Impact of Modified Frailty Index on Readmissions Following Surgery for NSCLC.

BACKGROUND: Analyzing the risk factors that predict readmissions can potentially lead to more individualized patient care. The 11-factor modified frailty index is a valuable tool for predicting postoperative outcomes following surgery. The objective of this study is to determine whether the frailty index can effectively predict readmissions within 90 days after lung resection surgery in cancer patients within a single health care institution. METHODS: Patients who underwent elective pulmonary resection for nonsmall cell lung cancer (NSCLC) between January 2012 and December 2020 were selected from the hospital's database. Patients who were readmitted after surgery were compared to those who were not, based on their data. Propensity score matching was employed to enhance sample homogeneity, and further analyses were conducted on this newly balanced sample. RESULTS: A total of 439 patients, with an age range of 68 to 77 and a mean age of 72, were identified. Among them, 55 patients (12.5%) experienced unplanned readmissions within 90 days, with an average hospital stay of 29.4 days. Respiratory failure, pneumonia, and cardiac issues accounted for approximately 67% of these readmissions. After propensity score matching, it was evident that frail patients had a significantly higher risk of readmission. Additionally, frail patients had a higher incidence of postoperative complications and exhibited poorer survival outcomes with statistical significance. CONCLUSION: The 11-item modified frailty index is a reliable predictor of readmissions following pulmonary resection in NSCLC patients. Furthermore, it is significantly associated with both survival and postoperative complications.

Laparoscopic Approach to Epiphrenic Diverticula Under Endoscopic Assistance: A Technical Report.

Introduction: Epiphrenic diverticulum is a rare disease caused by mucosa and submucosa herniation through the muscular layers of the esophageal wall. This study presents a case of a patient with a symptomatic epiphrenic diverticulum treated with surgery under endoscopic assistance. A review of the literature on this unusual condition was conducted, focusing on the pathogenesis, presentation, and surgical challenges. Methods: A 75-year-old woman who underwent an esophagogastroduodenoscopy (EGD) after experiencing worsening dysphagia for food and liquids. The EGD revealed a large epiphrenic diverticulum 36 cm from the upper incisor teeth. The presence of a diverticulum was verified by barium swallow, which revealed a 6 cm diameter epiphrenic diverticulum on the right side of the esophagus. Results: Patient underwent laparoscopic diverticulectomy associated with Heller's myotomy and anterior partial fundoplication. A gastroscope was placed intraoperatively to calibrate the esophagus to prevent stenosis during diverticulectomy, and it was also used to check the integrity of the esophageal wall. The patient tolerated clear liquids on postoperative day 2. Postoperative course was complicated by right pleural effusion and fever managed with antibiotics and pleural drainage. Conclusion: Epiphrenic diverticulectomy in conjunction with management of the underlying motor dysfunction and avoidance of gastroesophageal reflux disease is an effective procedure. Laparoscopy is considered the approach of choice for the majority of patients. Endoscopic assistance during surgery can help the identification of the diverticulum and verify the integrity of the staple line.

A Narrative Review on Treatment of Giant Hiatal Hernia.

Background: The current gold standard of treatment for giant hiatal hernias (GHHs) is laparoscopic surgery. Laparoscopic surgery was performed as a less invasive procedure for paraesophageal hernias more than 25 years ago. Its viability and safety have almost all been shown. Materials and Methods: A review of recent and current studies' literature was done. Prospective randomized trials, systematic reviews, clinical reviews, and original articles were all investigated. The data were gathered in the form of a narrative evaluation. We examine the state of laparoscopic GHH repair today and outline the GHH management strategy. Results: In this review, we clear up misunderstandings of GHH and address bad habits that may have contributed to poor results, and we have consequently performed a methodical evaluation of GHH. First, we address subcategorizing GHH and provide criteria to define them. The preoperative workup strategies are then discussed, with a focus on any pertinent and frequent atypical symptoms, indications for surgery, timing of surgery, and the importance of surgery. The approach to the techniques and the logic behind surgery are then presented along with some important dissection techniques. Finally, we debate the role of mesh reinforcement and evaluate the data in terms of recurrence, reoperation rate, complications, and delayed stomach emptying. Finally, we suggest a justification for common postoperative investigations. Conclusions: Surgery is the only effective treatment for GHH at the moment. If the right operational therapy principles are applied, this is generally successful. There is a growing interest in laparoscopic paraesophageal hiatal hernia repair as a result of the introduction of laparoscopic antireflux surgery. Today's less invasive procedures provide a better therapeutic choice with a lower risk.

