Publications by authors named "Diego González-Rivas"

165 Publications

Sleeve lobectomy after neoadjuvant chemoimmunotherapy/chemotherapy for local advanced non-small cell lung cancer.

Transl Lung Cancer Res 2021 Jan;10(1):143-155

Department of Thoracic Surgery, the First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Guangzhou, China.

Background: Sleeve lobectomy has been reported to be a safe procedure after neoadjuvant chemotherapy. We aim to evaluate the oncological and surgical outcomes of neoadjuvant chemoimmunotherapy (IO+C) for local advanced non-small cell lung cancer (NSCLC) patients who underwent sleeve lobectomy.

Methods: NSCLC patients that underwent sleeve lobectomy between December 2016 and December 2019 were retrospectively included. Patients were divided into two groups: neoadjuvant IO+C and chemotherapy. Oncological, intraoperative and postoperative variables were compared.

Results: In total, 20 patients underwent sleeve lobectomy after neoadjuvant IO+C (n=10) or chemotherapy (n=10). In the neoadjuvant IO+C group, 8/10 (80%) patients achieved a partial response (PR), 1/10 (10%) patients had a complete pathological response (CPR), and 5/10 (50%) patients achieved a major pathological response (MPR). In the neoadjuvant chemotherapy group, only 3/10 (30%) patients had PR, and 3/10 (30%) patients achieved MPR. No complications were found in the neoadjuvant IO+C group, 1 chylothorax occurred in the neoadjuvant chemotherapy group. Other peri- and postoperative outcomes were similar: bleeding volume (365.00 347.50 mL; P=0.267), operation time (291.88 287.50 min; P=0.886), chest tube duration (5.40 5.00 day; P=0.829), total drainage volume (815.50 842.50 mL; P=0.931) and the length of hospital-stay (7.00 6.56 day; P=0.915). In addition, less N1 (average number 4.70 7.40) and N2 (average number 9.80 vs. 20.10) lymph nodes were acquired in the neoadjuvant IO+C group than the neoadjuvant chemotherapy group. The number of lymph nodes positive for tumor cells was also less in the neoadjuvant IO+C group than the neoadjuvant chemotherapy group, both in N1 (0.40 1.60) and N2 (0.10 1.30). The positive lymph node ratio (LNR) was lower in the neoadjuvant IO+C group, both in N1 (0.05 0.15) and N2 (0.01 0.09). A greater destruction on elastic fiber of the blood vessels, vascular wall degeneration, fibrinoid necrosis and fibrosis, and greater pulmonary interstitial exudation were found in neoadjuvant IO+C patients compared to the neoadjuvant chemotherapy patients.

Conclusions: Sleeve lobectomy for advanced NSCLC following IO+C is feasible, although the operations become more complex, neoadjuvant IO+C did not delay postoperative recovery.
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http://dx.doi.org/10.21037/tlcr-20-778DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7867787PMC
January 2021

Current role of uniportal video-assisted thoracic surgery for lung cancer treatment.

J Clin Transl Res 2020 Oct 2;6(4):135-144. Epub 2020 Sep 2.

Department of Thoracic Surgery, Uniportal VATS Training Program, Shanghai Pulmonary Hospital, Tongji University, Shanghai, China.

The use of video-assisted thoracic surgery (VATS) as an approach for early-stage lung cancer treatment has revealed benefits compared to open surgery by minimizing trauma to the patients. This trend has brought the evolution of VATS to less and less invasive methods, eventually leading to the development of Uniportal VATS (UniVATS) technique. This new approach has shown to be resourceful, proving its feasibility even for complex oncological procedures. Furthermore, data is starting to express some benefits over multiport VATS, thus spurring on its development towards newer and more complex procedures. It is also been adopted by the surgical community achieving fast evolution and worldwide diffusion. Here, we review the evolution of UniVATS, its current state of evidence, some basic technical aspects, the present role it has in lung cancer treatment and the ongoing development of the technique.

Relevance For Patients: This article could help patients to understand how the UniVATS technique developed as part of the evolution of VATS, sharing its benefits and indications. Furthermore, patients would be able to understand technical aspects and the current applications of UniVATS for lung cancer treatment.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7837737PMC
October 2020

Uniportal versus multiportal video-assisted thoracoscopic surgery does not compromise the outcome of segmentectomy.

Eur J Cardiothorac Surg 2020 Nov 24. Epub 2020 Nov 24.

Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.

Objectives: The goal of this study was to compare the feasibility and safety of uniportal thoracoscopic segmentectomy (UTS) with that of multiportal thoracoscopic segmentectomy (MTS).

Methods: From January 2014 to December 2015, a total of 1056 patients who underwent thoracoscopic segmentectomy were identified, including 375 and 681 who had simple and complex segmentectomies, respectively. A propensity matched analysis was applied to compare perioperative indicators. Survival outcomes, which included disease-free survival and overall survival, were assessed by Kaplan-Meier estimates and Cox hazards regression analysis.

