Salivary metabolites as potential predictive biomarkers for lung surgery complications: a retrospective cross-sectional study.

PURPOSE: Saliva is often used as a tool for identifying systemic diseases because of the noninvasive nature of its collection. Moreover, salivary metabolites can be potential predictive factors for postoperative survival. We conducted the present study to establish whether salivary metabolites can function as predictive biomarkers for lung surgery complications. METHODS: Unstimulated salivary samples were collected from 412 patients before lung surgery. Salivary metabolites were analyzed comprehensively by capillary electrophoresis mass spectrometry. Clinical data with the discriminatory ability of biomarkers were assessed to predict lung surgery complications using multivariate logistic regression analysis. The primary endpoint was the risk factors for postoperative complications of Clavien-Dindo grade ≥ III. RESULTS: Postoperative complications of Clavien-Dindo grade ≥ III developed in 36 patients (8.7%). There was no postoperative 30-day mortality. Male sex (odds ratio [OR], 3.852; 95% confidence interval CI 1.455-10.199; p = 0.007) and salivary gamma-butyrobetaine (OR, 0.809; 95% CI 0.694-0.943; p = 0.007) were identified as significant risk factors for postoperative complications of Clavien-Dindo grade ≥ III. CONCLUSION: Salivary metabolites are potential noninvasive biomarkers for predicting postoperative complications of lung surgery.

Evaluation of the radiofrequency identification lung marking system: a multicenter study in Japan.

BACKGROUND: The radiofrequency identification (RFID) lung marking system is a novel technique using near-field radio-communication technology. The purpose of this study was to investigate the utility and feasibility of this system in the resection of small pulmonary nodules. METHODS: We retrospectively reviewed clinical records of 182 patients who underwent sublobar resection with the RFID marking system between March 2020 and November 2021 in six tertial hospitals in Japan. Target markings were bronchoscopically made within 3 days before surgery. The contribution of the procedure to the surgery and safety was evaluated. RESULTS: Target nodule average diameter and depth from the lung surface were 10.9 ± 5.4 mm and 14.6 ± 9.9 mm, respectively. Radiologically, one third of nodules appeared as pure ground-glass nodules (GGNs) on CT. The average distance from target nodule to RFID tag was 8.9 ± 7.1 mm. All surgical procedures were completed by video-assisted thoracoscopic surgery. Planned resection was achieved in all cases without any complications. The surgeons evaluated this system as helpful in 93% (necessary: 67%, useful; 26%) of cases. Nodule radiological features (p < 0.001) and type of surgery (p = 0.0013) were associated with the degree of contribution. In most cases, identification of the RFID tag was required within 1 min despite adhesion (p = 0.27). CONCLUSION: The RFID lung marking system was found to be safe and effective during successful sublobar resection. Patients with pure GGNs are the best candidates for the system.

Learning Curve for Thoracoscopic Individual Basilar Segmentectomy: 18-Year Experience.

BACKGROUND: Thoracoscopic anatomical individual basilar segmentectomy remains challenging owing to the deep intraparenchymal location of the hilar structures and anatomical variations. We analyzed and reported the experience and progress of thoracoscopic anatomical individual basilar segmentectomy at our university hospital. METHODS: We retrospectively examined the patients who underwent anatomical basilar segmentectomy at our institution from January 2004 to December 2021. We divided our analysis period into two parts: the first period (2004-2012) was the introductory period of video-assisted thoracoscopic surgery (VATS) segmentectomy, and the second period (2013-2021) was the maturity period of VATS segmentectomy. The learning curve of the leading surgeon in the second period was also evaluated based on the operative time and cumulative sum value of the operative time. RESULTS: Overall, 127 cases were evaluated, among whom 33 and 94 cases were assessed during the introductory and maturity periods of thoracoscopic segmentectomy, respectively. Age (P = 0.003) and Charlson comorbidity index (P = 0.002) were higher in the second period than in the first period. Use of a uniport (P = 0.006) was higher, and postoperative hospitalization duration (P = < 0.001) and operative time (P = 0.024) were shorter in the second period than in the first period. A learning curve obtained during the maturity period showed: The inflection point for the learning curve of thoracoscopic basilar segmentectomy was reached after 42 cases. CONCLUSIONS: We have demonstrated a single institution's progress and learning curve for difficult segmentectomies. This may be helpful to institutions considering performing this surgery.

