discharge on postoperative day (POD) 1 following subxiphoid thoracoscopic anatomical lung resection within an advanced Enhanced Recovery After Surgery (ERAS) program., Methods: A retrospective analysis of prospectively collected data was conducted. Characteristics, perioperative and outcome data, compliance with ERAS pathways and a home-transition QOR survey were analysed using a multivariable logistic regression model., Results: From January 2020 to January 2022, a total of 201 consecutive patients underwent subxiphoid multiportal thoracoscopic anatomical lung resection, comprising 108 lobectomies and 93 sublobar resections (SLRs) (59 complex SLRs and 34 simple SLRs). Among them, 113 patients (56%) were discharged on POD 1, 49% after a lobectomy, 59% after a simple sublobar resection and 68% after a complex sublobar resection. In the multivariable analysis, age > 74 years and duration of the operation were associated with discharge after POD 1, whereas forced expiratory volume in 1 s and complex SLRs were associated with discharge on POD 1. Chest tube removal was achieved on POD 0 in 58 patients (29%), and 138 patients (69%) were free from a chest tube on POD 1. There were 13% with in-hospital morbidity, 10% with 90-day readmission (7% after POD 1 discharge and 14% in patients discharged after POD 1), and 0.5% with 90-day mortality. Patients discharged on POD 1 showed better compliance with the ERAS pathway with early chest tube removal and opioid-free analgesia. The home-transition QOR survey reported a better experience of returning home after discharge on POD 1 and similar pain scores., Conclusions: Postoperative day 1 discharge can be safely achieved in appropriately selected patients after subxiphoid thoracoscopic anatomical lung resection, with excellent outcomes and high quality of recovery, supported by early chest tube removal as a determinant ERAS pathway., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Evidence comparing conventional minimally invasive esophagectomy (CMIE) via laparoscopy and thoracoscopy with robot-assisted minimally invasive esophagectomy (RAMIE) is scarce. The aim of this meta-analysis was to compare surgical outcomes after CMIE and RAMIE with an intrathoracic anastomosis., Methods: A systematic literature search was performed to identify original articles analyzing outcomes after CMIE and RAMIE. Main surgical outcomes included operative time, intraoperative blood loss, anastomotic leak rates, pneumonia, overall morbidity, length of stay (LOS), and 30-day mortality. Oncologic outcomes included lymph node yield and R0 resections rates. A meta-analysis of proportions and linear regression models were used to assess the effect of each procedure on the different outcomes., Results: A total of 6,249 patients were included for analysis; 5,275 (84%) underwent CMIE and 974 (16%) RAMIE. Robotic esophagectomy had longer operative time and less intraoperative blood loss. Anastomotic leakage rates were similar with both approaches. Patients undergoing RAMIE had significantly lower rates of postoperative pneumonia (OR 0.46, 95% CI 0.35-0.61, P < .0001) and overall morbidity (OR 0.67, 95% CI 0.58-0.79, P < .0001). Median LOS was similar in both procedures (RAMIE: 12.1 versus CMIE: 11.9 days, P = .64). Similar mortality rates were found after RAMIE and CMIE (OR 0.69, 95% CI 0.34-1.38, P = .29). Lymph node yield was similar in both procedures, but RAMIE was associated with higher rates of R0 resection (OR 2.84, 95% CI 1.53-5.26, P < .001)., Conclusion: Patients undergoing robotic esophagectomy have less intraoperative blood loss, lower rates of postoperative pneumonia, reduced overall morbidity, and higher rates of R0 resections, as compared with those undergoing a laparoscopic-thoracoscopic esophageal resection., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Aim: To provide a further insight into the usefulness of lung biopsy in children., Methods: Lung biopsies in children from January 2007 to December 2017 were reviewed (n=39). The histology results were categorised as: definitive diagnosis, normal lung parenchyma, inconclusive., Results: Lung biopsy provided a definitive diagnosis in 25 (64%) cases. A suspected diagnosis was confirmed in 16 (41%) and a new diagnosis was found in 9 (23%) children. Histology was inconclusive in 11 (28%) cases and normal in 3 (8%). Fifteen (38%) children had treatment altered due to the biopsy result., Conclusion: Lung biopsy mostly confirmed the suspected diagnosis and was associated with a low procedure related morbidity (n=1) and mortality (n=0). Importantly, the biopsy result identified a pathology which altered treatment in over one third of patients. However, in a number of cases the histology was inconclusive, therefore careful patient selection is recommended to maximise diagnostic yield., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Objective: LENT and PROMISE scores prognosticate survival in patients with MPE. Prognostication guides the selection of interventions and management. However, the predictive value of these scores and their refinements (modified-LENT) in Asians remain unclear. We aim to evaluate the performance of LENT, modified-LENT and clinical PROMISE scores; identify predictors of survival; and develop an alternative prognostication tool should current scores lack accuracy., Methods: Retrospective medical record review of an Asian pleuroscopy database from 2011 to 2018 of patients with MPE was conducted. The prognostic capability of current available scores were evaluated using C-statistics. Demographic and clinical variables as predictors of survival were assessed, and an alternative model was developed using logistic regression., Results: In 130 patients, the C-statistics for modified-LENT was not significantly different from LENT (0.59 (95% CI: 0.52-0.67) vs 0.56 (95% CI: 0.49-0.63); P = 0.403). In 57 patients, the PROMISE C-statistics was 0.72 (95% CI: 0.53-0.91). In our alternative prognostication model (n = 147), Sex, Eastern Cooperative Oncology Group status, Leukocyte count, EGFR mutation, Chemotherapy and primary Tumour type (SELECT) were predictors of 90-day mortality (C-statistic = 0.87 (95% CI: 0.79-0.95)). SELECT sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios using a predicted probability of 90-day mortality cut-off point of 10% were 0.91, 0.68, 0.34, 0.98, 2.83 and 0.13, respectively., Conclusion: The LENT, modified-LENT and PROMISE scores have poor accuracy of survival prognostication in Asian patients with MPE undergoing pleuroscopy. The proposed SELECT prognostication model is accurate at identifying patients with high probability of survival at 90 days., (© 2020 Asian Pacific Society of Respirology.)

Background: There is debate regarding the ideal instrument for medical thoracoscopy. The authors compared rigid mini-thoracoscopy with semirigid thoracoscopy for thoracoscopic pleural biopsy., Methods: Consecutive subjects with undiagnosed exudative pleural effusion were randomized (1:1 ratio) to mini-thoracoscopy or semirigid thoracoscopy groups. The primary objective was a comparison of the diagnostic yield of pleural biopsy. Key secondary outcomes were the comparison of sedative/analgesic dose, operator-rated and patient-rated pain on visual analog scale (VAS), operator-rated overall procedural satisfaction (VAS), pleural biopsy size, and complications between the groups., Results: Of the 88 screened subjects, 73 were randomized: 36 to mini-thoracoscopy and 37 to semirigid thoracoscopy. Diagnostic yield of pleural biopsy in the mini-thoracoscopy (69.4%) and semirigid thoracoscopy groups (81.1%) was similar on intention-to-treat analysis (P=0.25). Although the operator-rated overall procedure satisfaction scores were similar between groups (P=0.87), operator-rated pain [VAS (mean±SD), 43.5±16.7 vs. 31.7±15.8; P<0.001] and patient-rated pain (VAS, 41.9±17.3 vs. 32.1±16.5; P=0.02) scores were greater in the mini-thoracoscopy group. Mean dose of fentanyl and midazolam received was similar between the 2 groups (P=0.28 and 0.68, respectively). Biopsy size was larger in the mini-thoracoscopy group (16.1±4.5 vs. 8.3±2.9 mm; P<0.001). Three minor complications occurred in the mini-thoracoscopy group and 6 in the semirigid thoracoscopy group (P=0.11). There were no serious adverse events or procedure-related mortality., Conclusion: Diagnostic yield of rigid mini-thoracoscopy is not superior to semirigid thoracoscopy. Use of semirigid thoracoscope may provide greater patient comfort.