Results: Propensity matching generated 454 paired patients for the UTS and MTS cohorts; the perioperative results were comparable. Survival analysis indicated that the surgical approach (UTS versus MTS) was not an independent risk factor in either disease-free survival (P = 0.247) or overall survival (P = 0.870) of patients with invasive adenocarcinoma. A shorter operative time was observed in patients who had a UTS (P < 0.001) or an MTS (P = 0.011) via a simple segmentectomy compared with those who had a complex segmentectomy. Moreover, 147 and 266 corresponding cases were selected to compare the UTS and MTS in the simple and complex segmentectomy groups, respectively. MTS showed slightly longer operative times (119 vs 108 min; P = 0.007) and drainage duration (P = 0.010) in the simple segmentectomy group. In contrast, UTS was associated with statistically longer operative times (141 vs 133 min; P = 0.016) in the complex segmentectomy group.

Conclusions: Although minor differences could be found in the simple and complex segmentectomy groups, respectively, these results were clinically irrelevant. Our study supports UTS as a feasible and safe surgical technique.
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http://dx.doi.org/10.1093/ejcts/ezaa372DOI Listing
November 2020

Uniportal video-assisted thoracoscopic lung sparing tracheo-bronchial and carinal sleeve resections.

J Thorac Dis 2020 Oct;12(10):6198-6209

Thoracic Surgery Department, Tongji University Affiliated Shanghai Pulmonary Hospital, Shanghai, China.

Pathology arising from the intrathoracic portion of the trachea (distal trachea), the carina and the main bronchi is usually neoplastic and is mainly treated with surgery. Resection of the intrathoracic portion of the trachea, the carina and the main bronchi for neoplastic lesions does not necessitate lung resection and is traditionally being conducted via open surgery. Video-assisted thoracic surgery (VATS) is witnessing an exponential growth and is the treatment of choice for early-stage non-small cell lung cancer (NSCLC). The experience accumulated over the past two decades along with the introduction of reliable and ergonomic technology, has led to the expansion of its indications. In this article we provide a detailed description of lung sparing distal tracheal, carinal and main bronchi resection for primary neoplasms of the airway, without involvement of the lung, with the uniportal video-assisted technique. The chest is entered through the fourth intercostal space, mid-axillary line. Dissection of the paratracheal space anteriorly, the tracheoesophageal groove posteriorly and the subcarinal space and division of the azygos arch are essential to mobilize the distal trachea and carina. Lateral dissection should be avoided beyond the points of division of the airway, as it may hinder the blood supply to the anastomosis. Any tension to the anastomosis should be relieved by release maneuvers. Ventilation is achieved through an endobronchial catheter, inserted into the left main bronchus through which a high-frequency jet ventilation catheter can be also inserted through it. The rationale of applying a minimally invasive technique for the conduction of tracheal and carinal resections, is to exploit its advantages, namely less pain, earlier mobilization and lower morbidity. Uniportal video-assisted resections of the distal trachea, carina and the main bronchi, are safe when conducted by experienced surgical and anesthetic teams.
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http://dx.doi.org/10.21037/jtd.2020.04.05DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7656374PMC
October 2020

Uniportal video-assisted thoracoscopic thymectomy: the glove-port with carbon dioxide insufflation.

Gland Surg 2020 Aug;9(4):879-885

Unit of Thoracic Surgery, AOU Ospedali Riuniti, Ancona, Italy.

Background: Since 2004, uniportal video-assisted thoracic surgery (VATS) approach was progressively widespread and also applied in the treatment of thymoma, with promising results. We report the first series of patients who undergone uniportal VATS thymectomy using a homemade glove-port with carbon dioxide (CO) insufflation. The aim of this article is to analyze the safety and feasibility to perform an extended thymectomy (ET).

Methods: A prospective, single-centre, short-term observational study including patients with mediastinal tumours undergoing scheduled uniportal VATS resection using a glove-port with CO. Operations were performed through a single incision of 3.5 cm at the fifth intercostal space, right or left anterior axillary line. A 5 mm-30° camera and working instruments were employed through a glove-port with CO.

Results: Thirty-eight patients (20 men; mean age 61.6 years) underwent ET between September 2016 and October 2019. Thirteen patients had a history of Myasthenia Gravis (MG) with thymoma and 8 had incidental findings of thymoma. Additionally, 8 mediastinal cysts and 9 thymic hyperplasia were included. Mean diameter of the tumor was 5.1 cm (range, 1.6-14 cm) and mean operation time was 143 minutes. Mean postoperative drainage duration and hospital stay were 2.3 and 4.3 days, respectively. Mean blood loss was 41 mL. There was no occurrence of surgical morbidity or mortality. During the follow-up period (1-36 months), no recurrence was noted.

