Search Results (207)

Minimal access cardiac surgery (MACS) can mitigate the increasing risk profile of cardiac surgery patients and is associated with improved postoperative outcomes. One of the ways to manage the steep learning curve of MACS is the use of surgical simulation training. We conducted a narrative review to identify the relevant literature discussing MACS simulation training. We identified 20 studies using our search strategy. Various platforms were represented: high-fidelity (n = 8), low-fidelity (n = 6), and animal studies (n = 6). Virtual reality (VR) appeared in two wet-lab studies as an adjunct. The surgical approach was video-assisted thoracoscopic surgery (VATS) in 11 and robotic-assisted thoracoscopic surgery (RATS) in nine. The most simulated procedure was minimal access mitral valve (MV) repair (n = 16). Most studies (n = 16) evaluated the impact of simulation training on the surgical skill of participants with varying baseline MACS experience. A small proportion of included studies (n = 4) carried out only fidelity testing. While some standardised assessment tools were used, there was considerable variation in how surgical skill and fidelity were assessed. There are an increasing number of publications on MACS simulation training, with equal focus on bench and animal models. MV procedures were the most simulated, suggesting a drive towards increasing the scope of minimal access MV training. Full article

Background/Objectives: This study examined whether dynamic systemic inflammation- and nutrition-based scores measured at baseline (T0) and during follow-up (T1: days 7–10) are associated with treatment response and surgical requirement in first-episode primary spontaneous pneumothorax (PSP). Methods: A total of 216 consecutive patients with first-episode PSP, treated between January 2020 and December 2024, were retrospectively analyzed. All patients initially underwent tube thoracostomy. During follow-up, 117 patients recovered with drainage therapy, whereas 99 required VATS because of a prolonged air leak. The CAR, SIII, SIRI, PIII, NLR, PLR, and PNI, measured at T0 and T1, were analyzed. Δ-values (T1–T0 differences) were evaluated, and diagnostic performance was assessed using ROC curve analysis. Results: At T0, inflammation- and nutrition-based indices did not differ significantly between groups. In contrast, at T1, CAR, SIII, SIRI, PIII, NLR, and PLR values were significantly higher in the VATS group than in the drainage group (all p < 0.05). Over time, inflammatory indices increased markedly in the VATS group, whereas changes in the drainage group remained limited. PNI decreased significantly at T1 in both groups. ROC analysis demonstrated that CAR, SIII, and NLR showed moderate discriminative performance for identifying patients who required VATS (area under the curve ≈ 0.65). Conclusions: Dynamic assessment of systemic inflammation-based biomarkers provides clinically relevant insight for surgical risk stratification in first-episode PSP. While baseline measurements alone are insufficient, follow-up values and temporal changes—particularly in CAR, SIII, and NLR—may reflect progression toward a surgical phenotype and could serve as adjunctive, non-directive decision-support indicators in PSP management. Full article

Introduction: Lymph node status is a key prognostic factor of lung cancer. Although video-assisted thoracoscopic surgery (VATS) is widely used for early-stage disease, its consistency in achieving thorough lymph node dissection remains debated. While many studies show outcomes comparable to thoracotomy, others question its reliability for accurate staging in advanced cases. This study compared the oncologic efficacy of VATS and thoracotomy in pulmonary adenocarcinoma, focusing on lymph node dissection and postoperative outcomes. Materials and Methods: A retrospective analysis was conducted on 111 consecutive patients who underwent curative-intent resection for pulmonary adenocarcinoma between 2019 and 2023 at the “Prof. Dr. Alexandru Trestioreanu” Oncological Institute, 52 undergoing thoracotomy and 59 Video-Assisted Thoracoscopic Surgery (VATS). Results: Demographic and clinical characteristics were comparable between groups. Compared with thoracotomy, VATS was associated with a significantly higher number of harvested lymph nodes at stations 7 and 10. No significant differences between groups in the number of positive lymph nodes, postoperative morbidity, or 30-day mortality were observed. Conclusions: VATS appears to provide comparable lymph node retrieval and short-term outcomes to open surgery. These findings add valuable data from an underrepresented Eastern European population and support the broader adoption of minimally invasive techniques in lung cancer surgery. Full article