[Right Brachial Artery Thromboembolism After Left Upper Lobectomy].

A 71-year-old man underwent a computed tomography( CT) scan to check for prostate cancer metastasis. It revealed a lung tumor in the left upper lobe, and he was referred to our division. Under clinical diagnosis of primary lung cancer, left upper lobectomy was performed. Dense adhesion due to the history of tuberculosis was observed. On the first postoperative day, he complained of sudden numbness in his right arm during rehabilitation. The emergent contrast-enhanced CT revealed the right brachial arterial thromboembolism. We performed an embolectomy, and further analysis of the postoperative enhanced CT revealed a longer left upper pulmonary vein stump than usual. We thought it to be the cause of the thrombus formation and started anticoagulation therapy. The postoperative course was uneventful, without recurrence of thromboembolism.

Outcome of thoracoscopic anatomical sublobar resection under 3-dimensional computed tomography simulation.

BACKGROUND: Previous studies have reported the feasibility and efficacy of thoracoscopic anatomical sublobar resection under three-dimensional computed tomography (3DCT) simulation; however, its long-term outcomes have not been clearly established in primary lung cancer. This study aimed to evaluate the long-term outcomes of this technique. METHODS: We retrospectively reviewed data from 112 consecutive patients with selected clinical stage IA non-small cell lung cancer (NSCLC) who underwent thoracoscopic anatomical sublobar resection from 2004 to 2014. This procedure was planned using preoperative 3DCT simulation to ensure sufficient surgical margins and enabled tailor-made surgery for each patient. Patients who had predominantly ground glass opacity lung cancers underwent anatomical sublobar resection as a curative-intent resection. Other patients who were high-risk candidates for lobectomy underwent anatomical sublobar resection as a compromised limited resection. RESULTS: Of the 112 cases, 82 had a curative-intent resection, while 30 had a compromised limited resection. Recurrence occurred in only 2 cases (1.8%), both of which were in the compromised limited group. A second primary lung cancer was observed in 5 cases (4.5%). Of the 5 patients, 4 underwent surgery for a second cancer and had no recurrence. The 5-year overall survival, lung cancer-specific overall survival, and recurrence-free survival rates were 92.5%, 100%, and 98.2%, respectively, for all cases; 97.6%, 100%, and 100%, respectively, in the curative-intent group; and 75.8%, 100% and 92.6%, respectively, in the compromised limited group. CONCLUSIONS: Thoracoscopic anatomical sublobar resection under 3DCT simulation may be an acceptable alternative treatment in selected patients with NSCLC. TRIAL AND CLINICAL REGISTRY: Clinical registration number: IRB No. 2020-98 (Dated: 2020.6.30).

Video-Assisted Thoracoscopic Segmentectomy for Deep and Peripheral Small Lung Cancer.

BACKGROUND: We aimed to retrospectively compare the long-term prognosis and recurrence after segmentectomy between nonsmall cell lung cancer (NSCLC) patients with deep and peripheral lesions. METHODS: Data were extracted for 85 lobectomy-tolerable NSCLC patients with tumors measuring ≤2 cm, who underwent video-assisted thoracoscopic segmentectomy with curative intent during January 2006 to December 2014. Tumor location was determined by the surgeon using thin-slice (1 mm) and three-dimensional computed tomography. Overall and recurrence-free survival was compared between patients with peripheral and deep lesions using univariate and multivariate Cox proportional hazard models. The indications for segmentectomy included NSCLC measuring ≤2 cm and consolidation/tumor ratio ≤20%, solid NSCLC ≤1 cm, and indeterminate nodule ≤1.5 cm. RESULTS: No recurrence of peripheral and deep lesions was noted. The 5-year overall survival was 96.4% for all patients, and 100 and 95.3% for patients with deep and peripheral lesions, respectively. There was no significant difference between the overall survival rates associated with the deep and peripheral lesions (95% confidence interval [CI], 89.5-98.8, nonsignificant, 86.4-98.4, respectively; p = 0.189). In a multivariate analysis, the American Society of Anesthesiologists score (hazard ratio [HR], 13.30; 95% CI, 1.31-210.36; p = 0.028) and histology (HR, 0.03; 95% CI, 0.00-0.32; p = 0.037) were independent prognostic factors for overall survival; tumor location was not a prognostic factor. CONCLUSIONS: When video-assisted thoracoscopic segmentectomy with curative intent was performed with sufficient surgical margins, the location of small NSCLC did not affect recurrence risk and prognosis. Video-assisted thoracoscopic segmentectomy for small NSCLC is acceptable, regardless of the tumor location.