Conclusions: Our results suggest that uniportal VATS thymectomy through glove-port and CO is safe and feasible procedure, even with large thymomas. Furthermore, the glove-port system represents a valid, cheap and widely available alternative to the commercial devices usually adopted in thoracic surgery.
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http://dx.doi.org/10.21037/gs-19-521DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7475351PMC
August 2020

Outcomes of sleeve lobectomy versus pneumonectomy: A propensity score-matched study.

J Thorac Cardiovasc Surg 2020 Aug 14. Epub 2020 Aug 14.

Thoracic Surgery Department, Tongji University Affiliated Shanghai Pulmonary Hospital, Shanghai, China. Electronic address:

Objectives: To compare short- and long-term outcomes between sleeve lobectomy and pneumonectomy for lung cancer in a single center during a 15-year period.

Methods: One thousand nine hundred eighty-one patients who underwent either a sleeve lobectomy (n = 964; 48.7%) or a pneumonectomy (n = 1017; 51.3%) from January 2003 to December 2017 at the Shanghai Pulmonary Hospital, were matched according to a propensity score to produce 2 groups of 665 patients each. The study period was divided into 3 5-year subperiods.

Results: Sleeve lobectomy was associated with a lower 30- and 90-day mortality (0.60% and 0.90% vs 1.5% and 3.91%; P = .177 and P = .001, respectively, after matching), lower morbidity (4.36% vs 8.16%; P = .005 before matching, 3.61% vs 8.72%; P < .001 after matching), improved 5-year survival (62.7% vs 43.1%; P < .001 before matching and 61% vs 44.7%; P < .001 after matching), and 5-year disease-free survival after matching (56.6% vs 46.2%; P < .001). The sleeve lobectomy to pneumonectomy ratio increased by 78%, whereas 90-day mortality decreased by 66.81% between the first and the last subperiods.

Conclusions: Sleeve lobectomy is associated with improved short- and long-term outcomes and should be the resection of choice for centrally located lung cancers, when feasible.
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http://dx.doi.org/10.1016/j.jtcvs.2020.08.027DOI Listing
August 2020

Uniportal VATS approach to sub-lobar anatomic resections: literature review and personal experience.

J Thorac Dis 2020 Jun;12(6):3376-3389

Thoracic Surgery Department, Tongji University Affiliated Shanghai Pulmonary Hospital, Shanghai 200433, China.

Surgical scientific literature contains relatively little information regarding the surgical outcomes of anatomic sublobar resections performed with the uniportal video-assisted thoracoscopic surgery (U-VATS) technique. This paper attempts to evaluate the role of U-VATS segmentectomies in the landscape of a minimally invasive approach to the treatment of early stage non small cell lung cancer (NSCLC).
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http://dx.doi.org/10.21037/jtd.2020.01.12DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7330759PMC
June 2020

Uniportal video-assisted thoracoscopic carinal resections: technical aspects and outcomes.

Eur J Cardiothorac Surg 2020 08;58(Suppl_1):i58-i64

Department of Thoracic Surgery, Regional Clinic Hospital, Tyumen, Russia.

Objectives: Important benefits in uniportal video-assisted thoracoscopic surgery (VATS) for lung cancer have recently been achieved. However, the use of this technique for complex sleeve procedures is limited. We describe the technical aspects of and patient outcomes following carinal resections using uniportal VATS.

Methods: Since 2015, 16 sleeve carinal resections, including 11 right pneumonectomies, 4 right upper lobectomies and 1 lung-sparing carinal resection, have been performed at the Regional Clinic Hospital, Tyumen, Russia.

Results: The mean surgical time was 215.9 ± 67.2 min (range 125-340 min). The mean blood loss volume was 256.3 ± 284.5 ml (range 50-1200 ml). There was 1 case of conversion to thoracotomy. The morbidity rate was 25%, and the mortality rate was 0%. The median overall survival was 38.6 ± 3.5 months.

Conclusions: The use of uniportal VATS for carinal resections in certain patients allows for radical resections with low rates of morbidity and mortality.
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http://dx.doi.org/10.1093/ejcts/ezaa120DOI Listing
August 2020

Standardized surgical technique for uniportal video-assisted thoracoscopic lobectomy.

Eur J Cardiothorac Surg 2020 08;58(Suppl_1):i23-i33

Department of Thoracic Surgery and Lung Transplant, Coruña University Hospital, A Coruña, Spain.

Summary: Uniportal video-assisted thoracoscopic surgery may be the approach for any thoracic procedure, from minor resections to complex reconstructive surgery. However, anatomical lobectomy represents its most common and clinically proven usage. A wide variety of information about uniportal video-assisted thoracoscopic lobectomies can be found in the literature and multimedia sources. This article focuses on updating the surgical technique and includes important aspects such as the geometric approach, anaesthesia considerations, operating room set-up, tips about the incision, instrumentation management and the operative technique to perform the 5 lobectomies. The following issues are explained for each lobectomy: anatomical considerations, surgical steps and technical advice. Medical illustrations and videos are included to clarify the text with the goal of describing a standard surgical practice.
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http://dx.doi.org/10.1093/ejcts/ezaa110DOI Listing
August 2020

An individualized immune prognostic signature in lung adenocarcinoma.

