Update Course 2021: THORACOTOMY VS VATS FOR OSTEO METS

Welcome back everyone. Uh we're we're making the final turn on a great day of teaching and conferences. Uh it's my pleasure to introduce Dr. Chiro Esposito, a Chief of Surgery and Naples, Italy to discuss a topic that I love ICG fluorescence in pediatric surgery. Chiro, thank you for being with us. Thank you very much Mac. Thank you very much Todd, is a pleasure to be with you and to share my experience in ICG fluorescence technology. I am some slides with videos with three cases that we can discuss. First of all, I have nothing to disclose and only a short introduction as you know in particular in pediatric MIS surgery is important to detect anatomic structure above all to reduce the incidence of complication. For this reason the imaging technology has to help us as pediatric surgeon to do this. In the last three four years we use in our operative room, the near infrared in the cyana green fluorescence imaging technology that is very useful in different indication. And is ICG in a soluble molecule that is rapidly bound to albumin and is near spontaneously visualize with target organs and it is removed from circulation by the liver and bio juice. For this reason one of the main indication is the surgery of gallbladder. Uh you you to use this technology, you can adopt this technology use laparoscopy and you need an optic, you need for sure a camera, a vial of ICG, but you can use also in robotic surgery because above all the last generation of Da Vinci XI system is a system called Firefly that you can adopt ICG. I have three cases that we can discuss together. There are three three classic indication that I adopt in my clinical experience. The first case is is a 12 years old boy a little bit fatty of 70 kilos with a gallbladder disease and at the ultrasonography has several stones in the gallbladder. He he was and he had several episode of upper right quadrant pain and we have to decide what to do which is the diagnostic workup before surgery or during surgery and above all which management is indicated. the the first possibility can be a ultrasonography and then medical therapy. As you know sometime pediatric hepatology give for these children also the cyclic acid therapy for some weeks. The second option is to use pre-operative US and then to perform the old fashion laparotomy to remove the gallbladder. Then another alternative is to perform preoperatively cholangio MRI and then to perform a laparoscopic cholecystectomy or the classic pre-operative US and then a third laparoscopy or pre-operative US and then laparoscopy but using ICG technology. I don't know if you can discuss a little bit and then I will show some slides as which is my aptitude in this case. Well I suspect at this point people know that the right answer from you is E. Uh but if any anybody wants to weigh in on another comment about other therapy, please do so. Yes yes I I agree completely with you. if you haven't uh ICG system in your hospital, some colleagues prefer to perform a preoperative cholangio MRI to have a clear anatomy of the biliary tree to avoid complication. If you haven't you have to perform US and the standard laparoscopy. In the last three years we use ICG technology for this reason as you told us we prefer E, the preoperative US and then laparoscopy using ICG technology. Why because if you analyze international literature above all in adults there are a lot of complication in laparoscopic cholecystectomy and this is particularly true in pediatric patients because as you know compared to the adults as you can see in these slides in the adults perform about 100 to 300 cholecystectomy per year in an adult center compared to a pediatric center in which we perform 10 to 30 cholecystectomy per year. For this reason the learning curve is a little bit longer and above all if you find this case as you can see uh in this slide. In this video there is the uh a complex case in which the anatomy is not clear because you don't know where is exactly the cystic duct the main biliary, you can have the complication. Thanks to ICG you can have a real biliary mapping during the procedure. And the the ICG is in vial of 25 mg 4 ml. You have to dilute the the vial with 10 ml of sterile water and then you have to inject 6 ml of ICG intravenously the day before surgery above all 12 to 15 hour preoperatively. In this way you have a clear view. As you can see in this video, this is the ICG technology. You can see very well the biliary anatomy is absolutely amazing. As you can see the main biliary tree, the gallbladder and then the cystic duct and you can perform a safe dissection and also in this other case. As you can see there is a lot of adhesions and if you adopt ICG technology, you can see that there is an angulation of cystic duct with cystic fundus and thanks to ICG you can switch to a normal view to ICG view and to perform a very good isolation. And above all you have always a very good view of main biliary tree and this is a huge advantage during laparoscopic cholecystectomy above all for trainees. In this way you can low to zero the complication for this reason I think is an amazing technology to adopt. Now you have a new ICG system because the old ICG system you have to switch with a pedal and you see the picture in black and white. Now with the new Rubin system, you have the possibility to remain in color and the biliary tree is colored in green is absolutely amazing. I think then thanks to this system, you can load the complication to zero because you have a very clear view of the anatomy. As you can see in this picture is impossible to have a complication. The main drawback of this technique that you have to inject the product the day before surgery. For this reason you have to plan in advance ICG technology for cholecystectomy and in my center we use this technology routinely now for all the gallbladders. And this is the