Background and Aims: The aim of the study was to ascertain changes in the incidence, etiology, treatment, and outcomes of pleural infections over a decade in a Finnish University Hospital., Materials and Methods: All patients treated for pleural infections in Tampere University Hospital during 2000-2008 and 2012-2016 were included. The incidence rates and the epidemiologic data and medical history of patients, etiology of infection, and treatment trends and outcomes were compared between the cohorts., Results: The incidence of pleural infections increased from 4.4 during 2000-2008 to 9.9 during 2012-2016 per 100.000 patient-years, p < 0.001. The patients in the latter group were older, 63 versus 57 years, p = 0.001, and the prevalence of chronic lung disease, hypertension, heart failure, dyslipidemia, and immunosuppressive medication were higher. The causes of infection remained similar and pneumonia accounted for 70% of all cases. The identification rate of the microbe pathogens increased from 49% to 64%, p = 0.002, while the distribution of identified pathogens was unchanged. More patients in the latter cohort were treated operatively, 88.3% versus 80.9%, p = 0.005, and, in these, the proportion of thoracoscopic surgery was higher, 57.4% versus 8.0%, p < 0.001, and the delay to surgery shorter, 5 versus 7 days, p < 0.001. Radiologic outcomes were similar. The 30-day mortality rate was 3.1% during 2000-2008 and 5.1% during 2012-2016, p = 0.293., Conclusion: The overall incidence of pleural infections has increased significantly while the causes of pleural infections and the distribution of pathogens remain unchanged. Contemporary patients are older with higher prevalence of comorbidities and more frequently undergo thoracoscopic surgery.

In the last decade, the applicability of robotic surgery has been demonstrated in many interventions, expanding the indications of minimally invasive surgery also to pediatrics. The aim of the study is to evaluate postoperative pain to demonstrate better control following robotic procedures compared to thoraco-laparoscopic surgery. An observational, retrospective, multicentre study was performed involving 204 children undergoing robot-assisted surgery and thoraco/laparoscopic surgery at the Istituto Giannina Gaslini in Genoa and the Siena University Hospital (2013-2017): 83 children underwent robotic-assisted surgery and 121 thoracic-laparoscopic surgery. Personal data and type of intervention were assessed, dividing the patients into four categories: thoracic, gastrointestinal, hepatobiliary and urological surgeries. We analyzed the anesthetic risk according to ASA classification by type of intervention, the type of anesthesia used, the anesthetic drugs used during surgery and in the postoperative period. Both the problems that occurred during the procedures and the number of interventions converted into open during robotic surgery and laparoscopic thoracic surgery were analyzed. Pain was measured on the 1st, 2nd and 3rd day (FLACC or NRS scales). By comparing the two groups (robotics-non-robotics), the analysis shows that postoperative pain does not change with the chosen approach, but always maintains very low values, typical of minimally invasive surgery. The pain score is significantly higher in patients undergoing thoracic surgery, either robotic or thoracoscopic, compared to those undergoing gastrointestinal surgery (P corrected according to Bonferroni: 0.0006) and those undergoing urological intervention (P corrected according to Bonferroni: 0.04). In conclusion, no significant change in the intensity of postoperative pain between the two groups was found, while it is seen that the pain in patients undergoing thoracic interventions (robotic/thoracoscopic) is more intense than that reported for other types of interventions.