Unilateral Thoracoscopic Thymectomy for Thymoma: Does Side Matter? A Single Institutional Experience.

BACKGROUND: Thoracoscopic thymectomy is increasingly performed for the treatment of early stage thymoma. It is characterized by shorter postoperative hospital stay, decreased intraoperative blood loss, and fewer complications compared with transsternal thymectomy. Unilateral video-assisted thoracic surgery (VATS) thymectomy can be easily performed from either side of the thorax, because thymus is located in the middle of mediastinum. However, the side that provides better outcomes remains controversial. The purpose of this study was to compare the efficacy of right and left approaches in performing unilateral thoracoscopic thymectomy for thymoma. METHODS: Consecutive patients affected by thymoma who underwent VATS thymectomy on either side between February 2001 and March 2020 were enrolled in the study. Clinicopathologic, surgical, and oncological outcomes were retrospectively analyzed and compared among the two surgical approaches. RESULTS: Unilateral VATS approaches were performed on 29 patients: 12 (41%) on the left side and 17 (59%) on the right side. The mean age was 63.1 ± 11.3 years and the female/male ratio was 1.73:1. The mean operative time and the hospital stay for the left-side VATS and right-side VATS groups were, respectively, 168 ± 49.5 versus 171 ± 47.9 minutes (p = 0.9) and 3 ± 1.03 days versus 3.65 ± 1.93 days (p = 0.7). Postoperative complications occurred in one patient (3%) for left-side VATS group and one patient (3%) for right-side VATS. The 5-year disease-free survival was comparable between two groups (p = 0.74). CONCLUSION: Unilateral VATS thymectomy in patients with thymoma can be safely and effectively performed by experienced surgeons in either side of the thorax with equivalent oncological outcomes.

Association of the Extent of Resection with Survival in Multiple Primary Lung Cancer: A Systematic Review.

BACKGROUND: The incidence of synchronous multiple primary lung cancer (SMPLC) has progressively increased, due to recent advances in imaging. To date, no guidelines defining recommendations for patients' selection and no standard treatment of cases with SMPLC have been defined.The primary aim of this systematic review was to assess survival among patients treated with lobectomy or sublobar resection MPLC. METHODS: Comprehensive literature search of Medline, the Cochrane Library, reference lists, and ongoing studies was performed according to a prospectively registered design (PROSPERO: CRD42019115487). All studies published between 1998 and December 2020 that examined treatments with lobectomy compared to sublobar resection were included. Two double-blind investigators independently selected articles.Primary outcomes were to assess the 5-year overall survival (OS) rate among patients treated with lobectomy or sublobar resection and the impact of lymph node status on 5-year OS and 5-year disease-free survival in patients with MPLC. RESULTS: The search yielded 424 articles; 4 observational studies met the inclusion criteria and collectively evaluated 298 patients with a mean age ranging from 61.5 to 67 years. A total of 112 patients were treated for bilateral synchronous tumors and 186 patients for unilateral multiple synchronous tumors. All included studies showed that the type of resection, lobectomy or limited resection, had no significant impact on survival. CONCLUSION: Limited resection is a valuable treatment option for MPLC. However, the clinical level of evidence of the studies found is low and randomized studies are needed to clarify the extent of resection in MPLC.

Factors Associated with Early Discharge after Thoracoscopic Lobectomy: Results from the Italian VATS Group Registry.

