Techniques for intraoperative identification and confirmation of segmental bronchus in minimally invasive segmentectomy
Review Article

Techniques for intraoperative identification and confirmation of segmental bronchus in minimally invasive segmentectomy

María Teresa Gómez-Hernández1,2,3, Clara Forcada1, Cristina Rivas1,2,3, Marta Fuentes1,2,3, Marcelo F. Jiménez1,2,3

1Department of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain; 2Salamanca Institute of Biomedical Research, Salamanca, Spain; 3Department of Surgery, School of Medicine, University of Salamanca, Salamanca, Spain

Contributions: (I) Conception and design: MT Gómez-Hernández; (II) Administrative support: MF Jiménez; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: MT Gómez-Hernández, C Forcada; (V) Data analysis and interpretation: MT Gómez-Hernández, C Forcada; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: María Teresa Gomez-Hernandez, MD, PhD. Department of Thoracic Surgery, Salamanca University Hospital, Paseo de San Vicente, 58, 37007, Salamanca, Spain; Salamanca Institute of Biomedical Research, Salamanca, Spain; Department of Surgery, University of Salamanca, Salamanca, Spain. Email: mtgh@usal.es.

Abstract: In recent years, the early detection rate of lung cancer has increased worldwide mainly due to the implementation of screening programs. On the other hand, minimally invasive segmentectomy has increasingly been performed to treat small-sized lung lesions since the validity of this technique has been fully demonstrated. However, segmentectomy is considered a more challenging procedure than lobectomy based on the complex structure and anatomical variations of the segment. Therefore, accurate identification of the afferent broncho vascular structures is vital to achieve optimal outcomes in segmentectomy. Identifying the segmental bronchus is one of the essential steps of the procedure and constitutes one of the main technical difficulties in segmentectomy. Several methods to distinguish the target bronchus during minimally invasive segmentectomy have been reported. However, each of these methods has its own advantages and limitations and, to date, no consensus exists about which is the best way to intraoperatively recognize the segmental bronchus. Thus, the objective of this review is to determine techniques for identifying and confirming the target bronchus in minimally invasive anatomical segmentectomies. This review article emphasizes the importance of using a flexible approach that combines different methods tailored to specific clinical situations and available resources. The main goal is to improve segmentectomy outcomes, minimize the risk of complications, and safely shorten the duration of these procedures.

Keywords: Bronchial identification; minimally invasive surgery; segmentectomy; video-assessed thoracoscopic surgery (VATS); robotic-assisted thoracoscopic surgery (RATS)

Received: 15 November 2023; Accepted: 21 January 2024; Published online: 10 May 2024.

doi: 10.21037/vats-23-71

Video 1 Intraoperative view of the operating field showing the visualization of the bronchoscope light inside the lingular bronchus by transillumination after bronchoscopic identification during a video thoracoscopic lingulectomy.
Video 2 Intraoperative view of the operating field showing the visualization of the luminescence with near-infrared fluorescence of the left bronchial tree during a video thoracoscopic left upper lobectomy.
Video 3 Intraoperative view of the operating field showing the visualization of the luminescence with near-infrared fluorescence of the two segmental bronchi after bronchoscopic identification during a robotic right upper lobe posterior segmentectomy (S2).
Video 4 Intraoperative view of selective clamping with the endostapler of the right upper lobe posterior segmental bronchus and re-ventilation of the lung showing inflation of the anterior and apical segments during a robotic right upper lobe posterior segmentectomy (S2).
Video 5 Intraoperative view of the selective clamping of the apical trisegmental bronchus and re-ventilation of the lung showing inflation of the lingula during a video thoracoscopic trisegmentectomy.
Video 6 Intraoperative view of the isolation of the right upper lobe posterior segmental bronchus, ventilation of the lung, clamping of the bronchus with endostapler and deflation of the lung showing an inflated segment 2 during a robotic right upper lobe posterior segmentectomy (S2).
Video 7 Intraoperative bronchoscopic view of clamped segmental bronchus of the lingula showing permeability of the apical trisegmental bronchus.