first case. I don't know if you if you want to to ask something or want to to to pass to to run another indication as you know as you. I think I think because of time limitations, we need to move ahead but uh Okay perfect. I'd like everybody been thinking about when you give the ICG, the idea of giving it a day ahead of time uh kind of kind of was new to me. So let's keep going though. That that's an important point Mac that I'm glad you brought up because I didn't know that either. Yes. as I told you, the the you have to plan the use in uh about the indication of ICG, the call the cholecystectomy is the only pathology in which you have to use to inject the product in advance because in other other indication as you can see for kidney, for lymphomas or for varie indication, you have to use this inter-operatively. For this reason is easier. For cholecystectomy you have to plan in advance. Why? because if you use inter-operatively, you can see mainly the liver because is taken by the liver and you have the liver in green and is difficult to identify the gallbladder. After 12 15 hours there is a secretion of ICG in the bile juice and you see selectively the biliary tree. For this reason this is the only indication to inject ICG in advance. The other indication as you can see next slides you have to use this technology inter-operatively for this reason for the surgeon is easier. So can I just that for elective cases you bring the patient in the day beforehand to get injected. Yeah, absolutely. We is hospitalized the day before surgery, in the afternoon we perform the injection uh in the late afternoon if is operated early in the morning. So for some of our uh liver cases we we have them come to clinic and we give the injection in clinic and then they can come back for surgery the following day. Yeah. To avoid the additional hospitalization day. Let's keep going. Okay. We can move to the second to second indication of ICG, we move from GI to urinary tract. This is another classic example is a 27 months old girls of about 10 kilos with a Duplex kidney with a non functioning lower pole secondary to reflux. He has an uretocel already treated using endoscopy in neonatal period and now she has urinary tract infection and urinary incontinence probably for an ectopic uretocel. As for then diagnostic workup and management indicated, there are several option as usual. There are raphy and then clinical control plus antibiotic therapy considering that uretal was already treated at birth. Then other option raphy and partial nephrectomy using the old fashion laparotomy. The third option is raphy because raphy is essential to check the function of the moiety that we have to remove and partial nephrectomy via retroperitoneoscopy. the option D is raphy with partial nephrectomy using robotics also if there is a weight limit because as you know robotics you can use in general in patients higher than 10 15 kilos or you can use raphy in preoperative for for operative workup and then partial nephrectomy and via laparoscopy using ICG and I will show you why. It looks like in the poll results that most of them are saying that the last choice using laparoscopy with ICG 7 over 70%. Yes, I think that this is the right answer because in laparotomy I think is not no more indicated to to perform partial nephrectomy. Using via retroperitoneoscopy there is the problem because this child is has reflux and is difficult to remove the last part of the ureter and via robotics at the moment the robots on the market is huge for this kind of children. For this reason we prefer to perform the procedure in laparoscopy. And we use ICG why? Because you have three main advantage using this technology. First of all, you have the possibility to identify the ureter because when we perform a partial nephrectomy, we put via cystoscopy at beginning a catheter in the ureter and as you know when there is a duplex system, the two ureters are attached in each other and using ICG injecting the catheter, you can identify the normal ureter that you have to save, then you have to can clearly identify the vascularity, the vascularization of the kidney and above all of the kidney that you have to remove as you can see in the slide. And the third advantage is that you have to inject the third time intravenously ICG and you can identify after clipping the vessels of the moiety that you have to remove, there is the vascularization line. And you can see this is the the the videos uh this is the the old system in which you see in black and white but you can see very well the uh ureter, the normal ureter that is green. The ureter is attached and thanks to ICG technology, you can identify the ureter that is attached to the normal ureter with the pedal you can switch from ICG view to a normal view and you can start the dissection. As you can see the normal ureter is very small and you can see in green and the other is very big. If you switch to normal view is difficult to identify. The second and the second aspect, you have to inject intravenously 2 ml of ICG solution and you can see the vascularization of the kidney. As you can see this is the classic vascularization of a Duplex kidney. You have to remove the lower pole there is two huge vessels that vascularize the lower pole and thanks to the ICG technology, you can clearly identify that and in this way it easy to isolate the two vessel and to save the main vessels because you have to to leave a moiety. And the the third part is that at the end of procedure after clipping the vessels, you can see the line of vascularization between the moiety that remain and the vascularized moiety that you have to remove. In this way with the hook we mark this line and then using ceiling device, you can remove it. You can see clearly the upper pole that is very well vascularized and the lower pole that is devascularized. And as I told you also using uh the new Rubin system, the you can