Background: Hybrid ablation for the treatment of atrial fibrillation is a single combined procedure consisting in a minimally thoracoscopic surgical ablation followed by a catheter ablation. This promising technique is recommended in persistent atrial fibrillation according to the current guidelines but is not routinely performed in France, mainly due to the absence of reimbursement by the French National Health Insurance., Aims: The aim of this prospective and single-centre study was to analyse, for the first time in France, the feasibility, efficacy and complication rates of hybrid ablation in patients with persistent atrial fibrillation., Methods: Hybrid ablation was performed in 15 consecutive patients (13 men, mean age 61±6 years) with persistent (7 patients) or long standing persistent (8 patients) atrial fibrillation., Results: Hybrid ablation was completed in 14/15 patients. Eleven patients returned in sinus rhythm during the procedure. Two patients (13%) had major per-procedural complications and 2 had minor complications. During an average follow-up of 25±6 months, 6 patients (40%) underwent a redo catheter ablation because of atrial tachycardia, mainly peri-mitral atrial flutter. At 1 year follow up, 14/15 patients were in sinus rhythm, including 11 free of antiarrhythmic drugs., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Background: Clinical trials have demonstrated a mortality benefit from lung cancer screening by low-dose CT (LDCT) in current or past tobacco smokers who meet criteria. Potential harms of screening mostly relate to downstream evaluation of abnormal screens. Few data exist on the rates outside of clinical trials of imaging and diagnostic procedures following screening LDCT. We describe rates in the community setting of follow-up imaging and diagnostic procedures after screening LDCT., Methods: We used Clinformatics Data Mart national database to identify enrollees age 55 to 80 year who underwent screening LDCT from January 1, 2016, to December 31, 2016. We assessed rates of follow-up imaging (diagnostic chest CT scan, MRI, and PET) and follow-up procedures (bronchoscopy, percutaneous biopsy, thoracotomy, mediastinoscopy, and thoracoscopy) in the 12 months following LDCT for lung cancer screening. We also assessed these rates in an age-, sex-, and number of comorbidities-matched population that did not undergo LDCT to estimate rates unrelated to the screening LDCT. We then reported the adjusted rate of follow-up testing as the observed rate in the screening LDCT population minus the rate in the non-LDCT population., Results: Among 11,520 enrollees aged 55 to 80 years who underwent LDCT in 2016, the adjusted rates of follow up 12 months after LDCT examinations were low (17.7% for imaging and 3.1% for procedures). Among procedures, the adjusted rates were 2.0% for bronchoscopy, 1.3% for percutaneous biopsy, 0.9% for thoracoscopy, 0.2% for mediastinoscopy, and 0.4% for thoracotomy. Adjusted rates of follow-up procedures were higher in enrollees undergoing an initial screening LDCT (3.3%) than in those after a second screening examination (2.2%)., Conclusions: In general, imaging and rates of procedures after screening LDCT was low in this commercially insured population., (Copyright © 2019 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to evaluate the clinical presentation and operative outcomes of patients with congenital lobar emphysema (CLE) within a large multicenter research consortium., Methods: After central reliance IRB-approval, a retrospective cohort study was performed on all operatively managed lung malformations at eleven participating children's hospitals (2009-2015)., Results: Fifty-three (10.5%) children with pathology-confirmed CLE were identified among 506 lung malformations. A lung mass was detected prenatally in 13 (24.5%) compared to 331 (73.1%) in non-CLE cases (p < 0.0001). Thirty-two (60.4%) CLE patients presented with respiratory symptoms at birth compared to 102 (22.7%) in non-CLE (p < 0.0001). The most common locations for CLE were the left upper (n = 24, 45.3%), right middle (n = 16, 30.2%), and right upper (n = 10, 18.9%) lobes. Eighteen (34.0%) had resection as neonates, 30 (56.6%) had surgery at 1-12 months of age, and five (9.4%) had resections after 12 months. Six (11.3%) underwent thoracoscopic excision. Median hospital length of stay was 5.0 days (interquartile range, 4.0-13.0)., Conclusions: Among lung malformations, CLE is associated with several unique features, including a low prenatal detection rate, a predilection for the upper/middle lobes, and infrequent utilization of thoracoscopy. Although respiratory distress at birth is common, CLE often presents clinically in a delayed and more insidious fashion., Level of Evidence: Level III., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Cardiovascular complications contribute significantly to the morbidity and resource utilization after pulmonary resections. Maturation of less-invasive technologies, such as video and robot-assisted thoracoscopic surgery, aims at improving postoperative outcomes by reducing the trauma of surgery. The present work aimed to evaluate changes in cardiovascular complications after open and minimally invasive lobectomies in the United States., Methods: We performed a retrospective analysis of the Nationwide Inpatient Sample for patients having elective open, video-assisted, and robot-assisted thoracoscopic lobectomy during 2008-2014. Logistic regression was performed to determine predictors of in-hospital mortality, myocardial infarction (MI), cardiac arrest (CA), and postoperative pulmonary embolism (PE)., Results: A total of 201,226 patients underwent pulmonary lobectomy over the study period. Open thoracotomy (OPEN) approach has steadily decreased from 75%-52% (P < 0.0001), whereas minimally invasive surgery (MIS) utilization has increased from 25%-48% (P < 0.0001) of all lobectomies. MIS approach was independently associated with decreased odds of mortality (odds ratio [OR] 0.6, 95% confidence interval [CI] 0.50-0.73) and PE (OR 0.67, 95% CI 0.50-0.91). MIS patients at high volume institutions had the lowest odds of all-cause mortality (OR 0.27, 95% CI 0.26-0.53) and MI (OR 0.57, 95% CI 0.38-0.87). Operative approach and institutional lobectomy caseload reduced odds of mortality after MI, CA, or PE. Overall, the incidence of MI, CA, and PE increased., Conclusions: MIS lobectomies increased without a concurrent reduction in perioperative MI, CA, or PE incidence. High hospital lobectomy volume and MIS approach decrease odds of failure to rescue. Improved perioperative management of cardiovascular risk is warranted to reduce the morbidity, mortality, and resource utilization associated with these complications., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: The authors report the 2-year follow-up results of the AFACT (Atrial Fibrillation Ablation and Autonomic Modulation via Thoracoscopic Surgery) study., Background: The AFACT study randomized patients with advanced atrial fibrillation (AF) to thoracoscopic AF ablation with or without additional ganglion plexus (GP) ablation. At 1 year, there was no difference in AF freedom between the groups, but autonomic modification may exert beneficial effects during longer follow-up., Methods: Patients underwent thoracoscopic pulmonary vein isolation, with additional left atrial lines in persistent AF patients, and were randomized 1:1 to ablation of the 4 major GP and Marshall ligament or no GP ablation (control). Patients were followed every 3 months up to 18 months and at 24 months. After an initial 3-month blanking period, all antiarrhythmic drugs were discontinued., Results: The authors randomized 240 patients (age 59 ± 8 years, 73% men, 68% enlarged left atrium, 60% persistent AF), of whom 228 patients (95%) completed follow-up. Freedom of any atrial tachyarrhythmia did not differ significantly between the GP group (55.6%) and control group (56.1%) (p = 0.91), with no difference in paroxysmal (p = 0.60) or persistent AF patients (p = 0.88). Documented AF recurrences were similar between treatment arms: 11.8% (GP) versus 11.0% (control) had >3 recurrences/year (p = 0.82). More persistent AF patients (17.0%) than paroxysmal (3.2%) had >3 recurrences per year (p < 0.01). Despite this, 78% of patients were off antiarrhythmic drugs after 2 years. No procedural-related complications occurred in the second year., Conclusions: Additional GP ablation during thoracoscopic surgery for advanced AF does not affect freedom of AF recurrence. As GP ablation is associated with more major procedural complications, it should not routinely be performed. (Atrial Fibrillation Ablation and Autonomic Modulation via Thorascopic Surgery [AFACT]; NCT01091389)., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: To identify technical modifications concerning factors that may lower the risk of recurrence following thoracoscopic repair of congenital diaphragmatic hernia (CDH)., Methods: All CDH patients who underwent thoracoscopic repair from April 2003 to September 2017 were retrospectively reviewed. Some of the more recently treated patients underwent technically modified repairs with underlay and overlay buttresses., Results: Sixty-eight patients underwent thoracoscopic repair of a diaphragmatic hernia that presented either neonatally (n = 52) or beyond the neonatal period (>1 month) (n = 16). At our institution, the minimally invasive surgical approach is considered for clinically stable CDH patients, who are likely to have type A or B defects. 21 patients had a sac-type defect. Forty-seven patients with type A defect had primary closure, buttressed in 6 cases. In 21 patients, the type B defect was repaired with a patch, buttressed in 11 patients. Median follow-up was 36 months (IQR 9-45). Recurrence occurred in 13 patients (overall 19% recurrence rate); all had a neonatally presented defect (25% vs. 0%, p = 0.03). Patients with a sac-type defect had a lower recurrence rate than patients with no hernia sac (5% vs. 26%, p = 0.05). Recurrence complicated 7 of 47 (15%) patients after primary closure and 6 of 21 (29%) patients with patch repair; none of the 17 cases with buttressed repairs had a recurrence., Conclusions: Due to a higher rate of recurrence following thoracoscopic CDH repair compared to the standard open approach, we suggest a sandwich-type buttress repair with underlay and overlay components for both primary and patch repairs., Level of Evidence: Level III cohort study., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: This study sought to document the closure rate, safety, and stroke rate after thoracoscopic left atrial appendage (LAA) clipping., Background: The LAA is the main source of stroke in patients with atrial fibrillation, and thoracoscopic clipping may provide a durable and safe closure technique., Methods: The investigators studied consecutive patients undergoing clipping as part of a thoracoscopic maze procedure in 4 referral centers (the Netherlands and the United States) from 2012 to 2016. Completeness of LAA closure was assessed by either computed tomography (n = 100) or transesophageal echocardiography (n = 122). The primary outcome was complete LAA closure (absence of residual LAA flow and pouch <10 mm). The secondary outcomes were 30-day complications; the composite of ischemic stroke, hemorrhagic stroke, or transient ischemic attack; and all-cause mortality., Results: A total of 222 patients were included, with a mean age of 66 ± 9 years, and 68.5% were male. The mean CHA 2 DS 2 -VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65 to 74 years, sex category [female]) score was 2.3 ± 1.0. Complete LAA closure was achieved in 95.0% of patients. There were no intraoperative or clip-related complications, and the overall 30-day freedom from any complication rate was 96.4%. The freedom from cerebrovascular events after surgery was 99.1% after median follow-up of 20 months (interquartile range: 14 to 25 months; 369 patient-years of follow-up), and overall survival was 98.6%. The observed rate of cerebrovascular events after LAA clipping was low (0.5 per 100 patient-years)., Conclusions: LAA clipping during thoracoscopic ablation is a feasible and safe technique for closure of the LAA in patients with atrial fibrillation. The lower than expected rate of cerebrovascular events after deployment was likely multifactorial, including not only LAA closure, but also the effect of oral anticoagulation and rhythm control., (Copyright © 2018 American College of Cardiology Foundation. All rights reserved.)

Objectives: Large retrospective series have indicated lower rates of cN0 to pN1 nodal upstaging after video-assisted thoracic surgery (VATS) compared with open resections for Stage I non-small-cell lung cancer (NSCLC). The objective of our multicentre study was to investigate whether the presumed lower rate of N1 upstaging after VATS disappears after correction for central tumour location in a multivariable analysis., Methods: Consecutive patients operated for PET-CT based clinical Stage I NSCLC were selected from prospectively managed surgical databases in 11 European centres. Central tumour location was defined as contact with bronchovascular structures on computer tomography and/or visibility on standard bronchoscopy., Results: Eight hundred and ninety-five patients underwent pulmonary resection by VATS (n = 699, 9% conversions) or an open technique (n = 196) in 2014. Incidence of nodal pN1 and pN2 upstaging was 8% and 7% after VATS and 15% and 6% after open surgery, respectively. pN1 was found in 27% of patients with central tumours. Less central tumours were operated on by VATS compared with the open technique (12% vs 28%, P < 0.001). Logistic regression analysis showed that only tumour location had a significant impact on N1 upstaging (OR 6.2, confidence interval 3.6-10.8; P < 0.001) and that the effect of surgical technique (VATS versus open surgery) was no longer significant when accounting for tumour location., Conclusions: A quarter of patients with central clinical Stage I NSCLC was upstaged to pN1 at resection. Central tumour location was the only independent factor associated with N1 upstaging, undermining the evidence for lower N1 upstaging after VATS resections. Studies investigating N1 upstaging after VATS compared with open surgery should be interpreted with caution due to possible selection bias, i.e. relatively more central tumours in the open group with a higher chance of N1 upstaging., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Malignant pleural effusions (MPE) are a common clinical problem. Little is known about the burden of MPE and of the treatments used to alleviate its symptoms on the United States Health Care System., Objectives: We aimed to obtain a better portrait of inpatient pleural procedures performed in the United States., Methods: We conducted a retrospective analysis of MPE-associated hospitalizations using the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample, Agency for Healthcare Research and Quality (HCUP-NIS 2012). Descriptive statistics were used to analyze procedures performed and their complications. Univariate and multivariate logistic regression models were used to explore the relationship between procedures performed and inpatient mortality and length of stay., Results: Among the 126,825 hospital admissions with a diagnosis of MPE, 72,240 included one or more pleural procedures. Thoracentesis (54,070) was the most frequently performed procedure followed by chest tube placement (23,035), chemical pleurodesis (10,240), and thoracoscopy (6,615). Hospitalization for lung and breast cancer was more likely to include pleural procedures compared to hospitalization for other types of cancer (59.2 and 65.6%, respectively, p < 0.0001). Chemical pleurodesis through a chest tube compared to thoracoscopic chemical pleurodesis was performed more frequently (57 vs. 43%, p < 0.001) and associated with a longer hospital stay (4.9 vs. 5.9 days, p < 0.001)., Conclusions: Hospital admissions for MPE represent a large burden on the US Health Care System. Many hospitalizations are associated with procedures not expected to reduce the recurrence rate of this condition., (© 2018 S. Karger AG, Basel.)