Introduction

Background

Two main facts have marked the last decade in the thoracic surgery field. Firstly, the wide adoption of minimally invasive techniques for anatomical pulmonary resections (1) and secondly the launching of lung cancer screening programs (2) that have allowed the detection of small pulmonary nodules or ground glass opacities.

Pulmonary lobectomy has been considered the surgical procedure of choice for patients with early-stage non-small-cell lung cancer (NSCLC) since 1995 when the Lung Cancer Study Group conducted a prospective, multi-institutional randomized trial (3) comparing limited resection with lobectomy for patients with peripheral T1 N0 NSCLC that concluded that limited pulmonary resection was associated with higher death and locoregional recurrence rates, while it did not confer improved perioperative morbidity, mortality, or late postoperative pulmonary function. Therefore, sub-lobar resections remained indicated for unfit patients only. However, recent findings from the Japanese JCOG0802/WJOG4607L (4) randomized control trial comparing lobectomy with anatomical segmentectomy in patients with clinical stage IA NSCLC with a tumor size of 2 cm or less demonstrated that, after a median follow-up of approximately 7 years, anatomical segmentectomy was superior to lobectomy for overall survival (primary end point) and noninferior to lobectomy for relapse-free survival, although an increased local recurrence rate was found in the segmentectomy group. These findings are consistent with the recently reported results from the CALBG140503 (5) international randomized trial that compared sublobar resection (wedge resection or segmentectomy) with lobectomy in patients with clinical stage IA NSCLC with a tumor size of 2 cm or less. The authors concluded that sublobar resection was noninferior to lobectomy with respect to disease-free survival (primary end point) and that overall survival (secondary end point) was similar with the two procedures.

Regardless of the differences in the methodological design, both trials showed concordant findings demonstrating that sublobar resection for patients with clinical T1aN0 disease is an effective management approach and suggests that sublobar resection should be the standard surgical procedure for this population of patients with NSCLC.

As a consequence of the confluence of these facts (increase of early detection of small nodules due to screening programs, widespread adoption of minimally invasive surgery and proven value of sub-lobar resections in management of early-stage NSCLC), minimally invasive anatomical segmentectomies have gained relevance in recent years and a growing interest in this procedure has been generated.

Rationale and knowledge gap

Pulmonary segmentectomy is considered technically more challenging for surgeons than lobectomy, especially when a closed-chest approach is performed (6). Firstly, the anatomical structure of the different lung segments is complex and often demonstrates individual anatomical variations (7). Secondly, segmentectomies require a deeper hilar vascular and bronchial dissection and the division of one or several intersegmental planes. Therefore, accurate intraoperative identification of segmental structures is crucial to avoid potential complications such as venous congestion, infarction, and air leakage and guarantee optimal postoperative outcomes considering oncological validity such as resection margins and venous and lymph drainage and contemplating the anatomy of the remaining lung to avoid possible distortion (8,9).

To date, different methods have been used to preoperatively identify the segmental structures and the intersegmental plane. Three-dimensional (3D) computed tomography angiography and bronchography (10-12) is the most widely used technique. This method facilitates the correct interpretation of the 3D arrangement of the segmental structures and allows for 3D models to be printed.

In our experience, the intraoperative use of both virtual or printed 3D models may be useful to correctly identify the segmental arteries and veins during surgery, even if anatomic variations occur, since they are in a quite superficial plane and proximal branches may be easily exposed after a slightly dissection. Nevertheless, despite the bronchi being accompanied by the artery, accurate segmental bronchus division, one of the essential steps of segmentectomies (6), may be tough, since the bronchial plane is usually deeper within the parenchymal tissue and the deflation of the lung may lead to a misinterpretation of the broncho vascular distribution showed by the anatomical 3D model based on an inflated parenchyma. Therefore, the surgeon should ensure that the isolated segmental bronchus is the one afferent to the target segment to be removed, before definitive transection (6). For this purpose, it is recommended to use any of the available methods described in the literature to identify the target segmental bronchus.