Evaluation of effects of perioperative oral care intervention on hospitalization stay and postoperative infection in patients undergoing lung cancer intervention.

PURPOSE: This retrospective study investigated the effect of perioperative oral care intervention on postoperative outcomes in patients undergoing lung cancer resection, in terms of the length of postoperative hospital stay and the incidence of postoperative respiratory infections. METHODS: In total, 585 patients underwent lung resection for lung cancer, 397 received perioperative oral care intervention, whereas the remaining 188 did not. This study retrospectively investigated the demographic and clinical characteristics (including postoperative complications and postoperative hospital stay) of each group. To determine whether perioperative oral care intervention was independently associated with either postoperative hospital stay or postoperative respiratory infections, multivariate analysis, multiple regression analysis, and multivariate logistic regression analysis were conducted. RESULTS: Parameters significantly associated with a prolonged postoperative hospital stay in lung cancer surgery patients were older age, postoperative complications, increased intraoperative bleeding, more invasive operative approach (e.g., open surgery), and lack of perioperative oral care intervention (standard partial regression coefficient (ß) = 0.083, p = 0.027). Furthermore, older age and longer operative time were significant independent risk factors for the occurrence of postoperative respiratory infections. Lack of perioperative oral care intervention was a potential risk factor for the occurrence of postoperative respiratory infections, although not statistically significant (odds ratio = 2.448, 95% confidence interval = 0.966-6.204, p = 0.059). CONCLUSION: These results highlight the importance of perioperative oral care intervention prior to lung cancer surgery, in order to shorten postoperative hospital stay and reduce the risk of postoperative respiratory infections.

[Aspergillus Empyema with Bronchopleural Fistula due to Destroyed Lung after Postoperative Radiotherapy for Thymoma].

A 35-year-old man underwent adjuvant chemoradiation therapy to the surgical margin of the thymoma. Five years after the therapy, an area of the right upper lung lobe, which was included in the irradiation field, developed destroyed lung, resulting in Aspergillus empyema with bronchopleural fistula. To control the infection, an open window thoracostomy was performed. As the bronchopleural fistula resulted in pneumonia, bronchial embolization was performed with an Endobronchial Watanabe Spigot. After the empyema cavity was cleaned, the empyema space was closed with omental and muscular flap, thoracoplasty. Negative pressure wound therapy was carried out because of poor wound healing. The patient is doing well without relapse 15 months after the thoracoplasty.

[The Novel Procedure for Thoracoscopic Anatomical Segmentectomy].

Since 2004, over 300 patients have undergone thoracoscopic segmentectomy without mini-thoracotomy. Thoracoscopic segmentectomy is one of the most complicated surgeries. To perform the complex segmentectomies, pre-operative simulation and 3-dimensional multi-detector computed tomography( 3DCT) are both essential for safely performing operations and for securing adequate surgical margins. Comprehension of the intersegmental and intrasegmental veins to visualize the segmental border facilitates an easier parenchymal dissection. We describe our method and knack for creating an inflation-deflation line for lung segmentectomy that could especially be useful in thoracoscopic procedures for seg-mentectomy. The 5-year over overall survival, cancer specific survival and recurrence free survival rates were 91.8%( curative intent 98.1% versus compromised 74.6%), 100% and 98.1%( curative intent 100% versus compromised 93.3%). According to these technical aspects, our method of thoracoscopic segmentectomy is acceptable for selective patient.

[Thoracoscopic Surgery].

Thoracoscopic devices have become essential in general thoracic surgery. In the past 30 years, many reports about thoracoscopic surgery have expanded the indications to include malignant neoplasms. Various optional procedures including uniportal, non-intubated, robotic, and needlescopic techniques have been developed and more than 70% of lung cancer operations are currently performed using thoracoscopy in Japan. Although there are many choices for minimally invasive surgery, the long-term outcome of these options remains unclear. In addition, training systems for younger surgeons have not provided exposure to novel optional methods, as there are few high-volume centers in Japan.