Cancer Cell Int 2020 7;20:156. Epub 2020 May 7.

2Department of Thoracic Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325035 Zhejiang People's Republic of China.

Background: Tumor immune infiltration is closely associated with clinical outcome in lung cancer. We aimed to develop an immune signature to improve the prognostic predictions of lung adenocarcinoma (LUAD).

Methods: We applied "Cell type Identification by Estimating Relative Subsets of RNA Transcripts" method to quantify the fraction of 22 leukocyte cells from six public microarray datasets. Four datasets from GPL570 were treated as the training cohort and two datasets from GPL96 and GPL10379 as the validation cohorts. An immune risk score (IRS) based on leukocyte cell fraction was established by least absolute shrinkage and selection operator cox regression model.

Results: IRS consisting of 6 types of leukocytes was constructed in the training dataset. In the training cohort (520 patients), the IRS stratified patients into high-IRS group (215 patients) and low-IRS group (305 patients) with significant differences in overall survival (OS) (HR: 2.77, 95% CI 2.08-3.06). Multivariate analysis including age, gender, stage, IRS and tumor purity revealed the IRS to be an independent prognostic factor in all datasets (training: HR: 10.71, 95% CI 5.72-20.07; validation-1: HR 2.68, 95% CI 1.15-6.27; validation-2: HR 3.71, 95% CI 1.33-10.33); all p < 0.05). IRS was significantly positively correlated to the expression levels of PD1, PDL1, CTLA and LAG3 (all p < 0.001). When integrated with clinical characteristics including stage and age, the composite immune and clinical signature presented with improved prognostic accuracy than IRS (mean C-index 0.66 vs. 0.60).

Conclusions: The proposed immune-clinical signature could predict OS in patients with LUAD effectively.
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http://dx.doi.org/10.1186/s12935-020-01237-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7206750PMC
May 2020

Perioperative outcomes of robot-assisted vs video-assisted and traditional open thoracic surgery for lung cancer: A systematic review and network meta-analysis.

Int J Med Robot 2020 Oct 22;16(5):1-14. Epub 2020 Jun 22.

Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.

Background: The superiority of robot-assisted thoracic surgery (RATS) over video-assisted thoracic surgery (VATS) and thoracotomy remains controversial for lung cancer.

Methods: A network meta-analysis (NMA) and pairwise meta-analysis (PMA) were performed to evaluate the perioperative outcomes using five databases.

Results: Thirty-two studies involving 6593 patients were included for analysis. The NMA showed that RATS had similar operative time, conversion rate to thoracotomy, number of lymph node, postoperative morbidity, and length of hospital stay with VATS, except for lower 30-day mortality. Compared with thoracotomy, longer operative time and shorter hospital stay were observed in RATS, but no significant difference was observed in number of lymph node, postoperative morbidity, and 30-day mortality in both NMA and PMA. In lobectomy/segmentectomy subgroup, all outcomes, except for operative time of RATS vs VATS and number of lymph node, were similar with overall analyses.

Conclusions: RATS had comparable perioperative outcomes with VATS and open surgery.
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http://dx.doi.org/10.1002/rcs.2123DOI Listing
October 2020

Comparison of video-assisted thoracoscopic surgery with thoracotomy in bronchial sleeve lobectomy for centrally located non-small cell lung cancer.

J Thorac Cardiovasc Surg 2021 02 25;161(2):403-413.e2. Epub 2020 Mar 25.

Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China. Electronic address:

Objectives: The aim of this study was to investigate the adequacy of bronchial sleeve lobectomy by video-assisted thoracoscopic surgery in perioperative outcomes and its oncological efficacy by comparing with thoracotomy in a balanced population.

Methods: A total of 363 patients who received bronchial sleeve lobectomy for non-small cell lung cancer from January 2013 to December 2017 were included and placed in the thoracotomy (n = 251) and video-assisted thoracoscopic surgery (n = 112) groups. Statistical analyses were performed to compare patients' demographics, perioperative outcomes, and survival between the 2 groups.