Objective

The aim of this review is to describe the different techniques reported in the literature for identifying and confirming the target bronchus in minimally invasive anatomical segmentectomies.

Techniques for identification of the segmental bronchus

Given the complexity of the procedure and the possibility of anatomical variations (13), several methods have been described to intraoperatively identify the target bronchus and/or verify that the controlled bronchus is the correct target bronchus during minimally invasive segmentectomies. Each method described below requires that the surgeon, preoperatively, determines the appropriate target segment(s) for removal based on nodule localization, guided by preoperative assessments and adhering to oncological and surgical principles (9).

All clinical procedures described in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Publication of the videos included in the article was waived from patient consent according to the Salamanca University Hospital ethics committee/institutional review board.

Direct identification/marking of the target segmental bronchus

  • Intraoperative bronchoscopy. This method consists of endoscopic identification of the target segmental bronchus by fibreoptic bronchoscopy during the surgical procedure. No supplementary equipment is required, as the same fibreoptic bronchoscope employed for verifying tube placement can serve this function. Since optimal identification of the target bronchus may be challenging when performed in lateral decubitus, we recommend performing a bronchoscopy in supine decubitus before turning the patient to lateral decubitus in order to review the bronchial tree, detect potential anatomical variations not recognized in the computed tomography and identify the target bronchus. Moreover, ideally, a skilled physician should perform the bronchoscopy to guarantee the correct identification of the target segmental bronchus. Once the target segmental bronchus is identified, the tip of the fibreoptic bronchoscope should be placed at the entrance of the segmental bronchus and then, the light of the thoracoscopy platform is turned off to enable visualization of the bronchoscope light inside the segmental bronchus by transillumination. Although this technique is fast and safe and may be helpful for the main surgeon, the darkness of the operating field during the thoracoscopy light shutdown could be considered an inconvenience that may hinder the precise recognition of the segmental bronchus (Video 1).
  • Intraoperative bronchoscopy combined with near-infrared fluorescence. In 2023, Gómez Hernández et al. (14) described this method for the identification of segmental bronchi during minimally invasive segmentectomies (both video-assisted thoracoscopic and robotic). The technique consisted of intraoperative endoscopic identification of the target segmental bronchus by a physician with high expertise in bronchoscopy after the division of the segmental vessels if needed. Once the target segmental bronchus has been identified endoscopically, the tip of the bronchoscope is focused on the target segmental bronchus, and the standard video-thoracoscopic view of the thoracoscopy platform is changed to near-infrared fluorescence overlay, providing visualization of the luminescence of the target bronchi without the need to administer indocyanine green (Video 2). In robotic segmentectomies, the infrared fluorescence view is achieved by activating the FireFly infrared fluorescence system integrated into the daVinci robot (Intuitive Surgical, Sunnyvale, CA, USA) by the console surgeon Video 3). This method has a low risk of complications, no additional cost, and could safely shorten the duration of segmentectomies. The main advantages of the technique described are that it is a fast and safe procedure that does not require the administration of any agent with fluorescent properties or the consumption of additional material resources since it requires the same bronchoscope employed by the anaesthesiologist at the beginning of the procedure to confirm the correct placement of the endotracheal double lumen tube or the endobronchial blocker cuff. The essential requirements to successfully conduct this technique include a near-infrared fluorescence video-assisted thoracoscopy platform or the robotic FireFly system and a surgeon or anaesthesiologist expert in bronchoscopy present in the operating room to correctly identify the target segmental bronchus.
  • Electromagnetic navigation bronchoscopy (ENB)-guided dye marking method. In 2021, Xu et al. (15) described a technique for subsegmental bronchus identification based on bronchial labelling with methylene blue guided by ENB. Briefly, ENB is performed by using the superDimension system (Covidien Inc., Minneapolis, MN, USA) under general anaesthesia as previously described (16) and once the targeted lesion is reached, the sensor probe and extended working channel are gradually retracted back to the bronchial opening of the subsegment. Then, the locatable guide is carefully withdrawn to ensure the working channel remains in situ. Approximately 1.0 mL of methylene blue is injected into the subsegmental bronchus through the bronchial opening and, subsequently, approximately 2 mL of air is injected. One of the main advantages of this method is that ENB can also be used to locate small lung nodules and provide 3D information on targeted segments. However, although this method is feasible and effective for the identification of segmental and subsegmental bronchi, it has certain disadvantages, such as the need for specific equipment (ENB system) and its associated cost and the additional time required for the identification and marking of the bronchus. Moreover, the clinician should be skilled in thoracoscopic examination and ENB. Surgeons should also be familiar with the anatomical structure of the lung so that the sensor probe and extended working channel can be accurately sent to the opening of the target bronchus. In addition, the amount of methylene blue injected must be optimal to prevent dissemination of the dye in the bronchial tree and to avoid incorrect bronchial identification. Furthermore, airway injury and lung injury might occur as major complications, which could lead to bleeding in severe cases.