Background: Current guidelines recommend lobectomy for tumors > 20 mm on CT, yet systematic CT–pathology size discordance may contribute to size-threshold–driven surgical decisions. We hypothesized that CT-based tumor diameter differs from pathological size near the 20 mm surgical boundary, potentially leading a proportion of patients to undergo more extensive resection than pathology would indicate under a size-only rule. Methods: We retrospectively analyzed 1096 patients undergoing thoracoscopic surgery for clinical stage I non-small cell lung cancer at a single center (2020–2024). CT–pathology agreement was assessed via Bland–Altman analysis. Optimal CT cut-off was identified using restricted cubic spline (RCS) modeling, internally validated with bootstrap resampling (B = 2000), and evaluated by decision curve analysis (DCA). Results: CT showed size-dependent bias: overestimation in small tumors (T1a: +4.21 mm) transitioning to underestimation in larger lesions (≥T2: −7.49 mm). At the 20 mm threshold, 15.8% of patients (n = 173) underwent lobectomy despite pathological size ≤ 20 mm (potential overtreatment). RCS modeling and bootstrap-optimized DCA identified 23 mm as the candidate revised threshold. Adopting CT > 23 mm would reclassify 108 patients from lobectomy to sublobar resection, reducing size-threshold–defined potential overtreatment by 51.4% while maintaining sensitivity for true ≥ T2 tumors. Conclusions: CT demonstrates size-dependent discordance with pathological size; this discordance likely reflects both CT measurement inaccuracy and specimen shrinkage after fixation, and the relative contributions cannot be separated from these data. A candidate 23 mm CT threshold, supported by DCA and internal bootstrap validation, could reduce size-threshold–defined potential overtreatment by 51% in this cohort. Prospective multicenter validation is required before clinical implementation. Full article

Historically, stage T4 non-small cell lung cancer (NSCLC) with direct spinal invasion was considered a definitive surgical contraindication due to the perceived inability to achieve negative margins without catastrophic morbidity. This paradigm has shifted through the advancement of specialized surgical techniques, which facilitate radical en-bloc resection in highly selected candidates by adhering to the en-bloc concept. This concept mandates the retrieval of the tumor and invaded vertebral segments as a single, contiguous unit to prevent intralesional transgression and local recurrence. Achieving microscopic negative margins (R0) stands as the most critical prognostic factor, as radical resection offers a significantly improved potential for long-term survival. Technical success requires a meticulously planned multidisciplinary approach encompassing varied surgical corridors—ranging from combined anterior–posterior windows to single-stage posterior-only approaches—tailored to the tumor’s anatomical level. Furthermore, preoperative hemostatic optimization using dual-energy computed tomography (DECT) for vascular assessment and transarterial embolization (TAE) has become indispensable for managing the hypervascularity of the invaded vertebral bone. This review synthesizes these evolving strategies, illustrated by a case of a 74-year-old male with stage T4 NSCLC where an R0 resection was achieved through a two-stage approach integrating uniportal video-assisted thoracoscopic surgery (VATS). Ultimately, en-bloc management provides a feasible and potential surgical strategy toward long-term survival for localized, spine-invasive lung cancer within a multidisciplinary treatment framework. Full article