Objective. There are limited data for estimating the risk of early discharge following thoracoscopic lobectomy. The objective was to identify the factors associated with a short length of stay and verify the influence of these variables in uncomplicated patients. Methods. We reviewed all lobectomies reported to the Italian VATS Group between January 2014 and January 2020. Patients and perioperative characteristics were divided into two subgroups based on whether or not they met the target duration of stay (≤ or >4 days). The association between preoperative and intraoperative variables and postoperative length of stay (LOS) ≤4 days was assessed using a stepwise multivariable logistic regression analysis to identify factors independently associated with LOS and factors related to LOS in uncomplicated cases. Results. Among 10,240 cases who underwent thoracoscopic lobectomy, 37.6% had a hospital stay ≤4 days. Variables associated with LOS included age, hospital surgical volume, Diffusion Lung CO % (81 [69−94] vs. 85 [73−98]), Forced Expiratory Volume (FEV1) % (92 [79−106] vs. 96 [82−109]), operative time (180 [141−230] vs. 160 [125−195]), uniportal approach (571 [9%] vs. 713 [18.5%]), bioenergy sealer use, and pain control through intercostal block or opioids (p < 0.001). Except for FEV1 and blood loss, all other factors emerged significantly associated with LOS when the analysis was limited to uncomplicated patients. Conclusions. Demographic, clinical, and surgical variables are associated with early discharge after thoracoscopic lobectomy. This study indicates that these characteristics are associated with early discharge. This result can be used in association with clinical judgment to identify appropriate patients for fast-track protocols.

Inflammatory Microenvironment in Early Non-Small Cell Lung Cancer: Exploring the Predictive Value of Radiomics.

Patient prognosis is a critical consideration in the treatment decision-making process. Conventionally, patient outcome is related to tumor characteristics, the cancer spread, and the patients' conditions. However, unexplained differences in survival time are often observed, even among patients with similar clinical and molecular tumor traits. This study investigated how inflammatory radiomic features can correlate with evidence-based biological analyses to provide translated value in assessing clinical outcomes in patients with NSCLC. We analyzed a group of 15 patients with stage I NSCLC who showed extremely different OS outcomes despite apparently harboring the same tumor characteristics. We thus analyzed the inflammatory levels in their tumor microenvironment (TME) either biologically or radiologically, focusing our attention on the NLRP3 cancer-dependent inflammasome pathway. We determined an NLRP3-dependent peritumoral inflammatory status correlated with the outcome of NSCLC patients, with markedly increased OS in those patients with a low rate of NLRP3 activation. We consistently extracted specific radiomic signatures that perfectly discriminated patients' inflammatory levels and, therefore, their clinical outcomes. We developed and validated a radiomic model unleashing quantitative inflammatory features from CT images with an excellent performance to predict the evolution pattern of NSCLC tumors for a personalized and accelerated patient management in a non-invasive way.

Application of Indocyanine Green Enhanced Fluorescence in Esophageal Surgery: A Mini Review.

Despite recent technological innovations and the development of minimally invasive surgery, esophagectomy remains an operation burdened with severe postoperative complications. Fluorescence imaging, particularly using indocyanine green (ICG), offers the ability to address a number of issues faced during esophagectomy. The three main indications for the intraoperative use of ICG during esophagectomy are visualization of conduit vascular supply, allow identification of sentinel nodes and visualization of the thoracic duct. The purpose of this mini review is to present an overview of current practice in fluorescence imaging utilizing ICG during esophagectomy, as well as to demonstrate how this technology can guide lymphadenectomy and reduce surgical morbidity such as anastomotic leaking and chylothorax.

Analysis of Rates, Causes, and Risk Factors for 90-Day Readmission After Surgery for Large Hiatal Hernia: A Two-Center Study.

Background: Hospital readmissions have become a more examined indicator of surgical care delivery and quality. There is scarcity of data in the literature on the rate, risk factors, and most common reasons of readmission following major hiatal hernia surgery. The primary endpoint was 90-day readmission after surgery for large hiatal hernia. Secondary endpoint was to examine which characteristics related with a higher risk of readmission. Methods: A retrospective review of two distinct institutional databases was performed for patients who had surgery for a large hiatal hernia between January 2012 and December 2019. Demographic, perioperative, and outpatient data were collected from the medical record. Results: A total of 71 patients met the inclusion criteria, most of them suffering from a type III hernia (66.2%). Mean operative time was 146 (±56.5) minutes and median length of stay (LOS) was 6 days (interquartile range = 3). The overall morbidity was 21.1% and the in-hospital mortality was 1.4%. The 30- and 90-day readmission rates were 7% and 8.5%, respectively. The mean time to readmission was 14.3 (±15.6) days. The reasons for 90-day hospital readmission were dysphagia (50%), pneumonia (16.7%), congestive heart failure (16.7%), and bowel obstruction (16.7%). Grade of esophagitis ≥2, presence of Barrett's esophagus, and LOS longer than 8 days were significant risk factors for unplanned readmission within 90 days. Conclusion: We observed that about 6 out of 71 patients who had surgery readmitted within 90 days (8.5%). Readmissions were most often linked to esophagitis ≥2, presence of Barrett's esophagus, and LOS longer than 8 days. These findings point to the necessity for focused treatments before, during, and after hospitalization to decrease morbidity and extra costs in this high-risk population.