Results: A total of 116 thoracotomy cases were matched with 72 video-assisted thoracoscopic surgery cases by propensity score. Compared with thoracotomy, patients in the video-assisted thoracoscopic surgery group after matching had less intraoperative blood loss (P < .01) and length of postoperative hospital stay (P < .01), duration of chest tube drainage (P < .01), and intensive care unit stay (P = .03) despite comparable operative time, complication rate, and 30- to 90-day mortality rate. The overall survival and recurrence-free survival were similar in patients who received sleeve lobectomy by thoracotomy and video-assisted thoracoscopic surgery (log-rank, P = .24 and .20, respectively) at 3 years. Although advanced TNM stage was independently associated with worse overall survival and recurrence-free survival in multivariable analysis, older age was only predictive for worse overall survival (hazard ratio, 1.04; 95% confidence interval, 1.01-1.07; P = .02). Body mass index was also found be a predictive factor (overall survival: hazard ratio, 0.93; 95% confidence interval, 0.86-0.99, P = .03; recurrence-free survival: hazard ratio, 0.93; 95% confidence interval, 0.87-0.99, P = .02).

Conclusions: With appropriate patient selection and continued experience, video-assisted thoracoscopic surgery appears to be safe in the short-term perioperative period and does not appear to comprise oncologic outcomes in performing sleeve lobectomy.
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http://dx.doi.org/10.1016/j.jtcvs.2020.01.105DOI Listing
February 2021

Uniportal video assisted thoracoscopy versus open surgery for pulmonary hydatid disease-a single center experience.

J Thorac Dis 2020 Mar;12(3):794-802

Department of Cardiothoracic Surgery, Makassed Charitable Society Hospital, East Jerusalem, Palestine.

Background: Although rare in the Western world, the incidence of hydatid disease is still prevalent and strikingly endemic among the Palestinians. Until 2017, surgical treatment of lung pathologies was performed through the traditional incision (open thoracotomy). Uniportal video-assisted thoracoscopic surgery (VATS) approach has recently been applied in the cases of the pulmonary hydatid cysts with very satisfactory results.

Methods: Between January 2010 and January 2019, 39 patients with pulmonary HC disease have been surgically treated. The cases divided into two cohorts: operations performed by thoracotomy classified as group A, (n=16). Operations performed by uniportal VATS classified as group B, (n=23). Prospectively collected data was analysed retrospectively, and the results compared between both groups.

Results: No significant statistical differences were noticed in terms of demographics and comorbidity. Laboratory tests were similar except haemoglobin level, which was higher in group A (P=0.001). Despite that, blood transfusion was higher in group A (P=0.016). Moreover, operation time was longer in group A (P=0.000). Chest drainage remained longer in group A (P=0.077). The level of postoperative pain was significantly higher in group A certainly in POD 1 (P=0.000). Patients in group B discharged earlier from the hospital (P=0.011) and experienced lower complications (P=0.060). No significant difference in length of ICU stay. Neither recurrence nor 30-day mortality recorded in either group.

Conclusions: Uniportal VATS can be safely applied for pulmonary hydatidosis. It also seems to have a preference in several aspects compared to open Thoracotomy approach.
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http://dx.doi.org/10.21037/jtd.2019.12.73DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7139009PMC
March 2020

Novice training: The time course for developing competence in single port video-assisted thoracoscopic lobectomy.

Medicine (Baltimore) 2020 Mar;99(12):e19459

, Coruña University Hospital.

The competency in video-assisted thoracoscopic (VATS) lobectomy is expected to be achieved after surgeons practiced 30 to 50 cases according to previous reports. Does single port video-assisted thoracoscopic (SPVATS) lobectomy have a steeper learning curve and being harder to perform correctly, leading to long development times and high defect rates?From January, 2014 to February, 2017, 8 individual surgeons (3 were novices, 5 were pioneers in SPVATS surgery) submitted their cases chronologically to evaluate the learning curve of SPVATS lobectomy. Operating time (OT) was set as a surrogate marker for surgical competency. Postoperative outcomes and OT between the 2 groups were compared using propensity score matching (1:1 nearest neighbor). The learning curve for OT was evaluated using the cumulative sum (CUSUM) method.In the entire study cohort, a total of 356 cases were included (93 in junior consultant group [group A], 263 in senior consultant group [group B]). There were no significant differences between the 2 groups in operative time, conversion rate, postoperative complication rate, 30 and 90 days mortality rate. After propensity-score matching (86 pairs), operative time was longer in group A (214.33 ± 62.18 vs 183.62 ± 61.25 minutes, P = .001). Two-year overall survival rate was similar among 2 groups (P = .409). Competency was reached after junior surgeon completed 30th case of SPVATS lobectomy.SPVATS lobectomy is safe for the novice surgeon who wants to adopt this new surgical approach under well-developed training program. The learning curves for competence in SPVATS lobectomy are similar to VATS lobectomy in our series.
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http://dx.doi.org/10.1097/MD.0000000000019459DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7220107PMC
March 2020

Technical aspects of uniportal video-assisted thoracoscopic double sleeve bronchovascular resections.

Eur J Cardiothorac Surg 2020 08;58(Suppl_1):i14-i22

Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.