Background: Local anaesthetic thoracoscopy (LAT) is an important procedure in the management pathway of patients with pleural effusions, particularly those with suspected malignancy. The last survey evaluating the use and development of LAT services in the UK was conducted over a decade ago., Objectives: We performed a survey of LAT practices in the UK to explore procedural preferences and variations in practice., Methods: The online survey was cascaded via regional pleural specialists to sites performing LAT. One response per site was accepted., Results: Thirty-seven responses were received from England, Scotland and Wales. Most centres have regular access to a dedicated list and a designated area to perform LAT. 97% of the centres have at least 2 trained thoracoscopists. Some variation in practice is seen with patient preparation pre-procedure and medication use. Other procedures, such as insertion of indwelling pleural catheters and adhesiolysis, are not uncommon to be undertaken at the time of LAT., Conclusions: Overall, the results are comparable, excepting some minor variations in patient preparation pre-procedure. We hope that this survey functions as an information resource for centres developing a LAT service or for those considering expansion., (© 2018 S. Karger AG, Basel.)

Totally thoracosopic mitral valve replacement (MVR) has been applied to mitral stenosis for many years. Three working ports are usually necessary, among which the longest port ranges from 6 to 8 cm. This study aimed to determine the safety and feasibility of the two-incision totally thoracoscopic approach for MVR, with the longest incision of 3 cm.From January 2014 to February 2016, 90 patients with mitral valve stenosis were retrospectively analyzed. Thirty-six (40%) patients were included in the two-incision group and 54 patients were operated on using the sternotomy approach. Perioperative variables and postoperative 3-month follow-up data were analyzed.All patients underwent MVR. Tricuspid valvuloplasty was performed in 23 (25.5%) patients with the Kay technique. The mean total surgery time, cardiopulmonary bypass, and cross-clamp times were longer in the two-incision group (266 ± 42 versus 200 ± 38 minutes; 156 ± 23 versus 121 ± 21 minutes; 100 ± 17 versus 80 ± 17 minutes, respectively) (P < 0.05). The mean postoperative mechanical ventilation time was shorter in the two-incision group (8.6 ± 2.5 versus 11.2 ± 2.6 hours, respectively) (P < 0.05). The mean volume of blood drainage was less in the two-incision group (497 ± 120 versus 730 ± 198 mL, respectively) (P < 0.05). Reopening occurred in one (sternotomy group, 1.8%) patient. No deaths, perivalvular leakage, infectious endocarditis, atelectasis of the lungs, or moderate tricuspid regurgitation were found at the 3-month follow-up.The two-incision totally thoracoscopic approach for MVR is safe and feasible. Concomitant tricuspid valvuloplasty can be conveniently performed. However, further clinical data are needed in future studies.

Background: Solitary pulmonary nodules (SPN) are frequently detected in cancer patients. These lesions are often considered as pulmonary metastases and increasingly treated by non-surgical techniques without histological confirmation. The aim of this study is to determine the histological nature of SPN resected by thoracoscopy and to identify risk factors of malignancy., Methods: Single-institution retrospective analysis of all consecutive patients with previously known malignancies who underwent thoracoscopic resection of SPN with unknown diagnosis between 2001 and 2014., Results: One hundred and forty cancer patients underwent thoracoscopic resection of a SPN. The resected SPN was benign in 34 patients (24.3%) and malignant in 106 patients. The latter were metastasis in 70 patients (50%) and a primary lung cancer in 36 patients (25.7%). Upon univariate analysis, malignancy was significantly associated with age >60 years, disease-free interval ≥24 months, SPN size >8 mm, upper lobe localization and SUV max  > 2.5 on PET-CT. Upon multivariate analysis, upper lobe localization and SUV max  > 2.5 were associated with malignancy. Smoking was significantly associated with SPN containing primary lung cancer., Conclusion: In this series, only 50% of SPN in patients with known malignant disease were pulmonary metastases and 25% had a newly diagnosed NSCLC. Smoking was associated with primary lung cancer but no other predictor was found to allow the distinction between pulmonary metastasis and lung cancer. These results endorse the need of histological confirmation of SPN in patients with previous malignancies to avoid diagnostic uncertainty and suboptimal treatments.

Background: We assessed the quality of life (QOL) of postoperative esophageal atresia (EA) with tracheoesophageal fistula (TEF) cases, comparing open with thoracoscopic repair., Methods: A retrospective review of consecutive EA/TEF repairs (2001-2014) was performed, excluding cases with birth weight less than 2000 g and severe cardiac/chromosomal anomalies. Of 37 cases, 13 had thoracoscopic repair (TR) and 24 had open repair (OR) according to the operating surgeon's preference. QOL was determined regularly by scoring responses to a standard questionnaire about oral intake, vomiting, bougienage, coughing, growth retardation, learning ability, and thoracic deformity. Lower scores reflected poorer outcome. QOL after TR and OR was compared 1 year postoperatively (POQ) and after starting school (ScQ)., Results: Subject demographics were similar. Apart from two anastomotic leaks that resolved spontaneously after TR, there were no intraoperative complications or recurrence of TEF. Laparoscopic fundoplication was required for gastroesophageal reflux in four cases (OR 1; TR 3) (p = ns). QOL scores went from 6.5 → 11.5 in OR and 4.6 → 11.3 in TR, respectively. Final ScQ scores were similar, but POQ was significantly higher after OR (p < 0.05)., Conclusion: Initial QOL scores were significantly lower after TR, but by school age QOL scores were similar.

Background: Robotic surgery was introduced as a platform for minimally invasive lung resection in Canada in October 2011. We present the first Canadian series of robotic pulmonary resection for lung cancer., Methods: Prospective databases at 2 institutions were queried for patients who underwent robotic resection for lung cancer between October 2011 and June 2015. To examine the effect of learning curves on patient and process outcomes, data were organized into 3 temporal tertiles, stratified by surgeon., Results: A total of 167 consecutive patients were included in the study. Median age was 66 (range 27-88) years, and 46.1% ( n = 77) of patients were men. The majority of patients ( n = 141, 84%) underwent robotic lobectomy. Median duration of surgery was 270 (interquartile range [IQR] 233-326) minutes, and median length of stay (LOS) was 4 (IQR 3-6) days. Twelve patients (7%) were converted to thoracotomy. Total duration of surgery and console time decreased significantly ( p < 0.001) across tertiles, with a steady decline until case 20, followed by a plateau effect. Across tertiles, there was no significant difference in LOS, number of lymph node stations removed, or perioperative complications., Conclusion: The results of this case series are comparable to those reported in the literature. A prospective study to examine the outcomes and cost of robotic pulmonary resection compared with video-assisted thoracoscopic surgery should be done in the context of the Canadian health care system. We have presented the first consecutive case series of robotic lobectomy in Canada. Outcomes compare favourably to other series in the literature.