Extracorporeal versus intracorporeal anastomosis in laparoscopic right hemicolectomy for cancer.

INTRODUCTION: This study aimed at assessing the long-term oncological outcomes of intracorporeal ileocolic anastomosis (ICA) for laparoscopic right hemicolectomy for colon cancer compared with extracorporeal anastomosis (ECA). MATERIAL AND METHODS: We performed a retrospective analysis of 149 consecutive patients who underwent laparoscopic right hemicolectomy for colon cancer between January 2006 and December 2012. RESULTS: Eighty and 69 patients underwent intracorporeal and ECA, respectively. The two groups were demographically comparable. ICA exhibited a significantly shorter operative time (p < .0001), while local relapse and length of hospital stay did not significantly differ among the groups (p = .724 and .310, respectively). There was no significant difference in median number of retrieved lymph node. The overall survival and the disease-free survival at five years did not significantly differ among the groups. CONCLUSIONS: Intracorporeal ICA can reduce operative time and is associated with similar postoperative and long-term oncological outcomes compared to the ECA technique.

Video-assisted thoracoscopic lobectomy after neoadjuvant chemotherapy for non-small cell lung cancer: a multicenter propensity-matched study.

BACKGROUND: The role of video-assisted thoracoscopic surgery for the treatment of non-small-cell lung cancer after neoadjuvant chemotherapy remains controversial. The aim of this study is to demonstrate the reliability of video-assisted lobectomy compared to the open approach by evaluating perioperative and long-term outcomes. METHODS: In this retrospective, multicentric study from January 2010 to December 2018, we included all patients with non-small-cell lung cancer who underwent lobectomy through the video-assisted or open approach after neoadjuvant chemotherapy. The perioperative outcomes, including data concerning the feasibility of the surgical procedure, the occurrence of any medical and surgical complications and long-term oncological evidence, were collected and compared between the two groups. To minimize selection bias, propensity score matching was performed. RESULTS: A total of 286 patients were enrolled: 193 underwent thoracotomy lobectomy, and 93 underwent VATS lobectomy. The statistical analysis showed that surgical time (P < 0.001), drainage time (P < 0.001), days of hospitalization (P < 0.001) and VAS at discharge (P = 0.042) were lower in the VATS group. The overall survival and disease-free survival were equivalent for the two techniques on long-term follow-up. CONCLUSIONS: VATS lobectomy represents a valid therapeutic option in patients affected by non-small-cell lung cancer after neoadjuvant chemotherapy. The VATS approach in our experience seems to be superior in terms of the perioperative outcomes, while maintaining oncological efficacy.

A risk stratification scheme for synchronous oligometastatic non-small cell lung cancer developed by a multicentre analysis.

BACKGROUNDS: Oligometastatic Non-Small Cell Lung Cancer (NSCLC) patients represent a category without a standard therapeutic approach. However, in selected oligometastatic NSCLC, radical surgery seems to offer a good prognosis. This retrospective study aimed to analyse the long-term outcomes of synchronous oligometastatic patients treated with curative intent and identify the factors associated with better results and the proposal of a risk stratification system for classifying the synchronous oligometastatic NSCLC. METHODS: The medical records of patients from 18 centres with pathologically diagnosed synchronous oligometastatic NSCLC were retrospectively reviewed. The inclusion criteria were synchronous oligometastatic NSCLC, radical surgical treatment of the primary tumour with or without neoadjuvant/adjuvant therapy and radical treatment of all metastatic sites. The Kaplan - Meier method estimated survivals. A stratified backward stepwise Cox regression model was assessed for multivariable survival analyses. RESULTS: 281 patients were included. The most common site of metastasis was the brain, in 50.89 % patients. Median overall survival was 40 months (95 % CI: 29-53). Age ≤65 years (HR = 1.02, 95 % CI: 1.00-1.05; p = 0.019), single metastasis (HR = 0.71, 95 % CI: 0.45-1.13; p = 0.15) and presence of contralateral lung metastases (HR = 0.30, 95 % CI: 0.15 - 0.62; p = 0.001) were associated with a good prognosis. The presence of pathological N2 metastases negatively affected survival (HR = 2.00, 95 % CI: 1.21-3.32; p = 0.0065). These prognostic factors were used to build a simple risk classification scheme. CONCLUSIONS: Treatment of selected synchronous oligometastatic NSCLC with curative purpose could be conducted safely and at acceptable 5-year survival levels, especially in younger patients with pN0 disease.