remain in color and as you can see it easy to operate, you can see the normal ureter in green on lower part of your screen and on the upper part there is the huge ureter of the moiety that you have to remove. Thanks to this technology as you can see you can perform a safe surgery, avoid danger for the other ureter and this is the same also at level of the kidney. As you had on the kidney, you can see uh if you inject intravenously um the ICG, you can see the vascularization. This is a lower an upper pole that you have to remove is another case and you can see in green the vascularization of the upper pole. To summarize the advantage to use ICG for partial nephrectomy you have to inject this product three times. First of all, you have to perform cystoscopy before surgery. You put a catheter in normal ureter and you have to inject ICG inside the catheter and you can identify the normal ureter and you can save it. Second injection intravenously intraoperatively. In one minutes you can see the vascularization of the moiety that you have to remove. Then you clip the vascularization of the moiety that you have to remove and you have to perform a third injection always of 2 ml intravenously and you can see the line of de vascularization. In this way you can perform an easy surgery and a safe surgery. And that's all for partialtomy. Let's uh let's keep going uh Chiro, thank you. Okay. And then the the last case is varieal. As you know varieal is a big problem because there are several uh indication for treatment several techniques that you can to adopt. Sometimes Europe the technique that we can adopt is different from US. I will show you one classic case that we operate in in Europe is a 13 years old boy with a grade four varicocel according to Dublin and A classification and he has an hypotrophic ipsilateral test testic and he has left testic pain and this a classic indication for surgery for us. There is no spermiogram available because is too young to do it. And for this reason we have to decide which is the workup and the management of these children. The first option is to perform an ecocolor Doppler and clinical controls because there is an option because we have no spermiogram for this reason you can control until 16 years then to perform a spermiogram and then to check the management. The second option is to perform an ecocolor Doppler and then to perform an open inguinal approach. This is the pathology that in Europe sometimes adopt the adult surgery, the surgeons and the third option is to perform color Doppler technique and then scleroembolization. Then the first option is to perform color Doppler and laparoscopic Evenise in which you ligate the spermatic bundle but you spare the testicular artery or color Doppler and then to perform procedure in which you clips and section spermatic bundle but using ICG. My option is the four the the the E using laparoscopic Palomo with ICG and I will show you why. As you know that if you perform Palomo, you have the the higher rate of success more than 97 98%. But if you perform Palomo, you ligate also the lymphatic vessels. In the spermatic bundle there are three four lymphatics and if you ligate lymphatics you can have a post-operative seal in about 20% of cases. We publish a study to together with some uh some colleagues but after the introduction of Green, you can have an intra-operative fluorescence lymphography. In this way you can spare the lymphatic so you have no hyroil. To perform this procedure, you have to inject the product intratesticular, you have to always to create a solution as I show you and then you have to inject two ml of solution inside the test and you can see the lymphatics colored in green and is extremely easy to spare the lymphatic. This is the old system in which you have an black and white view but as you can see is extremely easy and safe to spare the lymphatic. If you switch to colored view, you can see also the lymphatic that is colored in green but you switch to ICG view is better. And then after the section of the spermatic bundle, you can check there are the lymphatics and we use this technique for more than 150 patients and we have zero seal in post-operative period. And thanks to the new technology, this is the ICG Rubin system is the special camera that permits to remain in color. As as you can see uh the lymphatics are colored in green and you remain in color and you can perform dissection easily and you can spare lymphatics. In conclusion some consideration. you need to use this technology is absolutely amazing. is uh you have you need special equipment uh if you use laparoscopy, you need a camera and an optic or you need if you have an XI robots with fire five system for sure a vial of ICG. The timing of injection change accordingly to the indication. As for cholecystectomy is the only indication in which you have to inject in advance the day before. For this reason you have to hospitalize the patient day before surgery. For all other indication kidney varieal nodes or tumors, you have to inject inter-operatively. There is real advantage for surgeon, no adverse effect in our experience and you can use the vial for six hours. This is the main indication for metomy partialtomy varieal are the best indication but also lymphoma tumors or to check the vascularization of anastomosis is others indication. You have to develop this. And in conclusion I think is a safe and useful and versatile technique to adopt in pediatric MIS to have a better visualization a surgical anatomy. Is absolutely amazing. You have to use it above all fortomy because you can avoid complication and above all can help surgeon to reduce complication for example fortomy in which we have few cases per year and I think that this technology can be considered in selected cases as you can show you to increase safety of laparoscopic procedure. And that's all thank you. Thank you so thank you so much that was