Search Results (125)

The diagnostic evaluation of interstitial lung diseases (ILDs) remains challenging when clinical assessment and imaging findings are inconclusive. Although surgical lung biopsy has traditionally represented the diagnostic gold standard, its invasiveness and perioperative risks limit its applicability, particularly in patients with advanced disease or impaired respiratory reserve. This review aims to examine the evolving roles of transbronchial lung cryobiopsy (TBLC) and awake video-assisted thoracoscopic surgery (Awake VATS) within contemporary diagnostic pathways for ILD. A narrative review of the current literature was performed, focusing on studies evaluating the diagnostic performance, safety profiles, clinical indications, and complementary integration of TBLC and Awake VATS in patients with suspected ILD. Evidence from multidisciplinary ILD referral centers and recent guideline recommendations was critically analyzed. TBLC has progressively emerged as an appropriate first-line histological procedure in many ILD centers, providing a pooled diagnostic yield of approximately 80% with an acceptable safety profile. Awake VATS has refined the surgical approach by preserving spontaneous ventilation while maintaining high diagnostic accuracy. Current evidence suggests that these techniques should be considered complementary rather than competitive. A TBLC-first strategy, followed by selective surgical escalation when endoscopic sampling is non-diagnostic or insufficient, appears to achieve diagnostic accuracy comparable to upfront surgical biopsy while reducing complications, length of hospital stay, and overall patient burden. The choice between Awake VATS and conventional surgical biopsy should be individualized according to patient characteristics, institutional expertise, and available resources. TBLC and Awake VATS represent complementary tools within a multidisciplinary, personalized, and risk-adapted diagnostic framework for ILD. Their integrated use enables optimization of diagnostic accuracy while minimizing procedural invasiveness and improving patient safety, supporting a stratified approach to histological assessment in contemporary clinical practice. Full article

For perioperative analgesia in thoracic surgery, epidural anesthesia has long been considered the gold standard. However, as surgical techniques have become less invasive, interest in less invasive analgesic strategies has increased. According to the procedure-specific postoperative pain management (PROSPECT) guidelines published by the European Society of Regional Anesthesia in 2021, epidural anesthesia is no longer recommended as the method of choice for regional anesthesia in video-assisted thoracic surgery (VATS), and thoracic paravertebral block (TPVB) and erector spinae plane block (ESPB) are now recommended. Understanding the effectiveness and limitations of each regional technique is essential to facilitating appropriate anesthetic planning for individual cases. This narrative review summarizes current evidence regarding thoracic epidural anesthesia, TPVB, ESPB, serratus anterior plane block, and emerging intertransverse process block techniques for thoracic surgery. Full article

The rapid expansion of video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery (RATS) has reshaped thoracic surgical practice over the last two decades, offering reduced perioperative morbidity, shorter hospital stay, and oncological outcomes comparable to conventional thoracotomy in appropriately selected patients. Minimally invasive techniques now account for the majority of anatomical pulmonary resections in many high-volume centers and are being explored, in selected patients at experienced institutions, for increasingly complex procedures. This shift, however, raises a question that has received comparatively little attention: whether reduced trainee exposure to open thoracotomy may, over time, erode open thoracic surgical competence. As minimally invasive approaches become the institutional default, exposure to open surgery is declining, and the skills required to perform complex open resections or to manage intraoperative emergencies may become confined to a diminishing cohort of senior surgeons. In this narrative review, we examine the current boundaries of minimally invasive thoracic surgery, define the clinical scenarios in which open surgery remains indispensable—including bronchoplastic and angioplastic resections, post-induction hostile surgical fields, and unplanned conversion—and consider the implications of the ongoing paradigm shift for training, taking into account the substantial variability of thoracic surgical practice across different regions. We argue that open thoracic surgery is not an obsolete discipline but a foundational competence whose preservation may warrant deliberate attention through structured exposure, simulation, mentorship, and dedicated competence assessment. Throughout, we have sought to distinguish documented trends from reasonable concern and from speculative future risk, and we frame the central issue explicitly as a credible and foreseeable risk rather than a demonstrated decline. 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