The techniques described above all involve a degree of parenchymal dissection necessary for achieving optimal exposure of the proximal bronchus. Once this area is exposed, these methods can aid in accurately identifying the target segmental bronchi and thereby confirming the isolation of the correct bronchus.

Confirmation that the target segmental bronchus has been correctly controlled

  • Selective clamping and re-ventilation of the lung. Once the surgeon has identified and isolated the target segmental bronchus, a selective bronchial clamping is performed and then the collapsed lung is re-expanded completely with controlled airway pressure by the anaesthesiologist. The target segment should remain deflated if the correct bronchus has been clamped. Since no exceptional materials or equipment are required, this method is widely accepted by thoracic surgeons and it is also used to determine the intersegmental plane (17,18). As a disadvantage of this method, we may mention that in emphysematous patients, gas administered with positive pressure ventilation may cross the intersegmental plane via Kohn’s pores, leading to ambiguous segmental inflation. Moreover, pulmonary re-expansion could lead to a reduction of the working space and limited vision of the operating field (Videos 4,5).
  • Ventilation of the lung, clamping of the selected bronchus and deflation. Once the target segmental bronchus is identified and isolated, the lung is inflated by the anaesthesiologist and then the isolated bronchus is selectively clamped. Then the lung is deflated again. In this case, the target segment should remain inflated if the correct segmental bronchus has been clamped. This technique showed the same advantages and disadvantages than the previously mentioned method. This technique requires slightly more ventilation than the previously mentioned option in which ventilation can be stopped as soon as the surrounding segments begin to ventilate. This may result in an even greater reduction in workspace, particularly in emphysematous patients with poor lung elastic recoil. Moreover, deflation of the lung may take a long time leading to increased surgical times. Both of these methods rely on adequate bronchial permeability, which may be compromised in patients with history of bronchitis or copious respiratory secretions, leading to potential confusion. It is important to adequately suction and clear out the airway prior to attempting to identify the segmental bronchus and the intersegmental plane via inflation or deflation, which may be done under vision by bronchoscopic aspiration or blind introduction of a suction catheter via the endotracheal tube (Video 6).
  • Intraoperative bronchoscopy. Once the target segmental bronchus is identified and isolated, it is selectively clamped and then, an experienced physician endoscopically identifies the segmental bronchial orifices by fibreoptic bronchoscopy. The lumen of the target segmental bronchus should be completely closed, while the lumen of the adjacent bronchi should be opened (Video 7). No additional equipment is needed as the fibreoptic bronchoscope used for verifying tube placement can fulfill this role. It is a rapid and safe technique that requires an experienced physician for precise identification of the target segmental bronchi.

Table 1 provides a comprehensive summary of all techniques, encompassing their primary advantages, associated equipment, and respective limitations.