outstanding. Uh any one comment from any of the the faculty or panelist that uh I just have a quick question. I have a quick question. Can you overdose on that cheer like you said you get three three injections for uh for the kidney surgery. Um is there is there a maximal dose you can give. Uh there is no limit. As you know uh this technology was used I think more than five years ago from adult surgeons. There are a great study performed from Jack Maresco at Irkad as fory and there is no limit for the dose that you can you can adopt. Uh you have I think there is a lot of indication and probably we have to discover other indication. I know that Steve Rodenberg adopt this technology also for tumors. We adopt for to identify nodes for lymphomas or to for uh to check the vascularization of the anastomosis is others indication. You have to develop this. And in conclusion I think is a safe and useful. So, um, this obviously Chiro, thank you so much for coming. Mac, thank you for moderating that. There's obviously going to be a million questions. I think we've seen today that ICG is definitely something to be paying attention to. This is something that every day we're finding more and more uses. We can probably go through all of us and figure out different cases that we've tried it on, thyroids, uh thoracic duct leaks, all these different things. So it's it's really we're getting more and more and next year we'll probably know more. Thank you for that incredible presentation Chiro and thank you for joining us from across the ocean. Uh next I'm going to introduce uh Dr. Roshni Das Gupta. Uh Roshni is uh also another one of the superstars from Cincinnati, uh, who uh does a lot of surgical oncology. She's also does a lot she's I think the they're director of quality and uh also runs the vascular malformations clinic there. But uh Roshni's going to talk to us about uh thoracoscopy versus thoracotomy for pulmonary metastasis. We already know the answer. I mean Of course you do. you all the answers to everything. Everybody knows the answers. Because I'm going to disagree with saying I don't know. Um, so actually, so um, Garrett or Sam, do you have her talk? I think it's up. Okay. So why don't we go to uh there we go. All right. Okay, can everybody hear me? Yep. Awesome. All right, so I was going to start with just a little case and then I'm just going to talk a little bit about um some of the data between thorcope and thoracotomy, why you actually need to do it. It's a little bit more focused than some of the other topics that we've talked about, but it's a little bit of a controversy in pediatric surgical oncology and there's a new study coming up that I want to advertise as well. So that's why we thought this would be a nice topical discussion. So a 16-year-old uh kid comes to your clinic, comes to clinic. Um, he has a lot of pain from his left tibia. Um, you get an X-ray and you see this lesion. Um, then you get a bone biopsy and it shows up with an osteoblastic osteosarcoma. We then do staging like we would normally do and you get a chest CT. In this chest CT, we see three small nodules on the right side, um, measuring two to six millimeters. and then on the left side, there's a sort of non-specific nodule um on the left side. So, oops, sorry. Um, he then undergoes his four cycles of chemotherapy. He goes to Orthopedics, has his limb salvage procedure, get another cat scan and um, the CT scan is unchanged. So same number of nodules both right and left side and so the next question I don't know if we have the um Oh, so is this are you sharing your own slides here Roshni? Uh, no. Oh okay, good. So let's go to the next question. So, um, um, Ellen, did you post it? Yeah, it's coming. Okay. It's up. Okay, perfect. Okay, so the question is, what is the role for metasis? Does it actually even make a difference or should we even bother? This kid's got metastatic disease has osteosarcoma. First question is, yes, it provides a survival advantage. Yes, it improves disease free recurrence but not an overall survival advantage. and no, it doesn't make a difference. So I can't see the results. No, you won't be able to see them unless you're logged into the thing. So um Okay, I'll just keep. We can get you logged in Roshni but that's what we have the magical Ellen here for. She's going to Okay magical Ellen, tell me what people are saying. But but it's going to take about a minute for them to catch up. I'll just keep I'll just keep talking. So so I'm curious what others think on here. So, Mark, what's your guess? What's my guess that it doesn't that it improves uh disease free recurrence but not overall survival. Okay, does anyone disagree? improves survival. Okay, that's what I said too. Dan'll be right. All right. Ellen, what's the answer from the audience? What does the crowd say? The crowd is saying that um it does improve disease free recurrence um but does not improve overall survival. Actually, it just changed. Now half of them are saying it provides survival advantage. Yeah. 51.9%. It keeps changing every second though, but they they were they waited for what Dan said. I know we swayed the audience. All right Roshni, what's the answer? Oh, you want to we'll go through all the questions. Okay. So write Roshni, you want to go through each of them and then tell us all at the end, right? I can't hear Roshni anymore. Roshni, can you hear me? Uh oh. Hold please. Be right back. Well, let let's can we go? Let's do this. Let's go to the I know she has three polls up. So that was the first poll. Um, so so let here she is. Oh, look. She's here. She's back. Mira saved the day. Mira. So, so but we still have time. So Roshni, if it's okay with you, I'm going to go to your second poll question. So let's bring up the next slide. Uh the next one after this. Here's the next question. Do small nodules matter? Doing a little switch root tad. I love the switch root. You guys can, this is awesome.