The Surgical Management of Acute Gastric Volvulus: Clinical Outcomes and Quality of Life Assessment.

Background: Surgery is the mainstay of treatment for gastric volvulus. Despite its rarity, early experience from recent publications suggests that laparoscopy is a safe and effective approach for the treatment of acute gastric volvulus. Yet, more data focusing on patients' postoperative quality of life (QoL) is needed. The aim of this study is to report our institutional experience with the management of acute gastric volvulus, assessing surgical outcomes and postoperative QoL. Materials and Methods: We performed a retrospective review of a prospectively maintained database, looking for patients with gastric volvulus, requiring emergency laparotomic or laparoscopic surgery, between 2016 and 2018. Follow-up included clinical evaluation, barium swallow X-ray, and two QoL questionnaires-Gastroesophageal Reflux Disease-Health-Related Quality of Life and Gastrointestinal Symptom Rating Scale. Results: Over a 3-year period, 9 patients underwent emergency surgery for acute gastric volvulus, 5 (55%) of which were performed laparoscopically. In this group, the only postoperative complication was found in 1 (20%) patient who presented mild delayed gastric empty. In the laparotomic group, 3 patients (75%) had immediate (30-day) postoperative complications-1 pneumonia, 1 bowel obstruction, and 1 sepsis with multiorgan failure. At a median follow-up of 25 (15-48) months, hiatal hernia recurred in 1 (20%) patient after laparoscopic repair. No recurrence occurred in the open group. With a 100% response rate, QoL questionnaires revealed that 80% of the subjects treated laparoscopically were fully satisfied of the surgical approach, reporting slightly better QoL scores than the open surgery group. Conclusions: Improved postoperative clinical outcomes and QoL after laparoscopic repair of acute gastric volvulus provide encouraging evidence in support of this minimally invasive approach as an alternative to laparotomy.

Thymic Epithelial Tumors: Prognostic Significance and Relationship between Histology and the New TNM Staging System.

BACKGROUND: This study aims to describe the relationship between the new tumor nodes metastasis (TNM) staging and World Health Organization (WHO) classification and to identify how these two variables relate to each other and whether they possess a prognostic value in predicting survival and recurrence of disease. METHODS: Medical records of 54 patients who underwent surgery for thymic epithelial tumors between 1996 and 2015 were reviewed.The histologic type of neoplasm was classified according to the criteria of WHO and staging was evaluated using the new TNM classification system. RESULTS: A significant correlation between the TNM stages and the histological classification was found (p < 0.001). Complete resection is related to both TNM stage and histological grading (p < 0.001). Evaluation of the 5- and 10-year survival curves shows how these are significantly correlated only at the stage (p = 0.03 and = 0.04, respectively). The risk of death at 5 and 10 years for stages III to IV is six and three times higher than in stages I to II, respectively. Regarding the disease-free survival, there is significant correlation with both staging and histology (p = 0.001 and = 0.02, respectively). CONCLUSIONS: There is a significant correlation between the new TNM staging and the histological grade WHO. The ability to implement a complete resection, the overall and disease-free survival is closely related to the thymoma stage. Furthermore, both histotype and stage correlate with disease-free survival. In fact, the least aggressive stages, both WHO and TNM, have a free time out of disease superior to advanced stages.

Chest wall reconstruction using a new titanium mesh: a multicenters experience.