Objectives: Thoracoscopic surgery for lung metastasectomy remains controversial. The study aimed at determining the efficacy of thoracoscopic surgery for lung metastasectomy., Methods: This was a multi-institutional, retrospective study that included 1047 patients who underwent lung metastasectomy for colorectal cancer between 1999 and 2014. Prognostic factors of overall survival were compared between the thoracoscopic and open thoracotomy groups using the multivariate Cox proportional hazard model. The propensity score, calculated using the preoperative covariates, included the era of lung surgery as a covariate. A stepwise backward elimination method, with a probability level of 0.15, was used to select the most powerful sets of outcome predictors. The difference between the radiological tumour number and the resected tumour number (delta&#95;num) was also evaluated., Results: The c -statistics and the P -value of the Hosmer-Lemeshow Chi-square of the propensity score model were 0.7149 and 0.1579, respectively. After adjusting for the propensity score, the thoracoscopy group had a better survival rate than the open group (stratified log-rank test: P  = 0.0353). After adjusting for the propensity score, the most powerful predictive model for overall survival was that which combined thoracoscopy [hazard ratio (HR): 0.468, 95% CI: 0.262-0.838, P  = 0.011] and anatomical resection (HR: 1.49, 95% CI: 1.134-1.953, P  = 0.004). Before adjusting for the propensity score, the delta&#95;num was significantly greater in the open group than in the thoracoscopy group (thoracoscopy: 0.06, open: 0.33, P  = 0.001); however, after adjustment, there was no difference in the delta&#95;num (thoracoscopy: 0.04, open: 0.19, P  = 0.114)., Conclusions: Thoracoscopic metastasectomy showed better overall survival than the open approach in this analysis. The thoracoscopic approach may be an acceptable option for resection of pulmonary metastases in terms of tumour identification and survival outcome in the current era., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Introduction: The surgical management of oesophageal atresia (OA) differs between pediatric surgical teams without consensus. We aimed to describe the current practice of OA treatment in Belgium and Luxembourg and compare this to the literature., Materials and Methods: A questionnaire was created and sent to all 18 hospitals (14 pediatric surgical units) performing OA surgery in Belgium and Luxembourg. The results were compared to the literature., Results: Most units treat an average of 2-5 OA+TOF (71%) and ≤1 pure OA (pOA) per year (86%). The preferred surgical approach for OA+TOF is thoracotomy (86%), mostly extra-pleural (75%). Thoracoscopic OA repair is performed in 21%. All centers perform an end-to-end anastomosis (interrupted sutures), and all leave a transanastomotic tube. A chest drain is routinely used in 8units (57%). In pOA the preferred surgical approach is gastrostomy formation with delayed primary anastomosis (77%). The timing for delayed anastomosis is 2 to 24months. Intra-operative lengthening is mostly attempted with Foker technique (46%). If oesophageal replacement is needed, gastric interposition is mostly used (75%). A postoperative contrast study is routinely performed in 86% for OA+TOF and in 100% for pOA. Anti-reflux medication is routinely prescribed by all units but one., Conclusion: There are still many differences and controversies in the perioperative management of OA. Part of this is based on habits and is difficult to change without scientific evidence. There is a need for prospective (inter)national registries to further identify the existing differences, leading to a more widely accepted consensus., Level of Evidence: Level III., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Many centers performing medical thoracoscopy (MT) to diagnose pleural disease will insert a chest tube and admit patients to hospital after the procedure, which is inconvenient for patients and contributes to healthcare costs. We report the data on the safety, outcomes, and performance characteristics of outpatient MT with indwelling pleural catheter (IPC) insertion in a large Canadian cohort., Methods: This retrospective cohort study reviewed patients who underwent outpatient MT and IPC insertion under conscious sedation. Patients without complications were discharged the same day. We report the data on safety, outcomes, and performance characteristics of our program., Results: Outpatient MT and IPC insertion was performed on 218 patients. 99.1% of patients were safely discharged the same day. There was no procedure associated mortality. Pleural malignancy (59.6%) and nonspecific pleuritis (29.4%) were the most common pathologies. Pleural nodularity detected endoscopically was excellent at predicting malignancy with a positive predictive value of 92.5% and is more frequently detected endoscopically when compared to CT scan ( p < 0.001)., Conclusions: In the setting of a comprehensive pleural disease program, outpatient MT can be safely performed and is an alternative to an inpatient surgical approach for undiagnosed pleural effusions.

Purpose: To determine if utilization of thoracoscopic resection of congenital cystic lung disease (CLD) is increasing and if this approach is associated with improved outcomes using a large national sample., Methods: Children ≤20years old who underwent resection of a congenital cystic adenomatoid malformation, bronchopulmonary sequestration, or bronchogenic cyst were identified from the Healthcare Cost and Utilization Project Kids' Inpatient Database (2009, 2012) and Nationwide Inpatient Sample (2008, 2010-2011). Patient characteristics and outcomes were compared between thoracoscopic and open approaches using univariate and multivariable analyses stratified by magnitude of resection., Results: Thoracoscopic resection was used in 39.4% of 1120 children who underwent resection of CLD. Utilization of the thoracoscopic approach increased from 32.2% in 2008 to 48.2% in 2012. Use of thoracoscopy was lower in lobectomy than segmental resection (32.5 vs 48.4%, p<.001). Newborns, those with comorbid congenital conditions, and those with respiratory infections also had lower rates of thoracoscopy. After stratifying by magnitude of resection and adjusting for patient complexity, complication rates and postoperative length of stay were similar between thoracoscopic and open approaches., Conclusion: Utilization of thoracoscopic resection for CLD in the United States is increasing with time. After adjusting for patient complexity, there is no difference in postoperative length of stay or complications between thoracoscopic and open lobectomy and sub-lobar resection., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives This study aims to evaluate the feasibility, safety, limitations, and outcomes of performing different surgical approaches and techniques for the bedside repair of congenital diaphragmatic hernia (CDH) in critically ill patients who cannot be transferred to the operating room. Study Design Between December 1997 and July 2013, medical charts of all neonates operated on at the bedside for CDH while on high-frequency oscillatory ventilation (HFOV) and nitric oxide were reviewed. Demographic data; contributing antenatal, perinatal, and postnatal factors; clinical presentation; associated anomalies; respiratory and hemodynamic status; operative details; complications, and outcome were analyzed. Results A total of 101 cases of CDH were operated on, of which 11 were in very critical condition and operated on at the bedside in the neonatal intensive care unit (NICU). The mean gestational age was 38.09 weeks, birth weight, 2.91 kg, and age at surgery, 10 days. All were on HFOV and inotropic support and had pulmonary hypertension. Nine of them were on nitric oxide. Mean preoperative parameters were as follows: O2, 52%; mean airway pressure, 15; pH, 7.40; Po 2, 88.5 mm Hg; and Pco 2, 47 mm Hg. Nine patients underwent laparotomy and two underwent thoracoscopy. All procedures were completed uneventfully. Conclusions Bedside repair of CDH in the NICU while on HFOV is feasible and safe. It is not associated with any compromise in the surgical approach or technique., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