Table 1

Summary of techniques

Method Requirements Advantages Disadvantages/limitations
Intraoperative bronchoscopy • Fibreoptic bronchoscope (usually the same employed for tube placement) • No additional cost or equipment • A skilled physician must conduct bronchoscopy for accurate identification of the target segmental bronchus
• Fast and safe technique • The darkness of the operating field during the thoracoscopy light shutdown could hinder the precise recognition of the segmental bronchus
Intraoperative bronchoscopy combined with near-infrared fluorescence • Fibreoptic bronchoscope (usually the same employed for tube placement) • Fast and safe technique • A skilled physician must conduct bronchoscopy for accurate identification of the target segmental bronchus
• A near-infrared fluorescence video-assisted thoracoscopy platform or the robotic FireFly system • Cost associated to near-infrared fluorescence systems
ENB-guided dye marking method • Fibreoptic bronchoscope (usually the same employed for tube placement) • Feasible and effective technique • Cost associated to ENB system
• ENB • Increased surgical time
• Dye marking is needed
• The physician performing the procedure should be skilled in ENB
Selective clamping and re-ventilation of the lung • No exceptional materials or equipment are required • No additional cost or equipment • Ambiguous segmental inflation (especially in emphysematous patients)
• Safe technique • Reduction in workspace
• Bronchial permeability is needed
Ventilation of the lung, clamping of the selected bronchus and deflation • No exceptional materials or equipment are required • No additional cost or equipment • Ambiguous segmental inflation (especially in emphysematous patients)
• Safe technique • Reduction in workspace
• Bronchial permeability is needed
• Increased surgical time

ENB, electromagnetic navigation bronchoscopy.

The current review article outlines several techniques, detailing essential equipment and limitations, with the goal of offering a degree of adaptability. This flexibility enables surgeons to select among these techniques based on the hospital’s available resources, integrated platforms, or the expertise of physicians in bronchoscopy assessment.

In our practice, the utilization of preoperative 3D imaging to pinpoint the target segment and its corresponding bronchus, coupled with intraoperative bronchoscopy using near-infrared fluorescence for segmental bronchus identification, has consistently yielded optimal outcomes in our series of segmentectomy cases. Remarkably, this approach incurs no added costs, surgical time extensions, or associated complications.

Looking ahead, we believe standardizing the surgical procedure, particularly focusing on defining key steps for identifying and dissecting bronchovascular structures, is essential for ensuring consistent perioperative results.

Strengths and limitations

This paper presents a clinical practice review focusing on the technical intricacies involved in intraoperative identification and confirmation of the target bronchus during segmentectomy using minimally invasive approaches. It has been crafted based on the author’s extensive experience, amalgamating empirical knowledge with the latest evidence gleaned from scientific publications. The review comprehensively delineates multiple techniques aimed at providing adaptability, allowing surgeons to judiciously select among these methodologies depending on the resources available at the hospital or the proficiency of physicians in bronchoscopy assessment. This aspect, coupled with its academic and educational emphasis, constitutes its primary strengths. However, it is important to acknowledge its limitations, notably the paucity of robust evidence supporting its development and the relatively modest level of recommendations derived from it.

Conclusions

Identifying the target bronchi is one of the main technical issues during minimally invasive segmentectomies. Given the complexity and anatomical variations, several effective techniques have been described for the intraoperative identification of segmental bronchi. The main idea of this review article emphasizes the utilization of a versatile and cohesive strategy that incorporates various methods customized to suit the specific clinical situation and available resources with the aim of optimizing segmentectomy outcomes, minimizing the risk of complications and safely shortening the duration of these procedures.

Acknowledgments

Funding: None.

Footnote

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-23-71/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-23-71/coif). M.T.G.H. serves as an unpaid editorial board member of Video-Assisted Thoracic Surgery from June 2022 to June 2026. M.F.J. serves as an unpaid editorial board member of Video-Assisted Thoracic Surgery from January 2023 to December 2024. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All clinical procedures described in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Publication of the videos included in the article was waived from patient consent according to the Salamanca University Hospital ethics committee/institutional review board.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