Background: Chronic pain following thoracotomy remains a common and clinically significant complication that adversely affects functional recovery and quality of life. Despite advances in perioperative analgesic techniques, chronic post-thoracotomy pain continues to be under-recognized and insufficiently managed in routine clinical practice. In this study, we aimed to determine the incidence of chronic pain after thoracotomy and evaluate its impact on daily activities and postoperative pain management behaviors. Methods: This retrospective observational study was conducted after institutional ethics committee approval was received (approval no. 2023/61). Patients aged ≥15 years who underwent thoracotomy between 15 June 2022 and 15 June 2023 and had undergone an operation at least three months prior to the study were included. Patients who underwent video-assisted thoracoscopic surgery were excluded. Demographic, surgical, anesthetic, and postoperative analgesia data were obtained from medical records. Patients were contacted by telephone to assess pain intensity using a Numeric Rating Scale (NRS), functional impact on daily activities, and analgesic medication use. The primary outcome was the incidence of chronic post-thoracotomy pain, defined as pain persisting beyond three months and reported at the time of the interview. Results: A total of 56 patients were included in the analysis. Chronic pain was reported by 55.4% of the patients. Pain that interfered with daily activities and required medication use was reported by 51.5% of the patients. Thirty-three patients (57.9%) reported an NRS score > 3 during movement. Among patients with chronic pain, 64.7% reported self-medication without physician consultation, whereas only 11.8% sought medical advice for pain management. Conclusions: Chronic pain remains highly prevalent after thoracotomy and substantially interferes with daily functioning. A considerable proportion of patients self-manage their pain without medical supervision, underscoring the need for structured postoperative follow-up, early identification of high-risk patients, and individualized multimodal analgesic strategies to reduce the burden of chronic post-thoracotomy pain. Full article

Non-small cell lung cancer (NSCLC) accounts for approximately 85% of lung cancers, and surgical resection is the gold-standard treatment for resectable disease. Minimally invasive surgery (MIS), which includes video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS), has emerged as an alternative option to thoracotomy, with the aim of minimizing perioperative morbidity without compromising oncological efficacy. This narrative review evaluates long-term oncological outcomes (overall survival (OS), disease-free survival (DFS) and recurrence-free survival (RFS)) in patients with NSCLC at different stages who underwent MIS. Retrospective and prospective studies, as well as meta-analyses, are included. VATS has shown comparable and, in many cases, superior oncological outcomes compared to open surgery, with more evident benefits in the early stages of the disease. Although mainly in retrospective studies, RATS has demonstrated efficacy in terms of oncological outcomes comparable to open surgery, even in advanced stages or complex resections. With regard to the direct comparison between VATS and RATS, the two MIS techniques have shown similar OS rates, albeit some prospective data and meta-analyses suggest a potential DFS advantage for RATS. MIS is a safe and effective surgical approach in terms of oncological outcomes for resectable NSCLC; nevertheless, it will be necessary to await the results of further randomized studies currently ongoing to better define the long-term benefits of each technique. Full article

Background: Intrapericardial extralobar pulmonary sequestration (ELPS) is an exceptionally rare congenital malformation. The location may mimic neoplastic lesions and poses diagnostic and surgical challenges. We present a new case and a systematic review of the literature. Case Presentation: A 3-month-old male infant was referred for evaluation of a congenital intrathoracic mass suspected to be an extralobar sequestration. However, intrapericardial location was not recognized. MRI and CT demonstrated a circumscribed lesion with arterial supply from the right pulmonary artery. Thoracoscopic exploration was attempted but converted to sternotomy. The mass was excised en bloc. Histopathological analysis confirmed extralobar pulmonary sequestration with cystic components, consistent with a hybrid lesion. Postoperative recovery was uneventful. Methods: A systematic literature review was conducted according to PRISMA guidelines across PubMed, Scopus and Embase databases, including only histologically confirmed intrapericardial ELPS. Results: Ten cases were identified. Including the present case, eleven cases have been reported. Prenatal detection occurred in 54% of cases. Fetal demise occurred in two cases due to cardiac tamponade. Aberrant arterial supply originated from the pulmonary arteries in 54% of patients and venous drainage into the right atrium or superior vena cava in 45%. Surgery via sternotomy was performed in all cases with excellent outcomes. Conclusions: Intrapericardial ELPS is an exceptionally rare but surgically curable entity. Early recognition and complete resection are essential to prevent life-threatening complications. This systematic review highlights a consistent vascular pattern supporting its classification as a unique embryologic variant within the CPAM–sequestration spectrum. Full article

