Background
High-energy devices allow better vessel sealing compared with monopolar electrocautery and could improve the outcomes of surgical operations. The objective of the study was to compare ...tissue dissection by the LigaSure™ device with that by monopolar electrocoagulation for thoracoscopic lobectomy and lymphadenectomy.
Methods
This pragmatic, parallel group, prospective randomized controlled trial was funded by the Medtronic External Research Program (ISR-2016–10,756) and registered at
www.clinicaltrials.gov
(NCT03125798). The study included patients aged 18 years or older, who had undergone thoracoscopic lobectomy with lymphadenectomy at the Department of Thoracic Surgery of Poznan University of Medical Sciences between May 3, 2018, and November 4, 2021. Using simple randomization, the patients were assigned to undergo tissue dissection with either the LigaSure device (study group) or monopolar electrocautery (control group). Participants and care givers, except operating surgeons, were blinded to group assignment. The primary outcome was postoperative chest drainage volume. Secondary outcomes were change of the esophageal temperature during subcarinal lymphadenectomy and C-reactive protein level 72 h after surgery.
Results
Study outcomes were analyzed in 107 patients in each group. We found no differences between the study and control groups in terms of chest drainage volume (550 vs. 600 mL, respectively;
p
= 0.315), changes in esophageal temperature (− 0.1 °C vs. − 0.1 °C, respectively;
p
= 0.784), and C-reactive protein levels (72.8 vs. 70.8 mg/L, respectively;
p
= 0.503). The mean numbers of lymph nodes removed were 12.9 (SD: 3.1; 95% CI, 12.4 to 13.5) in the study group and 11.6 (SD: 3.2; 95% CI, 11.0 to 12.2) in the control group (
p
< 0.001).
Conclusions
The use of the LigaSure device did not allow to decrease the chest drainage volume, local thermal spread, and systemic inflammatory response. The number of lymph nodes removed was higher in patients operated with the LigaSure device, which indicated better quality of lymphadenectomy.
Stage III non-small cell lung cancer (NSCLC) encompasses a variety of local invasion and nodal involvement and its management is still under debate. Immune checkpoint inhibitors (ICIs) have been ...shown to improve the survival in metastatic NSCLC, but are far from being accepted as an induction therapy.
We retrospectively collected data of all patients who received induction ICIs (nivolumab or pembrolizumab) and chemotherapy (carboplatin with paclitaxel) for stage IIIA-B NSCLC followed by surgery in our unit between January 2019 and March 2020.
Of the 12 patients (9 men, 3 women) 6 had a squamous cell carcinoma, 4 had adenocarcinoma, 1 had an undifferentiated adenocarcinoma, and 1 had adeno-squamous carcinoma. Seven patients had stage IIIA disease and 5 had stage IIIB. After induction therapy, 6 patients had stable disease and 6 had a partial response. The median tumor reduction was 3.05 cm (range, 2.30-8.70 cm). All patients, but 1 due to the COVID-19 outbreak, had no delay in surgery. Two patients experienced myelosuppression after induction therapy, 2 had minor adverse effects. Three patients had postoperative complications not related to the induction therapy. All patients had a pathologic response: 5 complete, 4 major, and 3 partial. Eleven patients are alive (mean follow-up, 18.17 ± 4.97 months) and free of disease.
Induction ICI chemotherapy may be a valid treatment in patients with locally advanced NSCLC, providing important tumor downstaging and rendering patients operable. In our experience patients had few side effects and a good pathologic response.
Posterior mediastinal tumors are not infrequent, and among them neurogenic masses and schwannomas are the most common histologic varieties. These benign, initially asymptomatic tumors later become ...symptomatic as a result of mass effect. Surgical excision is the preferred therapy, and the approach can be determined according to the dimensions of the lesion. This report describes the case of a giant schwannoma originating from the left vagus nerve in a middle-aged woman whose symptoms were exertion-induced dyspnea and atrial fibrillation.
The Nuss procedure for pectus excavatum requires that the sternal elevation be maintained by indwelling metal bars that are traditionally removed approximately 3 y after the repair.
A retrospective ...cohort study was conducted of all patients who underwent primary Nuss repair from 2007 to 2018 in two institutions and had a follow-up of at least 24 mo. Pectus bars had been left in place beyond 3 y in patients concerned over possible recurrence after bar removal. Structured interviews were held to assess pain, chest tightness, or other discomfort, and any adverse events related to pectus bars. Results were compared between patients in whom pectus bars were removed after 3 y (standard group) and those in whom bars were left in place longer (extended bar duration group).
Two hundred and thirty-one patients (91% males, mean age 23.9 ± 8.3, mean Haller index 4.9 ± 2.3) were included. Bar duration was 30.6 ± 6.6 mo in the standard group (51 patients) versus 69.1 ± 26.3 mo in the extended group (180 patients). Some discomfort was reported by 81.6% in the standard group versus 62.9% in the extended group (P = 0.033), and discomfort occurring at least monthly or more often was only reported by 30% in the standard versus 30.3% in the extended group (P = 1.000). Quality of life improved in 92.6% of the standard group versus 94.7% of the extended group (P = 1.000). No significant adverse events were reported in either group.
Our data suggest that an extended bar duration after the Nuss repair may not cause any adverse event nor negatively affect quality of life.
Prolonged air leaks (PAL) complicate 10% to 15% of lung resections, delaying chest tube removal and prolonging length of hospital stay. No consensus exists for managing this common complication, ...despite favorable results for autologous blood patch pleurodesis (ABPP) in the literature. The aim of this study was to evaluate the effectiveness and safety of ABPP.