BACKGROUND: Many new surgical techniques and materials have been introduced in the last decade for chest wall reconstruction or stabilization with the purpose of improving the incorporation, maintaining chest wall stability with reduction of infections. However, none of them are yet considered a gold standard procedure. The aim of this work is to evaluate the initial experience using a new titanium mesh for chest wall reconstruction in four Italian Thoracic Surgery Departments. METHODS: A review was performed of all patients undergoing chest wall reconstruction using a new titanium mesh between January 2014 and September 2018. Surgical indications, the location and size of the chest wall defect, intraoperative variables and postoperative complications were analyzed. RESULTS: A total of 26 consecutive patients were included. The most common indications for surgery were primary or secondary chest wall tumors (38%) followed by lung cancer invading chest wall (31%). The most common localization of chest wall defect was anterolateral (46%). Sternal reconstruction was required in 3 patients (12%). The average size of the defect was 9.3×7.8 cm. The median number of resected ribs was 3.6. No perioperative deaths occurred. Mean hospital stay was 11.9 days. Overall morbidity was 19%. One failure of reconstruction (4%) was reported during follow up. CONCLUSIONS: In our early clinical experience chest wall reconstruction using titanium mesh can be performed as a safe and effective surgical procedure. This mesh has excellent biomechanical characteristics between rigid and malleable materials, it's easy to trim and fix for optimal adaptation without necessity of dedicated instruments. The early and mid-term results are satisfactory with low incidence of complications related to the titanium mesh implant.

Surgical excision of a tufted angioma of the hand in an adult-a rare case report with a review of literature.

Tufted Angiomas, also known as angioblastomas/Angioblastoma of Nagakawa, are rare vascular neoplasms of both sexes localised to the skin and subcutaneous tissues with the upper trunk and neck being the most common sites. They are more common in children but a few cases in juveniles and adults have been reported. Typically, Tufted Angioma remains stable or can show rarely a spontaneous regression. This article wants to evaluate the efficacy of current treatment modalities for tufted angioma (TA). A review was performed using PubMed database (Medline) for clinical studies. We report our case, a 29-year-old female who presented with a second finger of the left hand, painful, slowly progressive, firm swelling diagnosed as Tufted Angioma on histopathology and immunohistochemistry after complete surgical excision.

Technical results, clinical efficacy and predictors of outcome of intercostal arteries embolization for hemothorax: a two-institutions' experience.

BACKGROUND: To evaluate the clinical efficacy and identify the predictors of outcome of intercostal arterial embolization for hemothorax caused by intercostal artery (ICA) injuries. METHODS: A retrospective multi-institutional study was conducted. Outcomes were analyzed in 30 consecutive patients presenting with hemothorax caused by active ICA hemorrhage undergoing transcatheter arterial embolization (TAE). Clinical and procedural parameters were compared between outcomes groups. RESULTS: Overall technical success rate was 87% (n=26). Among the 4 failed cases, 2 underwent repeated TAE and 2 underwent additional surgery. Overall 30-day mortality rate was 23%. Low haemoglobin levels and haematocrit, hepatic comorbidities and more than one artery undergoing embolization increased technical failure rate significantly. Survival was poorer in patients with massive bleeding. CONCLUSIONS: ICA embolization was found to be a safe and effective method in treating hemothorax caused by active ICA haemorrhage. Careful pre-embolization evaluation may be required for patient with low haemoglobin levels and haematocrit, hepatic comorbidities and active haemorrhage from more than one artery.

A rare case of intralobar pulmonary sequestration: combined endovascular and video-assisted thoracoscopic approach.

Pulmonary sequestration is a congenital malformation characterized by cystic, non-functioning embryonic lung tissue supplied by an abnormal systemic artery. It's a rare disease widely variable in clinical presentation and severity, depending mostly on the degree of lung involvement and location in the thoracic cavity. Most patients have recurrent infections and inflammatory conditions in the affected lobe. Surgical resection continues to be the gold standard of therapy and in this context anatomical resection is the procedure of choice and yields excellent long-term results. There are few studies reporting the use of combined endovascular and thoracoscopic approaches for pulmonary sequestration. We describe a case of intralobar pulmonary sequestration located in the lower lobe of the right lung, which was treated with video-assisted thoracoscopic surgery (VATS) after endovascular embolization of systemic artery arising from celiac trunk.