Background and Aims: Although combined general anesthesia and epidural analgesia are used in open surgery to promote rehabilitation and expectoration, as well as to prevent postoperative pulmonary complications, their effect in thoracoscopic esophagectomy remains unclear. This study aimed to address this issue. Patients and Methods: We enrolled 150 patients who underwent thoracoscopic esophagectomy between May 2017 and July 2025. Patient characteristics and postoperative outcomes, including maximum numerical rating scale (NRS) after surgery and pneumonia, were compared between the use and non-use of epidural analgesia. Epidural analgesia was not administered in patients using antithrombotic/anticoagulant drugs or in those with a history of thoracic spine surgery. Postoperative analgesia involved the scheduled administration of acetaminophen in all cases, with patient-controlled analgesia using opioids administered to the non-epidural analgesia group. Results: Epidural analgesia was administered to 113 patients (75.3%). The most common levels of epidural catheter placement were Th8/Th9 in 55 patients (36.7%) and Th7/Th8 in 41 patients (27.3%). Laparoscopy was performed in 129 patients (86.0%). Median NRS was five, and pneumonia occurred in 16 patients (10.7%). The epidural anesthesia group had a higher proportion of squamous cell carcinoma (88.5% vs. 73.0%, p = 0.024), lower lymphocyte counts (1680 vs. 2065, p = 0.020), diabetes (16.8% vs. 37.8%, p = 0.007), and hypertension (54.9% vs. 81.1%, p = 0.006), and circular stapler anastomosis (83.2% vs. 62.2%, p < 0.001). No significant differences were observed in the postoperative NRS, pneumonia, or length of postoperative hospital stay. Conclusions: There was no significant difference in the postoperative NRS and pneumonia between those with or without epidural analgesia in thoracoscopic esophagectomy. Full article

Background: Recent trials, including JCOG0802/WJOG4607L and CALGB140503, have confirmed the oncological adequacy of segmentectomy for early-stage non-small-cell lung cancer (NSCLC). This shift emphasizes the preservation of pulmonary function and minimal invasiveness. Robot-assisted thoracic surgery (RATS) offers enhanced anatomical precision and potentially improves segmentectomy outcomes. Methods: We reviewed the current evidence comparing sublobar resection and lobectomy for early-stage NSCLC, focusing on RATS segmentectomy. Clinical trials, perioperative and long-term outcomes, technical innovations, and patient selection criteria were analyzed. Comparative data among RATS, video-assisted thoracoscopic surgery (VATS), and open approaches were synthesized, including the emerging roles of AI and 3D imaging. Results: Segmentectomy yields survival outcomes equivalent or superior to lobectomy for stage IA peripheral NSCLC ≤2 cm, with better pulmonary function despite higher locoregional recurrence. RATS enhances visualization, dexterity, and ergonomics, thereby enabling precise dissection and lymph node assessment. Compared to VATS and open surgery, RATS shows lower conversion rates, reduced pain, and comparable oncological control. Innovations, such as indocyanine green imaging, 3D modeling, and AI-guided navigation, support margin accuracy and personalized care. Conclusions: Segmentectomy has redefined the surgical standards for early-stage NSCLC. RATS maximizes the minimally invasive benefits by combining oncological safety and functional preservation. Its technical precision facilitates complex resections and integration with digital planning tools to advance personalized thoracic surgery. RATS represents the next evolution of minimally invasive thoracic surgery, redefining the balance between oncological safety and functional preservation in early-stage NSCLC. Full article