We retrospectively reviewed medical records of 510 patients with PAL after lobectomy in four centers between January 2010 and December 2019. They were divided into two groups: group A consisted of patients who received ABPP for PAL of more than 5 days; and group B was patients for whom no ABPP or other procedure was performed for PAL unless strictly necessary. Propensity score matched analysis was performed, and 109 patients were included in each group. Time to cessation of air leak and chest tube removal, length of hospital stay, reoperation, and complications rate were examined.
After the propensity score matching, ABPP significantly reduced the number of days before chest tube removal (8.12 vs 9.30, P = .004), and length of hospital stay (10 vs 11 days, P = .045) with fewer perioperative complications (6 vs 17, P = .015). Furthermore, ABPP was related to lower incidence of any additional invasive procedures (0 vs 9, P = .002) and reoperation (0 vs 4, P = .044). No patient in the ABPP group had long-term complications related to pleurodesis.
Autologous blood patch pleurodesis is safe and effective in reducing length of hospital stay and leads to earlier chest tube removal without increasing complications.
Mediastinal infection caused by anastomotic leak is hard to cure, mainly because the poor drainage at the site of mediastinal infection leads to persistent cavity infection, which in turn becomes a ...refractory mediastinal abscess cavity after minimally invasive esophagectomy (MIE)-McKeown. Herein, we explored sternocleidomastoid (SCM) muscle flaps and emulsified adipose tissue stromal vascular fraction containing adipose-derived stem-cells to address this issue. We studied 10 patients with esophageal cancer who underwent MIE-McKeown + 2-field lymphadenectomy and developed anastomotic and mediastinal leak and received new technology treatment in the Affiliated Cancer Hospital of Zhengzhou University from June 2018 to March 2022. The clinical data and prognosis of the patients were collected and analyzed. A total of 5 patients received this surgery, and no other complications occurred during the perioperative period. Among the 5 patients, 1 patient was partially cured, and 4 patients were completely cured. During the follow-up 3 months postoperatively, all these 5 patients could eat regular food smoothly, and no relapse of leak and mediastinal infection occurred. The new surgical method has achieved good results in the treatment of anastomotic leak. Compared with the traditional thoracotomy, it is a less invasive and feasible surgical approach, which can be used as a supplement to the effective surgical treatment of cervical anastomotic leak contaminating the mediastinum.
Total lung-sparing tracheobronchial sleeve resections are a step forward in the treatment of low-grade bronchial tumors in which minimal resection margins are required to achieve complete control of ...the disease.
This study retrospectively collected data on patients who underwent total lung-sparing procedures for low-grade tracheobronchial tumors at 2 thoracic surgical centers from January 1984 to October 2019.
The study included 98 patients, 46 –female (47%) and 52 –male (53%), with a median age of 39 years (range, 7 to 70 years). Thirty-four patients underwent operative endoscopy before surgery (32 had laser treatment, and 2 had endobronchial stenting). The surgical resections were as follows: 9 (9%), tracheal carina; 18 (18%), second carina; 31 (32%), left main bronchi; 25 (26%), right main bronchi; and 15 (15%), intermediate bronchus. The median length of the resected bronchus was 2.2 cm. The median postoperative in-hospital stay was 8 days, and no perioperative mortality was observed. Postoperative complications were recorded in 26-patients (27%). The final histologic classification was as follows: 37 typical carcinoids (38%); 10 atypical carcinoids (10%); 29 adenoid cystic carcinomas (30%); 15 mucoepidermoid carcinomas (15%); 6 inflammatory myofibroblastic tumors (6%); and 1 glomic tumor (1%). Twenty-two patients had positive resection margins and underwent adjuvant radiotherapy. Three patients with adenoid cystic carcinoma had recurrences (1 local and 2 systemic). After a median follow-up time of 54.5 months (range, 4 to 360 months), the overall actuarial 5-year survival was 97%.
Total lung-sparing tracheobronchial sleeve resection for low-grade malignant disease requires advanced surgical skills, but the hospital morbidity and mortality are very low. This technique is adequate and safe for highly selected patients with low-grade endobronchial malignant diseases, and its use should be encouraged in experienced centers.
Primary spontaneous pneumothorax (PSP) is a relatively common disease. Different studies have been published but lung resection, when no emphysema-like changes (ELC) are detected, is unclear. The aim ...of our study is to retrospectively investigate the role of lung resection of the apex of the lung in patients with no ELC.
This is a retrospective multicenter study of 516 patients who underwent surgical treatment of PSP with no ELC between January 2007 and December 2017. Patients were divided into two groups: pleurodesis alone group, only mechanical pleurodesis performed (53 patients), and apical resection group, apical resection of the lung and mechanical pleurodesis performed (463 patients). The following were the primary end points considered: recurrence rate and perioperative complications; the following were the secondary end points considered: length of stay, chest tube removal, residual pleural space, prolonged air leak, and reoperation rate.
No differences were found in the baseline and operative characteristics of the two groups. Both primary end points were statistically different: recurrence rate (15.1% versus 6.5%, P = 0.023) and perioperative complications (18.9% versus 7.3%, P = 0.004). Among secondary end points length of stay (6.94 versus 5.55, P = 0.033) and prolonged air leak (15.1% versus 4.3%, P = 0.001) were statistically different. On multivariate analysis, lung resection emerged as a protective factor for recurrence (hazard ratio 0.182, P < 0.001).
In our experience, apical lung resection in patients without ELC may reduce recurrence rate and perioperative complications when compared with pleurodesis alone.
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