  1. Leschber G. Video-assisted thoracic surgery: A global development. Chirurg 2018;89:185-90. [Crossref] [PubMed]
  2. Lancaster HL, Heuvelmans MA, Oudkerk M. Low-dose computed tomography lung cancer screening: Clinical evidence and implementation research. J Intern Med 2022;292:68-80. [Crossref] [PubMed]
  3. Ginsberg RJ, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg 1995;60:615-22; discussion 622-3. [Crossref] [PubMed]
  4. Saji H, Okada M, Tsuboi M, et al. Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer (JCOG0802/WJOG4607L): a multicentre, open-label, phase 3, randomised, controlled, non-inferiority trial. Lancet 2022;399:1607-17. [Crossref] [PubMed]
  5. Altorki N, Wang X, Kozono D, et al. Lobar or Sublobar Resection for Peripheral Stage IA Non-Small-Cell Lung Cancer. N Engl J Med 2023;388:489-98. [Crossref] [PubMed]
  6. Brunelli A, Decaluwe H, Gonzalez M, et al. European Society of Thoracic Surgeons expert consensus recommendations on technical standards of segmentectomy for primary lung cancer. Eur J Cardiothorac Surg 2023;63:ezad224. [Crossref] [PubMed]
  7. Wąsik J, Tubbs RS, Zielinska N, et al. Lung segments from anatomy to surgery. Folia Morphol (Warsz) 2024;83:20-34. [Crossref] [PubMed]
  8. Lutz JA, Kocher GJ. Technical aspects of video-assisted and robotic-assisted thoracoscopic segmentectomy. J Thorac Dis 2017;9:2320-2. [Crossref] [PubMed]
  9. Sato M, Murayama T, Nakajima J. Concepts and techniques: how to determine and identify the appropriate target segment in anatomical pulmonary segmentectomy? J Thorac Dis 2019;11:972-86. [Crossref] [PubMed]
  10. Wu WB, Xu XF, Wen W, et al. Three-dimensional computed tomography bronchography and angiography in the preoperative evaluation of thoracoscopic segmentectomy and subsegmentectomy. J Thorac Dis 2016;8:S710-5. [Crossref] [PubMed]
  11. Wu Z, Huang Z, Qin Y, et al. Progress in three-dimensional computed tomography reconstruction in anatomic pulmonary segmentectomy. Thorac Cancer 2022;13:1881-7. [Crossref] [PubMed]
  12. Gossot D, Lutz J, Grigoroiu M, et al. Thoracoscopic anatomic segmentectomies for lung cancer: technical aspects. J Vis Surg 2016;2:171. [Crossref] [PubMed]
  13. Martín-Ruiz S, Gutiérrez-Collar C, Forcén Vicente De Vera E, et al. The bronchial segmentation and its anatomical variations. A clinical-anatomic and bronchoscopy study. Ann Anat 2021;235:151677. [Crossref] [PubMed]
  14. Gómez Hernández MT, Rivas Duarte C, Forcada Barreda C, et al. Usefulness of near-infrared fluorescence for identifying the segmental bronchus in minimally invasive segmentectomy. Cir Esp (Engl Ed) 2023;101:51-4. [Crossref] [PubMed]
  15. Xu R, Zhao M, Zhao Y, et al. Electromagnetic navigational bronchoscopy-guided dye marking to identify the subsegmental bronchus in thoracoscopic anatomic subsegmentectomy. Thorac Cancer 2021;12:2819-21. [Crossref] [PubMed]
  16. Leong S, Ju H, Marshall H, et al. Electromagnetic navigation bronchoscopy: A descriptive analysis. J Thorac Dis 2012;4:173-85. [PubMed]
  17. Zhang X, Li C, Jin R, et al. Intraoperative Identification of the Intersegmental Plane: From the Beginning to the Future. Front Surg 2022;9:948878. [Crossref] [PubMed]
  18. Andolfi M, Potenza R, Seguin-Givelet A, et al. Identification of the intersegmental plane during thoracoscopic segmentectomy: state of the art. Interact Cardiovasc Thorac Surg 2020;30:329-36. [Crossref] [PubMed]
doi: 10.21037/vats-23-71
Cite this article as: Gómez-Hernández MT, Forcada C, Rivas C, Fuentes M, Jiménez MF. Techniques for intraoperative identification and confirmation of segmental bronchus in minimally invasive segmentectomy. Video-assist Thorac Surg 2024;9:25.

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