Double sleeve, bronchial and vascular reconstructions are challenging procedures indicated for centrally located tumours to avoid pneumonectomy. Traditionally, these resections have been performed by thoracotomy, but thanks to advances in imaging systems, better surgical instruments and the gained experience in video-assisted thoracic surgery (VATS), the scenario now is different. During the last decade, we have seen a rapid evolution of the uniportal VATS technique from simple lobectomies to advanced double sleeve bronchovascular procedures and carinal resections. The advantages of VATS over open surgery for major lung resections in terms of postoperative pain and morbidity, length of hospital stay and quality of life have prompted experienced surgeons to adopt uniportal VATS for cases requiring a sleeve resection. However, when a double bronchial and vascular sleeve resection is required, the adoption rate of minimally invasive surgery is still very low even for very experienced VATS surgeons. The difficulty of tumour mobilization, complexity of the suturing technique and the concern about possible uncontrolled massive bleeding during VATS are the main reasons for this low rate of adoption. In this article, we describe the technical aspects and tricks of this procedure when it is done by the uniportal VATS approach.
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http://dx.doi.org/10.1093/ejcts/ezaa037DOI Listing
August 2020

International expert consensus on the management of bleeding during VATS lung surgery.

Ann Transl Med 2019 Dec;7(23):712

Division of Thoracic Surgery, Sun Yat-Sen Cancer Center, Taipei, Taiwan, China.

Intraoperative bleeding is the most crucial safety concern of video-assisted thoracic surgery (VATS) for a major pulmonary resection. Despite the advances in surgical techniques and devices, intraoperative bleeding is still not rare and remains the most common and potentially fatal cause of conversion from VATS to open thoracotomy. Therefore, to guide the clinical practice of VATS lung surgery, we proposed the International Interest Group on Bleeding during VATS Lung Surgery with 65 experts from 10 countries in the field to develop this consensus document. The consensus was developed based on the literature reports and expert experience from different countries. The causes and incidence of intraoperative bleeding were summarised first. Seven situations of intraoperative bleeding were collected based on clinical practice, including the bleeding from massive vessel injuries, bronchial arteries, vessel stumps, and bronchial stumps, lung parenchyma, lymph nodes, incisions, and the chest wall. The technical consensus for the management of intraoperative bleeding was achieved on these seven surgical situations by six rounds of repeated revision. Following expert consensus statements were achieved: (I) Bleeding from major vascular injuries: direct compression with suction, retracted lung, or rolled gauze is useful for bleeding control. The size and location of the vascular laceration are evaluated to decide whether the bleeding can be stopped by direct compression or by ligation. If suturing is needed, the suction-compressing angiorrhaphy technique (SCAT) is recommended. Timely conversion to thoracotomy with direct compression is required if the operator lacks experience in thoracoscopic angiorrhaphy. (II) Bronchial artery bleeding: pre-emptive clipping of bronchial artery before bronchial dissection or lymph node dissection can reduce the incidence of bleeding. Bronchial artery bleeding can be stopped by compression with the suction tip, followed by the handling of the vascular stump with energy devices or clips. (III) Bleeding from large vessel stumps and bronchial stumps: bronchial stump bleeding mostly comes from accompanying bronchial artery, which can be clipped for hemostasis. Compression for hemostasis is usually effective for bleeding at the vascular stump. Otherwise, additional use of hemostatic materials, re-staple or a suture may be necessary. (IV) Bleeding from the lung parenchyma: coagulation hemostasis is the first choice. For wounds with visible air leakage or an insufficient hemostatic effect of coagulation, suturing may be necessary. (V) Bleeding during lymph node dissection: non-grasping en-bloc lymph node dissection is recommended for the nourishing vessels of the lymph node are addressed first with this technique. If bleeding occurs at the site of lymph node dissection, energy devices can be used for hemostasis, sometimes in combination with hemostatic materials. (VI) Bleeding from chest wall incisions: the chest wall incision(s) should always be made along the upper edge of the rib(s), with good hemostasis layer by layer. Recheck the incision for hemostasis before closing the chest is recommended. (VII) Internal chest wall bleeding: it can usually be managed with electrocoagulation. For diffuse capillary bleeding with the undefined bleeding site, compression of the wound with gauze may be helpful.
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http://dx.doi.org/10.21037/atm.2019.11.142DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6989967PMC
December 2019

Subxiphoid thymectomy with a double sternum retractor: a pilot study.

Gland Surg 2019 Dec;8(6):657-662

Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China.

Background: Our study aims to describe the experience of a single team in terms of the potential and benefits of subxiphoid thymectomy using a double sternum hook retractor.