For patients with atrial fibrillation (AF) who are refractory to anti-arrhythmic drugs (AADs), minimally invasive video-assisted thoracoscopic surgical ablation (SA) and catheter ablation (CA) are potential alternative treatment options. The recent FAST randomized study suggested that thoracoscopic SA was superior to CA in achieving freedom of AF in patients who have failed at least one prior AAD. To assess the relative merits and risks of SA versus CA, a systematic review and meta-analysis was conducted. Electronic searches were performed using six databases from their inception to December 2014. Relevant studies comparing thoracoscopic SA and CA were identified; data were extracted and analysed according to predefined clinical endpoints. Relative risk (RR) and weighted mean difference were used as summary statistics. Freedom from AF/arrhythmias was significantly higher in SA versus CA at 12-month off-AAD (78.4 vs 53%; RR, 1.54; P < 0.0001) and on-AAD (82.6 vs 45.7%; RR, 1.85; P < 0.00001). This difference was maintained in paroxysmal and persistent AF subgroups. The SA cohort had a significantly lower requirement for repeat ablations compared with the CA cohort (4.7 vs 24.4%; RR, 0.21; P = 0.0001). However, major complications were significantly higher in the SA group (28.2 vs 7.8%; RR, 3.30; P = 0.0003), driven by pleural effusion and pneumothorax. SA may be more efficacious than CA treatment in a selected patient population with refractory AF and prior failed catheter intervention. Improved freedom from arrhythmias at up to 12-month follow-up is counterbalanced by higher procedural complication rates., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Introduction: Totally thoracoscopic (TT) epicardial ablation combined with endocardial catheter ablation is an emerging treatment for persistent AF. The effects of timing of the TT and endocardial portion on AT/AF recurrence are not known., Methods: We retrospectively analyzed patients undergoing TT staged versus simultaneous hybrid AF ablation at our institution. Arrhythmia-free outcome was compared using time to recurrence (AF or AT greater than 30 seconds after a 3-month blanking period from endocardial ablation) at 12 months. All subjects had continuous ILR or PM monitoring., Results: Eighty-three patients (52 same-day, 31 staged) underwent TT hybrid AF ablation. Recurrence was observed in 23 (29%) patients at a median time of 147 days (IQR 91,238). In univariate analysis, a staged approach significantly increased the likelihood of detecting incomplete PVI (OR 6 [95% CI 2-17] P = 0.001). However, only longstanding persistent AF (LSP-AF) status predicted recurrence (HR 4 [95% CI 1.4-12] P = 0.01). Neither a staged approach (HR 1.0 [95% CI 0.4-2.4] P = 0.9), nor detection of incomplete PVI (HR 0.9 [95% CI 0.4-2.3] P = 0.8) predicted time to first AF/AT recurrence., Conclusions: Staged hybrid ablation of AF significantly increases the likelihood of discovering incomplete PVI at the time of endocardial mapping versus a same-day procedure. However, the staged approach did not improve time to first AT/AF recurrence., (© 2015 Wiley Periodicals, Inc.)

Background: We report a single-center study of minimally invasive thoracoscopic lung surgery with pediatric patients., Methods: We performed a retrospective analysis of patients who underwent thoracoscopic lung surgery between 2004 and 2013. The procedures were divided into anatomic and non-anatomical lung resections., Results: Seventy-six patients with a mean age of 6.5 years (range: 7 days-17 years) and a mean weight of 11 kg (range: 2.6-56.0 kg) received thoracoscopic lung surgery for tumor metastases (n = 20), sequestration/congenital adenomatoid malformation (19), cysts (12), aspergillomas (7), bullae (5), middle lobe syndrome (3), bronchiectasis (3), emphysema (2), and other reasons (5). Twenty-nine anatomical lung resections (Group I: lobectomies, segmentectomies) and 47 non-anatomical lung resections (Group II: wedge resections, lung tissue-sparing surgery) were performed. In 6 cases, preoperative CT-guided coiling was used to localize the lung lesions. Specimen removal was achieved using a widened (2 cm) trocar site. The operating times of Group I patients were longer compared than those of Group II patients (means: 154 and 68 min, respectively); conversion rates (8 versus 2), chest tube insertion rates (100% versus 51%), and postoperative ventilation (48% versus 13%) also differed., Conclusion: Thoracoscopic anatomical lung resections appear to be safe and effective in infants and children. In congenital lung diseases, the key to success is the intraoperative destruction of space-occupying lesions. Limitations exist in cases with infectious adhesions. Non-anatomical lung resections are technically easier and should remain standard in pediatric surgery. Limitations exist in cases of metastases, which are deep within the parenchyma and are not visible on the lung surface., (Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

Objective: To evaluate a diagnostic flow chart applying medical thoracoscoy (MT), adenosine deaminase (ADA) and T-SPOT.TB in diagnosis of tuberculous pleural effusion (TPE) at a high TB burden country., Patients and Methods: 136 patients with pleural effusion (PE) were enrolled and divided into TPE and Non-TPE group. MT (histology), PE ADA and T-SPOT.TB were conducted on all patients. ROC analysis was performed for the best cut-off value of PE ADA in detection of TPE. The diagnostic flow chart applying MT, ADA and T-SPOT.TB was evaluated for improving the limitations of each diagnostic method., Results: ROC analysis showed that the best cut-off value of PE ADA was 30U/L. The sensitivity and specificity of these tests were calculated respectively to be: 71.4% (58.5%-81.6%) and 100% (95.4-100.0%) for MT, 92.9% (83.0-97.2%) and 68.8% (57.9-77.9%) for T-SPOT.TB, and 80.0% (69.6-88.1%) and 92.9% (82.7-98.0%) for PE ADA. The sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, positive predictive value and negative predictive value of the diagnostic flow chart were 96.4% (87.9-99.0%), 96.3% (89.6-98.7%), 25.714, 0.037, 97.4 and 94.9, respectively., Conclusions: The diagnostic flow chart applying MT, ADA and T-SPOT.TB is an accurate and rapid diagnostic method in detection of TPE.

Background: Bronchopulmonary malformations (BPM) are rare conditions, which typically arise below the carina and can result in significant morbidity (infection and/or hemorrhage) and mortality (respiratory failure)., Materials and Methods: All children with BPM surgically treated from 2001-2014 at a tertiary care children's hospital were identified. Patient demographics, surgical indications, procedure type, estimated blood loss, pathology, perioperative complications, length of stay, and outcomes were analyzed., Results: A total of 41 BPM patients underwent surgery with 98% overall survival (one abdominal BPM expired) but 100% for thoracic lesions. Resections were performed thoracoscopically (37%), thoracoscopy converted to open (22%), and via thoracotomy (37%). Poor visualization (67%) or inability to tolerate single lung ventilation (33%) led to conversions. No conversions resulted from hemorrhage or received blood transfusions. Patients with prenatally diagnosed BPM were more likely to undergo thoracoscopic surgery (odds ratio [OR], 18.2) versus nonprenatally diagnosed, P = 0.002. Open/converted patients had longer chest tube days (6.2) versus thoracoscopic (2.9), P = 0.048. Additionally, respiratory distress was a more common indication in patients aged <4 mo (OR, 28.0) versus ≥4 mo and <6 kg (OR, 40.5) versus ≥6 kg, P < 0.001. Open resections were more common in patients aged <4 mo (OR, 26.3) versus ≥4 mo, P = 0.002. Operative time was shorter and estimated blood loss (mL/kg) was greater for <6 versus ≥6 kg, P < 0.05., Conclusions: BPM resections have high overall survival. Chest tube days are shorter among thoracoscopic patients, but conversion to thoracotomy can avoid hemorrhage and need for transfusion. Size and respiratory distress limit use of thoracoscopy in young infants with BPM., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Minimally invasive general thoracic surgery entered a new era with the introduction of thoracoscopic surgery into clinical practice in the early 1990s. Thoracoscopic surgery is already widely accepted in most countries. However, single-port thoracic surgery, needlescopic thoracic surgery, and robot-assisted thoracic surgery are not yet accepted widely. More advances in the instruments and equipment appear necessary.