Objectives: To evaluate the short-term safety (30-day and in-hospital morbidity and mortality) and technical feasibility of uniportal video-assisted thoracic surgery (U-VATS) for anatomical lung resection in octogenarians (≥80 years) compared with younger patients (<80 years) at a single center. Methods: Ninety consecutive patients undergoing U-VATS anatomical lung resections between January 2020 and January 2024 were retrospectively analyzed. Patients were stratified by age: 60 patients < 80 years and 30 octogenarians ≥ 80 years. Propensity score matching (nearest-neighbor, 1:2 ratio, caliper 0.2 SD) yielded a matched cohort of 60 patients (40 younger, 20 octogenarians) for comparative analysis. Results: After matching, standardized mean differences (SMD) were <0.25 for most covariates, indicating good balance. Octogenarians demonstrated lower FEV1 (75.2 ± 15.3% vs. 87.5 ± 18.2%, p = 0.012) and DLCO (68.4 ± 12.1% vs. 78.5 ± 14.3%, p = 0.009), consistent with age-related pulmonary changes. Charlson Comorbidity Index was higher (5.3 ± 1.2 vs. 3.8 ± 1.4, p = 0.001). Surgical parameters were comparable: operative time (143.80 ± 42.3 vs. 136.55 ± 38.7 min, p = 0.524), blood loss (median 80 [IQR 50–120] vs. 95 [IQR 60–130] mL, p = 0.742). Zero conversions occurred. Major complications (Clavien–Dindo ≥ 3) occurred in 10% vs. 0% (absolute risk difference 10%, 95% CI: −3.2% to 23.2%). No 30-day mortality. 90-day mortality: 5% vs. 0% (p = 0.333); one-year: 15% vs. 0% (p = 0.035). Conclusions: U-VATS is technically feasible in carefully selected octogenarians with comparable intraoperative parameters to younger patients. Postoperative recovery differed meaningfully, with higher delirium rates, longer hospitalization, and greater rehabilitation needs. One-year mortality was higher in octogenarians, reflecting competing comorbid risk rather than surgical harm. Residual imbalance in comorbidity burden and pulmonary reserve after matching limits causal inference. These hypothesis-generating findings support U-VATS in selected octogenarians when comprehensive geriatric assessment and structured delirium prevention guide perioperative management; validation in larger multicenter prospective studies is required. Full article

Background/Objectives: This study aimed to assess the safety and efficacy of lung surgery for the treatment of early-stage non-small cell lung cancer (NSCLC) in octogenarians, with a specific focus on the Uniportal-VATS approach, evaluating surgical outcomes and short-term oncological results within a precision medicine perspective. Methods: This retrospective, single-center study included octogenarian patients who underwent surgical treatment for early-stage NSCLC between January 2018 and March 2024. Among 1329 patients treated during the study period, 136 octogenarians were carefully evaluated by a multidisciplinary board and selected for surgical management. Results: The mean age was 82.41 ± 2.72 years, with a prevalence of men (63.2%). In 107 (78.7%) cases, lung resection was performed using the Uniportal-video-assisted thoracic surgery (U-VATS) approach. Overall, 71 lobectomies (52.2%) and 65 segmentectomies or wedge resections (47.8%) were performed, balancing oncological radicality with comorbidities. Only minor complications occurred, such as atelectasis (2.9%), atrial fibrillation (4.4%), pneumonia (1.5%), or air-leakage (2.2%). Factors significantly associated with postoperative complications included open approach (p = 0.014), lobectomy as the extent of resection (p = 0.008), and chronic obstructive pulmonary disease (COPD) (p = 0.010). On multivariable analysis, lobectomy remained the only independent predictor for postoperative complications (OR: 5.95, 95% CI [1.24–28.62], p = 0.026). In-hospital and 90-day mortality were null. The median length of hospital stay in octogenarians was 6 days and was significantly shorter in the Uniportal-VATS group compared with the open surgery one (p < 0.001). All patients were discharged home independently. One- and three-year overall survival rates were 88% and 71%, respectively. No risk factor was associated with mortality in our series. Conclusions: Lung surgery, particularly the Uniportal-VATS approach, appears to be a safe and effective treatment option for octogenarian patients with early-stage NSCLC, provided that patient selection is carefully based on individual clinical characteristics within a multidisciplinary framework based on individualized risk stratification. When feasible, sublobar resection should be preferred in order to minimize postoperative complications. Full article