Background/Objectives: Minimally invasive thoracic surgery has evolved rapidly, with uniportal video-assisted thoracoscopic surgery (U-VATS) and robotic-assisted thoracic surgery (RATS). Biportal-RATS (Bi-RATS) has emerged as a hybrid technique, combining robotics advantages with the reduced invasiveness of U-VATS. The aim of this study was to evaluate the safety, perioperative outcomes, lymphadenectomy, and postoperative quality of life (QoL) of Bi-RATS compared with U-VATS for lung resections. Methods: This single-center, observational cohort study included 130 consecutive patients undergoing anatomical lung resection between December 2021 and December 2024. Baseline and perioperative characteristics, including complications, chest drain duration, hospital stay, and lymph node yield, were analyzed. Health-related QoL was assessed preoperatively and 6 months postoperatively using the EQ-5D-5L questionnaire and EQ-VAS. Propensity score matching (PSM) at a 1:1 ratio was performed to minimize selection bias, obtaining 32 patients per group. Results: After PSM, the baseline characteristics were comparable between groups. Operative time was longer with Bi-RATS (221.3 ± 84.5 vs. 119.3 ± 53.4 min, p < 0.001). No significant differences were observed in postoperative complications, drain duration, or hospital stay. Bi-RATS seemed to be associated with a higher lymph node yield, particularly in segmentectomies. At 6 months, the overall EQ-VAS was comparable between techniques (78.9 U-VATS vs. 78.1 Bi-RATS; p = 0.832), while among the EQ-5D-5L dimensions, only mobility favored Bi-RATS (p = 0.045). Conclusions: Bi-RATS appears safe and effective, with perioperative outcomes and overall EQ-VAS comparable to those of U-VATS 6 months after surgery. These findings suggest that Bi-RATS may represent a valuable evolution of minimally invasive thoracic surgery. Full article

Background: Prenatal detection of congenital lung lesions has increased with improved imaging. These abnormalities are safely treated with thoracoscopic lobectomy. We implemented an enhanced recovery after surgery (ERAS) protocol to standardize care and aim to evaluate its safety and efficacy compared to a non-ERAS cohort. Methods: A single-center retrospective chart review was conducted for twenty patients (n = 10 ERAS, n = 10 non-ERAS) undergoing thoracoscopic lobectomy from 2014–2024. Results: ERAS patients were generally younger at the time of surgery (ERAS: 4.25 ± 2.76 months vs. non-ERAS: 6.45 ± 6.78 months, p = 0.17). Postoperative length of stay was shorter in ERAS (1.77 ± 0.60 days) vs. non-ERAS patients (5.25 ± 3.79 days, p = 0.03) as well as chest tube duration (ERAS: 1.44 ± 0.73 days vs. non-ERAS 3.64 ± 2.38 days, p = 0.01). ERAS patients received lower amounts of opioid analgesics compared to non-ERAS (p = 0.0046). Use of the ERAS protocol also decreased cost for the healthcare system compared to non-ERAS patients (p = 0.0037). ERAS patients had no reintubations or prolonged air leaks (defined as >48 h), compared to four reintubations (p = 0.04) and three prolonged air leaks (p = 0.07) in the non-ERAS group. Crucially, there were no complications in the ERAS group, whereas five non-ERAS patients experienced Clavien–Dindo level III (one IIIa, two IIIb, two IVa) complications (p = 0.02). Conclusions: Our preliminary findings demonstrate the successful integration of a novel ERAS protocol in pediatric thoracoscopic lobectomies and its efficacy in reducing standard post-operative recovery times without an increased rate of complications. Earlier discharge in the ERAS group constitutes less healthcare burden with improved resource utilization and less family, work, and social disruption. Full article

Precise intraoperative identification of the canine thoracic duct remains challenging due to anatomical variability and limited visualization. This exploratory cadaveric feasibility study aimed to describe the technical applicability of fluorescence-guided thoracic duct mapping using video-assisted thoracoscopy (VATS) and robot-assisted thoracoscopy (Versius™ system). Four adult Beagle cadavers underwent bilateral thoracoscopic exploration after intranodal injection of indocyanine green (ICG, Verdye^®, 0.05 mg/kg; 0.5 mL). Near-infrared (NIR) fluorescence imaging enabled real-time visualization of the thoracic duct and its branches. Fluorescence quality was quantitatively characterized using signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and contrast resolution (CR) calculated from standardized image frames. Both approaches achieved successful duct identification in all cadavers. VATS provided brighter overall fluorescence, whereas the robotic-assisted approach offered stable imaging, enhanced instrument dexterity, and improved duct-to-background discrimination. These findings confirm the feasibility of fluorescence-guided thoracic duct identification using both minimally invasive modalities in canine cadavers. The standardized assessment of optical parameters proposed here may support future in vivo studies to optimize imaging protocols and evaluate the clinical impact of fluorescence-guided thoracic duct surgery in dogs. Full article