Severe tracheomalacia (TM) is a difficult problem in esophageal atresia (EA) patients. We reviewed our experience with aortopexy and other interventions for severe TM in this population. With review ethics board approval, a retrospective review of TM in postoperative EA patients was conducted (1989-2010). Demographics, perinatal, and surgical information regarding EA repair was collected. TM infants were analyzed for symptomatology, clinical severity, investigations, interventions, and outcomes. Data are presented as proportions or median(range). One hundred and thirty-two EA patients were reviewed. Most had type C atresia (87.3%), and 18 patients (13.6%) died. Twenty-five patients (18.9%) had TM of whom five (20%) died. Median symptom onset was 18 days (0-729) after EA repair, with stridor (64%) or retractions/distress (44%) being most frequent. Four and two patients had airway obstruction or cardiorespiratory arrest, respectively. Median time from symptom onset to investigations was 11 days; these were most commonly rigid bronchoscopy (56%) and fluoroscopy (36%). Ten patients (40%) had severe TM on bronchoscopy. Six underwent aortopexy, one fundoplication, and three were treated medically. Length of hospital stay (LOS) post-aortopexy was 13 days (5-60), and ventilation time was 2 days (0-9). LOS was 60.5 (1-69) days postdiagnosis in non-aortopexy patients. Readmission rates for respiratory issues were significantly less in the aortopexy (median 0 vs. 5; P = 0.048) group over 2-year follow up after discharge. Complications of aortopexy included transfusion (1) and temporary diaphragmatic paresis (1), and one mortality secondary to severe congenital cardiac anomalies. Our experience suggests that aortopexy is safe and effective for the treatment of severe TM. It is associated with reduced LOS compared with other treatment strategies and few complications or long-term sequelae., (© 2014 International Society for Diseases of the Esophagus.)

Introduction: The published experience with minimally invasive techniques to treat injured children is currently small. In this multicenter case series, we aimed to characterize the contemporary role of minimally invasive surgery (MIS) in pediatric trauma., Materials and Methods: After obtaining Institutional Review Board approval at six pediatric regional trauma centers in the United States, a retrospective review was conducted on children who have undergone thoracoscopy or laparoscopy for the management of trauma over the past 13 years., Results: There were 200 patients with a mean age of 9.6 ± 4.2 years, and 73% were male. Laparoscopy was performed for 187 (94%) and thoracoscopy for 8 (4%), whereas 5 (2%) patients had both, for a total of 205 MIS procedures. Conversion to open surgery occurred in 36% (n=73). Median operative time was 77 (range, 16-369) minutes. Of the 132 procedures completed without conversion, 81 (61%) were diagnostic, whereas the remaining were therapeutic, including the repair of bowel injuries (n=20), distal pancreatectomy (n=5), splenectomy (n=2), repair of traumatic abdominal wall hernias (n=2), evacuation of hemothorax (n=3), and other thoracoscopic or laparoscopic interventions (n=19). Procedures that required conversion were most commonly for bowel injury (n=56). Patients with peritonitis were most likely to require conversion to an open procedure (77.4%). Mean time to a regular diet was 4.2 ± 8.6 days, and mean hospital stay was 6.3 ± 6.5 days. Postoperative complications occurred in 19 patients, long-term sequelae in 10 patients, and permanent disability in 2 patients. There were no deaths or missed injuries., Conclusions: In the stable pediatric trauma patient, laparoscopy and thoracoscopy can be performed safely and effectively for both diagnostic and therapeutic purposes.

The BTS pleural procedures audit collected data over a 2-month period in June and July 2011. In contrast with the 2010 audit, which focussed simply on chest drain insertions, data on all pleural aspirations and local anaesthetic thoracoscopy (LAT) was also collected. Ninety hospitals submitted data, covering a patient population of 33 million. Twenty-one per cent of centres ran a specialist pleural disease clinic, 71% had a nominated chest drain safety lead, and 20% had thoracic surgery on site. Additionally, one-third of centres had a physician-led LAT service., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Video-assisted thoracic surgery (VATS) has been widely applied in the treatment of lung cancer. However, few studies have focused on the clinical factors predicting the major postoperative complications., Methods: Clinical data from 525 patients who underwent resection of primary lung cancer with VATS from January 2007-August 2011 were retrospectively analyzed. Risk factors related to major postoperative complications were assessed by univariate and multivariate analyses with logistic regression., Results: Major complications occurred in 36 (6.86%) patients, of which seven died (1.33%) within 30 d, postoperatively. Major complications included respiratory failure, hemothorax, myocardial infarction, heart failure, bronchial fistula, cerebral infarction, and pulmonary embolism. Univariate and multivariate logistic regression analyses demonstrated that age >70 y (odds ratio [OR], 2.105; 95% confidence interval [CI] 1.205-3.865), forced expiratory volume during the first second expressed as a percentage of predicted ≤70% (OR, 2.106; 95% CI 1.147-3.982) combined with coronary heart disease (OR, 2.257; 95% CI 1.209-4.123) were independent prognostic factors for major complications., Conclusions: Age >70 and forced expiratory volume during the first second expressed as a percentage of predicted ≤70% combined with coronary heart disease are independent prognostic factors for postoperative major complications. Patients in these groups should undergo careful preoperative evaluation and perioperative management., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Introduction: Because many aspects of the management of esophageal atresia (EA) are still controversial, we evaluated the practice patterns of this condition across Europe., Methods: A survey was completed by 178 delegates (from 45 [27 European] countries; 88% senior respondents) at the EUPSA-BAPS 2012., Results: Approximately 66% of respondents work in centers where more than five EA repairs are performed per year. Preoperatively, 81% of respondents request an echocardiogram, and only 43% of respondents routinely perform preoperative bronchoscopy. Approximately 94% of respondents prefer an open approach, which is extrapleural in 71% of respondents. There were no differences in use of thoracoscopy between Europeans (10%) and non-Europeans (11%, p = nonsignificant). Approximately 60% of respondents measure the gap intraoperatively. A transanastomotic tube (90%) and chest drain (69%) are left in situ. Elective paralysis is adopted by 56% of respondents mainly for anastomosis tension (65%). About 72% of respondents routinely request a contrast study on postoperative day 7 (2-14). Approximately 54% of respondents use parenteral nutrition, 40% of respondents start transanastomotic feeds on postoperative day 1, and 89% of respondents start oral feeds after postoperative day 5. Pure EA: 46% of respondents work in centers that repair two or more than two pure EA a year. About 60% of respondents opt for delayed primary anastomosis at 3 months (1-12 months) with gastrostomy formation without esophagostomy. Anastomosis is achieved with open approach by 85% of respondents. About 47% of respondents attempt elongation of esophageal ends via Foker technique (43%) or with serial dilations with bougies (41%). Approximately 67% of respondents always attempt an anastomosis. Gastric interposition is the commonest esophageal substitution., Conclusion: Many aspects of EA management are lacking consensus. Minimally invasive repair is still sporadic. We recommend establishment of an EA registry., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Despite progress of medical, the fast and accurate diagnosis of tuberculous pleuritis (TP) continues to be a challenge, mainly because of the lack of specific clinical features and the difficulty in isolating the Mycobacterium tuberculosis., Objectives: To investigate the role of medical thoracoscopy in definite diagnosis of tuberculous pleuritis, especially the feature of visual diagnosis in tuberculous pleuritis via medical thoracoscopy. We performed a retrospective review of the utility of medical thoracoscopy in tuberculous pleuritis., Patients and Methods: A retrospective chart review was performed of 91 patients who had medical thoracoscopy for suspected TP at the Second Xiangya Hospital from October 1, 2006 to July 30, 2012., Results: In ninety one cases, 76 patients were diagnosed with TP by pathologic diagnosis. The visual findings via thoracoscopy of 76 TP patients included the following: (1) necrosis (76.32%, n=58), (2) diffuse miliary nodules (64.67%, n=49), (3) single or multiple pleural nodules (14.47%, n=11), (4) hyperemic, edematous and thickened pleura (56.58%, n=43), and (5) pleural adhesions or fibrotic septa (78.95%, n=60), and all of these samples had hydrothorax or loculated effusion. The diagnostic efficiency of visual diagnosis via medical thoracoscopy about tuberculous pleuritis was 93.41%. In the non-invasive test, ADA > 40 u/l with LDH > 200 u/l for TP showed relatively high sensitivity and specificity (73.68%, 80.00%, respectively)., Conclusions: TP presents a variety of scopic phenotypes under medical thoracoscopy. The experienced pulmonologists visually diagnose TP efficiently and directly via medical thoracoscopy. Medical thoracoscopy with combined biopsy is an accurate and safe method for diagnosing TP.