Background and Objectives: Minimally invasive surgery (MIS) has become a cornerstone approach in cardiac surgery. A debate persists regarding the optimal aortic clamp occlusion strategy, with limited comparative data. The two principal strategies, which are transthoracic cross-clamping (TTCC) and endo-aortic balloon occlusion (EABO), offer distinct advantages, but comparative clinical data remain limited. This study compares the two techniques in terms of procedural safety and early outcome. Materials and Methods: This single-center retrospective study included consecutive adult patients undergoing elective MIS via video-assisted right mini-thoracotomy between 2012 and 2018 for mitral valve surgery. Tricuspid repair, atrial fibrillation and redo surgery were included in the final cohort. Aortic occlusion was performed with transthoracic cross-clamping (TTCC) or endo-aortic balloon occlusion (EABO). Primary endpoints were intra-operative complications and the rate of conversion to full sternotomy; secondary outcomes were overall mortality and Society of Thoracic Surgeons (STS)-defined comorbidities. Results: A total of 163 patients were analyzed (TTCC: n = 99, 60%; EABO: n = 64, 40%). While both techniques demonstrated equivalent safety profiles (overall mortality: 0%), EABO was associated with higher conversion to full sternotomy [(n = 7, 10.9%) vs. TTCC (n = 1, 1.3%), p = 0.016]. In a generalized estimation equations (GEE) model, no patient-level covariate predicted conversion, suggesting technical or procedural factors as the primary contributors. In addition, EABO was associated with longer cross-clamp time [median: 87 min (IQR: 73, 100) vs. TTCC median: 77 min (IQR: 65.5, 87.5), p = 0.03]. Stroke, acute kidney injury, respiratory failure, reoperation and wound infection did not differ significantly; also, hospital stay was similar between groups. Conclusions: In this single-center series, EABO showed longer operative times and a higher conversion rate to sternotomy, but without excess mortality or major complications. This may be correlated with the initial learning phase and redo cases; further comparison is needed to assess the benefits of EABO. Full article

Background: Lung cancer remains the leading cause of cancer-related morbidity and mortality. Despite advances in surgical management, economically disadvantaged patients experience inequalities in the receipt of treatments. We evaluated the association between socioeconomic status (SES) and type of surgery: robotic-assisted thoracic surgery (RATS), video-assisted thoracic surgery (VATS), and open thoracotomy. Methods: Data came from the National Cancer Database (2015–2022) and included Stage 0–IIIa NSCLC patients. SES was measured by quartiles of median household income in the patient’s zip code. Adjusted multinomial logistic regression was used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Results: Among 84,931 patients with a mean age of 67.8 years, 38.4% underwent open thoracotomy, 33.3% underwent VATS, and 28.2% underwent RATS. Patients residing in the low-income areas (<$46,277) were significantly less likely to undergo RATS (aOR: 0.79, 95% CI: 0.77–0.86) or VATS (aOR: 0.62, 95% CI: 0.59–0.66) compared to patients living in high-income areas (≥$74,063). Community hospitals were less likely to provide RATS (aOR: 0.32, 95% CI: 0.29–0.35) or VATS (aOR: 0.58, 95% CI: 0.54–0.63) than academic centers. Conclusion: Socioeconomic disadvantage is associated with lower use of minimally invasive surgical approaches for NSCLC. Efforts to expand access to advanced surgical care may be necessary to reduce treatment disparities and improve outcomes. Full article

Background: Mounting evidence suggests that medical management may differ significantly between female and male patients. Despite studies showing increased sensitivity to pain, female patients receive less opioid analgesia compared to male patients after surgery. It is uncertain whether perioperative multimodal analgesia differs between sexes in thoracic surgery. Methods: A retrospective cohort study from January to July 2023 comparing multimodal analgesia and perceived pain in the early postoperative period between female and male patients after video-assisted thoracic surgery (VATS). The primary endpoint was the opioid demand in the post-anaesthesia care unit (PACU). Secondary outcomes included pain scores, regional anaesthesia and pain therapy by female, male or mixed teams. Results: Overall, 46.0% (n = 92) of the 200 included patients were female and 54% (n = 108) were male. Following VATS, the median piritramide demand was 9.0 [5.3 to 14.9] mg in female vs. 7.7 [4.5 to 12.9] mg in male patients (p = 0.35). Pain scores and regional anaesthesia were comparable between groups. In the early postoperative period, more opioids were administered overall and to female patients by all female anaesthesia teams, compared to mixed or all-male teams. Conclusions: The weight-adjusted dose of postoperative opioids did not differ between groups; neither did postoperative pain scores or the application of nerve blocks. The increased opioid demand in female patients was met by all female teams but not by all-male or mixed teams. Full article