Background: Thoracic paravertebral block (TPVB) is an established component of multimodal analgesia and enhanced recovery pathways following thoracoscopic lung resection. A surgeon-performed, thoracoscopy-guided approach has been proposed to improve intraoperative workflow, but high-quality comparative data are limited. Methods: In this single-center, randomized, non-inferiority trial, adult patients undergoing thoracoscopic lobectomy or segmentectomy received either thoracoscopy-guided TPBV (T-TPVB) conducted by surgeons or ultrasound-guided TPBV (U-TPVB) conducted by anesthesiologists. Blocks were performed at the end of surgery at the T4 and T7 vertebra levels, using 10 mL of 0.5% ropivacaine per level. The primary outcome was dynamic pain during coughing at 1–6 h postoperatively (visual analog scale, VAS). Secondary outcomes included resting/dynamic pain scores, opioid consumption over 48 h, block-related complications, and procedural time. Results: Seventy-three patients were included in the intention-to-treat analysis. Mean dynamic VAS scores at 1–6 h were 3.3 (T-TPVB) and 3.1 (U-TPVB), with a mean difference of 0.2 (95% CI: −0.3 to 0.7), meeting the non-inferiority criterion (margin 0.9). Secondary outcomes, including pain trajectories and opioid consumption, were comparable between groups. Procedural time was significantly shorter in the T-TPVB group, with no differences in complication rates. Conclusions: Surgeon-performed thoracoscopy-guided TPVB was non-inferior to the standard ultrasound-guided technique for early postoperative pain after thoracoscopic lung resection. Both methods provided comparable analgesic efficacy and safety profiles, while T-TPVB significantly reduced procedural time. This approach may support streamlined perioperative workflows and optimize enhanced recovery protocols in thoracic surgery. (Trial registration number, KCT0006471). Full article

Objective: The optimal extent of segmentectomy for clinical T1N0 non-small cell lung cancer (NSCLC) remains unclear. This study compared perioperative and oncological outcomes of video-assisted thoracoscopic surgery (VATS) single segmentectomy (SS) versus multiple segmentectomy (MS) for tumors ≤ 3 cm. Methods: This single center study retrospectively analyzed all consecutive patients who underwent VATS anatomic segmentectomy for cT1N0 NSCLC between 2017 and 2022. Patient demographics, perioperative outcomes, and survival were compared between SS and MS groups. Results: In total, 334 patients underwent pulmonary segmentectomy: single in 211 (63%) and multiple in 123 patients (37%). In the SS group, 83 (39%) were simple and 128 (61%) complex segmentectomies; while in the MS group, 67 (54%) were simple and 56 (46%) were complex. Baseline characteristics were similar between groups. SS was associated with shorter operative time (117 vs. 132 min; p = 0.007), reduced length of drainage (1 vs. 3 days; p < 0.001), reduced hospital stay (5 vs. 6 days; p < 0.001), and lower atrial fibrillation (1.4% vs. 5.7%; p = 0.042). Total mean tumor size was 14.3 mm, with no statistical difference between groups (14.3 vs. 15.5 mm; p = 0.115). Surgical margins were larger in SS (median 13 vs. 11 mm; p = 0.038), while the number of lymph nodes dissected was similar. After a median follow-up of 30 months, no significant differences were observed in overall survival (OS) (94.5% vs. 90.7%) and disease-free survival (DFS) (83.2% vs. 79.1%). Conclusions: SS and MS provide equivalent short-term oncological outcomes in cT1N0 NSCLC ≤ 3 cm. SS may be preferred when adequate margins are achievable, offering equivalent oncologic outcomes with better perioperative recovery. Full article