A frequency of postoperative complications varied from 1-2% after endoscopic thoracal operations to 4-12% after open operations using thoracotomic access. There isn't any common approach to indications and terms of the recurrent endoscopic intervention. An analysis of postoperative complications was made after 2795 thoracothomies and 3632 videothoracoscopies required the recurrent operation in 139 patients (2.2%). The rethoracoscopies were performed on 62 patients (44.6%), thoracoscopies were carried out after thoracotomies in 40 cases (28.8%) and rethoracotomies were in 37 cases (26.6%). The more frequent indication to recurrent operation was bleeding (26.6%), pleural empyema (20.9%), fragmented pleuritis (11.5%). It was shown that thoracoscopy was an alternative to rethoracotomy as the rethoracoscopy in case of nonmassive intrapleural bleeding, clotted hemothorax, postoperative fragmented pleuritis, non-sanitized empyema region, the presence of sequestrums in this area, limited postoperative pleuritis, chylothorax, bronchopleural fistula of the size of 1-2 mm, leakage of the lung, a foreign body in pleural cavity. The lethality consisted of 35.1% after rethoracotomies and it was 12.7% after recurrent endoscopic operations.

Objectives: This study reports an early, single-institution experience of combined thoracoscopic and laparoscopic robotic-assisted minimally invasive esophagectomy (RAMIE) using a four-arm robotic platform, with special attention given to the pitfalls and complications during procedure development., Methods: We conducted a prospective, single-cohort, observational study of patients undergoing RAMIE at a single institution., Results: A total of 21 patients (median age, 62 years [range, 37-83 years]) underwent RAMIE with a four-arm robotic platform (17 by Ivor Lewis and 4 by McKeown). Of the patients, 17 (81%) had a complete (R0) resection, and 16 (76%) received induction treatment, the majority (14/21 [67%]) with combined chemoradiation. The median operative time was 556 min (range, 395-807 min), which decreased to 414 min (range, 405-543 min) for the last 5 cases in the series. The median estimated blood loss was 307 cm(3) (range, 200-500 cm(3)), and the median length of hospital stay was 10 days (range, 7-70 days). The median number of lymph nodes resected was 20 (range, 10-49). Five (24%) patients were converted to open procedures. Five patients (24%) had major complications. One (5%) died of complications on postoperative Day 70, and 3 (14%) had clinically significant anastomotic leaks (Grade II or greater, by Common Terminology Criteria for Adverse Events version 3.0). Three patients (14%) in this early experience developed airway fistulas., Conclusions: While four-arm RAMIE may offer advantages over standard minimally invasive esophagectomy approaches, its adoption in a structured program, with critical evaluation of adverse events and subsequent adjustment of technique, is paramount to maximize patient safety, minimize complications and improve the conduct of operation early in the learning curve. Particular technical consideration should be given to prevention of airway complications.

Aim: Aim of the present study was to investigate the clinical and pathological features of surgical treatment for primary bronchogenic carcinoma in adolescent patients., Patients: We retrospectively reviewed the clinico-pathological records documenting surgical outcomes and prognostic factors in 68 lung cancer patients aged less than 30 years old enrolled in our hospital between March 1980 and December 2009., Results: Sixty-eight patients were identified (38 male, 30 female) with a mean age of 22±5 years (range 8 to 29 years). Preoperative clinical manifestations were present in 82.4% (56/68) of the patients and 26.5% (16/68) of patients were initially misdiagnosed. Fifty-two patients had undergone radical surgery, 4 palliative surgery, 9 had exploratory thoracotomies, and 3 had thoracoscopic lung biopsies. Eight patients were classified (TNM) stage Ia, 7 stage Ib, 9 stage IIa, 13 stage IIb, 17 stage IIIa, 10 stage IIIb, and 4 stage IV. Postoperative atelectasis was observed in 4.41% (3/68) of the patients, and 1.47% (1/68) died of respiratory failure 5 days after exploratory thoracotomy. The overall 5-year survival rate in very young people was 31%, while those who underwent radical surgery was slightly higher at 36.7%. Five-year survival rates were correlated with the surgical procedures and pTNM stage (P <0.05). Multivariate analysis indicated that the TNM stage is the only independent prognostic factor (P=0.000)., Conclusion: We conclude that radical surgeries, the predominant comprehensive therapies are the best choice for primary lung cancer patients younger than 30 years of age.

Background: Alimentary tract duplications (ATD) are a rare cause of intestinal obstruction in childhood. There are many case reports but few series about laparoscopy or thoracoscopy for ATD. The aim of our study was to report the outcome of minimally invasive surgery (MIS) for ATD., Methods: This was a retrospective multicenter study from the GECI (Groupe d'Etude en Coeliochirurgie Infantile). We reviewed the charts of 114 patients operated on by MIS for ATD from 1994 to 2009., Results: Sixty-two patients (54 %) had a prenatal diagnosis. Forty-nine patients (43 %) were symptomatic before surgery: 33 of those patients (63 %) with postnatal diagnosis compared to 16 (25 %) with prenatal diagnosis (P < 0.01). In this last group, the median age at onset of symptoms was 16 days (range = 0-972). One hundred and two patients had laparoscopy (esophageal to rectal duplications) and 12 patients had thoracoscopy for esophageal duplications. The mean operative time was 90 min (range = 82-98). There were 32 (28 %) resection anastomoses, 55 (48 %) enucleations, and 27 (24 %) unroofings. The conversion rate was 32 %, and in a multivariate analysis, it was significantly higher, up to 41 % for patients weighing <10 kg (P < 0.01). Ten patients (8 %) had unintentional perioperative opening of the digestive tract during the dissection. Eight patients had nine postoperative complications, including six small bowel obstructions. The median length of hospital stay was 4 days (range = 1-21) without conversion and 6 days (range = 1-27) with conversion (P = 0.01). The median follow-up was 3 months (range = 1-120). Eighteen of the 27 patients who underwent partial surgery had an ultrasound examination during follow-up. Five (18 %) of them had macroscopic residue., Conclusion: This study showed that MIS for ATD is feasible with a low rate of complications. Patients with prenatal diagnosis should have prompt surgery to prevent symptoms, despite a high rate of conversion in small infants.

Background: Thoracoscopic repair of esophageal atresia is considered to be one of the more advanced pediatric surgical procedures, and it undoubtedly has a learning curve. This is a single-center study that was designed to determine the learning curve of thoracoscopic repair of esophageal atresia., Methods: The study involved comparison of the first and second five-year outcomes of thoracoscopic esophageal atresia repair., Results: The demographics of the two groups were comparable. There was a remarkable reduction of postoperative leakage or stenosis, and recurrence of fistulae, in spite of the fact that nowadays the procedure is mainly performed by young staff members and fellows., Conclusions: There is a considerable learning curve for thoracoscopic repair of esophageal atresia. Centers with the ambition to start up a program for thoracoscopic repair of esophageal atresia should do so with the guidance of experienced centers.

Aims: The purpose of this EP Wire is to survey clinical practice in this rapidly evolving field as the variety of surgical techniques and the heterogeneity of treated patients make the comparison of results and outcomes challenging., Methods and Results: Twenty-four European centres, all members of the EHRA EP research network, responded to this survey and completed the questions. Of the participating centres, 11 (46%) performed (irrespective of the technique) stand-alone surgical atrial fibrillation (AF) ablation in 2011. Seven hospitals (64%) performed totally thoracoscopic AF ablation procedures off-pump (in 20-100% of their cases). The most commonly used lesion set was only pulmonary vein isolation in five hospitals (46%). Eight centres (73%) performed validation of the surgical lesion set at the time of intervention. The most important indication for performing stand-alone, totally thoracoscopic surgical AF ablation in seven participating hospitals was failed catheter ablation. According to their definition of success, participating centres reported their success rate to be 10-100% for paroxysmal AF and 0-95% for (longstanding) persistent AF. The most frequently encountered complications during stand-alone, surgical AF ablation were pneumothorax and haemothorax in up to 10% of the cases., Conclusion: This EP Wire survey shows a wide variation not only in indications for stand-alone, surgical AF ablation, but also in surgical techniques, lesion sets, follow-up, and outcome.