Background: The heritage of occupational and environmental asbestos exposure in Piedmont, Italy, has resulted in an enduring diffuse pleural mesothelioma (DPM) epidemic. Our study aimed to investigate the accuracy of Pleural biopsy (PB) via thoracoscopy (or video-assisted thoracic surgery—VATS) and analyze the diagnostic path of patients who experienced an initial DPM misdiagnosis. Methods: Patients who underwent PB by VATS for suspected DPM from 2004 to 2013 were analyzed. The Registry of Malignant Mesothelioma (RMM) records were examined to cross-check incident cases and identify misdiagnosed DPM. The sensitivity and specificity of the initial PB assessment versus the final classification of cases by RMM were evaluated. Results: Data from 552 patients were analyzed, and DPM was diagnosed in 178 cases (32%). Sensitivity and specificity were 93% and 100%, respectively. The number of false-negative PBs was 14 (2%). Of those, 10 (71%) had an initial diagnosis of chronic pleuritis, 3 (28.5%) were initially classified as mesothelial proliferation, and 1 had reactive mesothelial proliferation. All of them reported a history of asbestos exposure, and the correct diagnosis was reached after a median of 160 days. One- and four-year survival rates were 52% and 10% in DPM PB-positive cases and 50% and 19% in false-negative cases. Conclusions: When a strong clinical suspicion after a negative PB remains, iterative biopsy attempts should be considered, especially if a history of asbestos exposure is reported. In high-volume centers, the DPM misdiagnosis rate remains low, and future advancements in diagnostic technologies could further increase the accuracy and efficacy of histologic diagnosis. 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

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: In ectopic adrenocorticotropic hormone (ACTH) syndrome, locating the responsible lesion is often challenging. Case Presentation: A 68-year-old woman was transferred to Nara Medical University hospital for a detailed investigation of her ACTH-dependent Cushing’s syndrome. Because of hypercortisolism-induced immunosuppression, she subsequently developed severe Nocardia pneumonia and was forced to temporarily depend on noninvasive positive pressure ventilation (NIPPV). Intravenous antifungal agents and antibiotics were administered, resulting in significant symptomatic improvement. Metyrapone was administered to suppress excessive cortisol. Contrast-enhanced magnetic resonance imaging of the pituitary revealed a 4 mm sized poorly enhanced area, and microadenoma was suspected. Although cavernous venous sampling was indispensable prior to trans-spheroidal surgery (TSS), this examination could not be performed because of the presence of deep vein thrombosis. TSS was performed for both diagnostic and therapeutic purposes, but hypercortisolism did not improve. Moreover, immunohistochemical findings of the specimen revealed nonfunctional pituitary tumor. Methods: We re-evaluated the responsible lesion causing ACTH-dependent Cushing’s syndrome. Fluorine-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) revealed weak and abnormal FDG uptake in the right pericardium, but the possibility of nonspecific uptake could not be ruled out. However, gallium-68 1,4,7,10-tetraazacyclododecane-N,N′,N′′,N′′′-tetraacetic-acid-D-Phe¹-Tyr³-octreotide (⁶⁸Ga-DOTATOC)-PET demonstrated the same degree of abnormal uptake; therefore, a functional pulmonary tumor was strongly suspected. Results: Video-Assisted Thoracic Surgery (VATS) was performed, and histopathological findings of the specimen revealed a neuroendocrine tumor with positive ACTH staining. After VATS, ACTH and cortisol levels were normalized. Conclusions: Here, we report a case of ACTH-dependent Cushing’s syndrome caused by a lung neuroendocrine tumor, in which ⁶⁸Ga-DOTATOC PET was helpful in detecting the functional tumors. 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