Methods: From November 2016 to July 2018, 34 patients have been undergone subxiphoid thymectomy at our Department. Twenty patients were diagnosed with Masaoka Stage I-III thymomas, 12 with thymic hyperplasia or cysts of the thymus, 2 with thymic tumors. All patients underwent a chest computed tomography (CT) with enhancement. 18-Fludeoxyglucose positron emission tomography (FDG-PET) was performed when recurrence was suspected. Neurological examinations were set. Patients underwent video-assisted thoracoscopic surgery (VATS) subxiphoid thymectomy with a double sternum retractor. A retrospective analysis of clinical, perioperative data, and follow-up was performed. Incidence rates for death or recurrence were calculated. Average pain score (NRS scale), average mental health, and physical health scores (SF-12) were analyzed.

Results: Thirty-four patients (mean age 54; 12 men and 22 women) with thymic neoformation (from 1.0 cm × 1.0 cm × 1.0 cm to 14.0 cm × 9.0 cm × 4.5 cm) were enrolled. All patients underwent subxiphoid thymectomy. No mortality or recurrence was observed. Median follow-up time was 17.9 months (range, 2.2-23.3 months). The morbidity rate was 9.7 events per 100 person-years. Average pain scores after surgery and after follow-up were 1.7±0.4 and 0.1±0.4, respectively; average mental health and physical health scores on the SF-12 scale were 45.6±2.4 and 33.6±2.4, respectively.

Conclusions: Subxiphoid thymectomy is a high satisfaction approach with positive aesthetic outcomes and low pain. Double sternum retractors are especially useful for creating space during thymectomy. However, the qualified experience is needed.
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http://dx.doi.org/10.21037/gs.2019.11.05DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6989895PMC
December 2019

ERAS in VATS-do we really need to follow the trend?

Transl Lung Cancer Res 2019 Dec;8(Suppl 4):S451-S453

Department of Thoracic Surgery and Minimally Invasive Thoracic Surgery Unit (UCTMI), Coruña University Hospital, Coruña, Spain.

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http://dx.doi.org/10.21037/tlcr.2019.11.02DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6987343PMC
December 2019

Uniportal video-assisted thoracoscopic lobectomy in a 9-week-old patient.

Interact Cardiovasc Thorac Surg 2020 02;30(2):327

Department of Cardiothoracic Surgery, Makassed Charitable Society Hospital, East Jerusalem, Palestinian Territories.

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http://dx.doi.org/10.1093/icvts/ivz263DOI Listing
February 2020

Nonintubated Anesthesia for Tracheal/Carinal Resection and Reconstruction.

Thorac Surg Clin 2020 Feb;30(1):83-90

Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, No.151 of Yanjiangxi Road, Yuexiu, Guangzhou, Guangdong, China. Electronic address:

Nonintubated anesthesia is feasible and might be associated with shorter surgery time and shorter hospitalization for tracheal/carinal resection and reconstruction. Only case reports and a few small retrospective series study were conducted to evaluate nonintubated anesthesia for tracheal/carinal resection and reconstruction; no randomized control trials exist. Further exploration should focus on selection of optimal candidates and prospective validation.
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http://dx.doi.org/10.1016/j.thorsurg.2019.08.007DOI Listing
February 2020

Devising the guidelines: the concept of uniportal video-assisted thoracoscopic surgery-incisions and anesthetic management.

J Thorac Dis 2019 Sep;11(Suppl 16):S2053-S2061

Thoracic Surgery Department, Tongji University Affiliated Shanghai Pulmonary Hospital, Shanghai 200433, China.

Uniportal video-assisted thoracoscopic surgery (VATS) is an already established minimally invasive technique in the field of thoracic surgery. The feasibility, safety and efficacy of the technique are already well documented. Comparative studies and meta-analyses have shown a clear advantage over open surgery and other minimally invasive techniques in terms of pain, length of stay (LOS), chest drain duration and morbidity. It covers a broad spectrum of indications for both malignant and benign diseases, including pulmonary and mediastinal tumor resections, diaphragm procedures (plication), esophageal surgery and airway surgery (bronchial resections, carinal resections). Its swift and wide adoption has resulted into many variations, all of whom are common in the fact they utilize a single incision to enter the chest and conduct the planned procedure. With this article, we attempt to standardize the technique as to the incision and the anesthetic management.
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http://dx.doi.org/10.21037/jtd.2019.02.45DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6783705PMC
September 2019

Uniportal VATS for non-small cell lung cancer.

Gen Thorac Cardiovasc Surg 2020 Jul 15;68(7):707-715. Epub 2019 Oct 15.

Uniportal VATS Training Program, Thoracic Surgery Department, Shanghai Pulmonary Hospital, Tongji University, 200433, Shanghai, China.

The video-assisted thoracic surgery (VATS) technique has evolved from its multiport origins to even less invasive approaches grounded in its proven benefits over open surgery for the treatment of early stage lung cancer. In this evolution process, the Uniportal VATS (UniVATS) strategy emerged. This technique is giving some evidence of benefits when compared to the multiport VATS and has been embraced by the surgical community spreading its geographical and surgical boundaries. Moreover, UniVATS has proven its feasibility for numerous and more complex procedures for lung cancer diagnosis and treatment, which are reviewed in this document as well as its current and future development.
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http://dx.doi.org/10.1007/s11748-019-01221-4DOI Listing
July 2020

Reply from the authors: The quantification of nodal disease has prognostic relevance.

J Thorac Cardiovasc Surg 2020 02 11;159(2):e146-e147. Epub 2019 Oct 11.

Department of Thoracic Surgery, Hospital Universitari Mútua Terrassa, University of Barcelona, Terrassa, Spain; Network of Centers for Biomedical Research in Respiratory Diseases Lung Cancer Group, Terrassa, Spain.

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http://dx.doi.org/10.1016/j.jtcvs.2019.09.007DOI Listing
February 2020

Long-term survival following thoracoscopic versus open lobectomy for stage I non-small cell lung cancer.

Ann Transl Med 2019 Jul;7(Suppl 3):S147

Department of Thoracic Surgery and Minimally Invasive Thoracic Surgery Unit (UCTMI), Coruña University Hospital, Coruña, Spain.

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http://dx.doi.org/10.21037/atm.2019.06.24DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6685904PMC
July 2019

Dramatic Response of Leptomeningeal Carcinomatosis to Nivolumab in PD-L1 Highly Expressive Non-small Cell Lung Cancer: A Case Report.

Front Oncol 2019 6;9:819. Epub 2019 Sep 6.

Medical Oncology Department, University Hospital Complex of Ourense, Ourense, Spain.

In a patient who had been diagnosed of located squamous cell lung carcinoma, pneumonectomy, and adjuvant chemotherapy were performed. Brain recurrence and subsequent lung metastatic disease were uncontrolled by neurosurgery, holocranial radiotherapy, and first-line chemotherapy. In August 2015, appearance of leptomeningeal carcinomatosis triggered severe clinical deterioration and threatened the patient's life. Anti-PD1 immune checkpoint inhibitor was initiated in an attempt to stop tumor growth, achieving a spectacular brain and pulmonary complete response and clinical improvement, without serious adverse effects. High expression PD-L1 level (100%) was found in the pathological tissue sample. Nivolumab was maintained for more than 2 years and stopped in December 2017 after 28 months of treatment, with no disease evidence. More than 3 years after its onset, the patient maintains an outstanding PS with complete tumor response and no evidence of disease in last surveillance CT scan and brain MRI.
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http://dx.doi.org/10.3389/fonc.2019.00819DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6743439PMC
September 2019

Pulmonary carcinosarcoma: analysis from the Surveillance, Epidemiology and End Results database.

Interact Cardiovasc Thorac Surg 2020 01;30(1):4-10

Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.

Objectives: Pulmonary carcinosarcoma (PCS) is a rare neoplasm. This study explored the clinicopathological characteristics and survival outcomes of PCS.

Methods: The Surveillance, Epidemiology and End Results (SEER) database (1988-2014) was queried for PCS. Overall survival (OS) was evaluated by multivariable Cox regression and nomograms were constructed to predict 3-year OS for PCS. Prognostic performance was evaluated using concordance index and area under the curve analysis. In M0 surgically treated patients, interaction assessments were performed using likelihood ratio tests. Subgroup analysis was performed according to patient age. The clinical features of PCSs were further compared to other non-small-cell lung cancers (NSCLCs).

Results: Multivariable analysis identified age [hazard ratio (HR) 1.03, 95% confidence interval (CI) 1.01-1.04], surgery (HR 0.53, 95% CI 0.36-0.77) and chemotherapy (HR 0.51, 95% CI 0.36-0.73) as significantly associated with OS. The nomogram had a concordance index of 0.747 and an area under the curve of 0.803. The association between age and OS was stronger in those receiving pneumonectomy (P = 0.04 for interactions) compared to those that did not (HR 5.14, 95% CI 1.64-16.07), and was associated with a poorer outcome compared to lobectomy amongst the elderly (age ≥ 70 years). Patients with PCS were more likely to receive surgical treatment and had lower lymphatic metastasis compared to adenocarcinoma, squamous cell carcinoma and large cell carcinoma (all P < 0.05).

Conclusions: PCS had unique clinical features compared to common types of NSCLCs in terms of lymphatic invasion and surgical treatment. Pneumonectomy was associated with poorer survival in elderly patients.
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http://dx.doi.org/10.1093/icvts/ivz215DOI Listing
January 2020

Uniportal video-assisted sleeve resections: how to deal with specific challenges.

J Thorac Dis 2019 Aug;11(Suppl 13):S1670-S1677

Thoracic Surgery Department, Tongji University Affiliated Shanghai Pulmonary Hospital, Shanghai 200433, China.

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http://dx.doi.org/10.21037/jtd.2019.06.52DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6706617PMC
August 2019