[Complete Resection of Non-seminomatous Germ Cell Tumor with Plastron Approach].

A 17-year-old man was admitted to our hospital for the abnormal chest shadow. Chest computed tomography(CT) demonstrated mediastinal tumor, measuring 13 cm in diameter with high serum level of alpha fetoprotein (AFP) and human chorionic gonadotropin (hCG). The lesions were diagnosed as mixed germ cell tumors including a non-seminomatous malignant component by CT guided needle biopsy. After 5 courses of chemotherapy, the serum AFP and hCG were decreased almost normal level but the tumor size was not changed. Because it seemed to be difficult to get sufficient operating field with standard median sternotomy and patient wanted to treat funnel chest, we selected tumor resection with plastron approach. The tumor was completely resected with a good operation field by this procedure.

[Chest Wall Reconstruction Using Titanium Plates Sandwiched Between Sheets after Resection of Chest Wall Chondrosarcoma].

Extensive chest wall resection carries the risk of difficult reconstruction and surgical complications. We report our experience on chest wall reconstruction using titanium plates for a wide thoracic defect after tumor resection. A 74-year-old man was diagnosed with chondrosarcoma of the 6th rib on the right. He needed extensive chest wall resection because of skip lesions on 4th rib noted on operative inspection, leaving a defect measuring 33 × 20 cm. Reconstruction using 5 transverse titanium plates sandwiched between an expanded polytetrafluoroethylene patch and a polypropylene mesh sheet stabilized the chest wall. This reconstruction allowed successful separation from ventilatory support after operation. The postoperative course was uneventful, and he was discharged on postoperative day 20. The advantages of this form of reconstruction over conventional prostheses are rigidity, and stability and usability.

[Curative Left Pulmonary Resection Combined with Total En Bloc Spondylectomy for Lung Cancer Invading the Second and Third Thoracic Vertebral Bodies].

Introduction of spinal surgery into the operation of lung cancer has made extensive surgical treatment feasible with acceptable long-term survival. We report our experience on total en bloc total spondylectomy for lung cancer invading the spine. A 60-year-old man was diagnosed with lung adenocarcinoma of the apicodorsal segment of the left lobe with invasion of the 2nd and 3rd thoracic vertebral bodies. After induction chemoradiotherapy, we performed en bloc resection through a posterolateral thoracotomy in the right decubitus position and a posterior median approach in the prone position. The thoracic manipulation was done earlier, making it useful for the dissection of the prevertebral plane from the posterior mediastinum at the upper thoracic level in addition to confirmation of non-N2 disease. Vertebral stabilization was achieved with rod fixation and placement of a titanium mesh cage between the remaining vertebral bodies.

[Application of medical imaging to general thoracic surgery].

Medical imaging technology is rapidly progressing. Positron emission tomography (PET) has played major role in the staging and choice of treatment modality in lung cancer patients. Magnetic resonance imaging (MRI) is now routinely used for mediastinal tumors and the use of diffusion-weighted images (DWI) may help in the diagnosis of malignancies including lung cancers. The benefits of medical imaging technology are not limited to diagnostics, and include simulation or navigation for complex lung resection and other procedures. Multidetector row computed tomography (MDCT) shortens imaging time to obtain detailed and precise volume data, which improves diagnosis of small-sized lung cancers. 3-dimensional reconstruction of the volume data allows the safe performance of thoracoscopic surgery. For lung lobectomy, identification of the branching structures, diameter, and length of the arteries is useful in selecting the procedure for blood vessel treatment. For lung segmentectomy, visualization of venous branches in the affected segments and intersegmental veins has facilitated the preoperative determination of the anatomical intersegmental plane. Therefore, the application of medical imaging technology is useful in general thoracic surgery.

[Large cell neuroendocrine carcinoma of the thymus; report of a case].

A 55-year-old man presented with an anterior mediastinal tumor, which was detected on a computed tomography scan for close investigation of blood-stained sputum. Operation was performed with the clinical diagnosis of a thymic carcinoma and the tumor was resected completely. The pathological findings revealed Masaoka stage IV, large cell neuroendocrine carcinoma of the thymus. The patients received postoperative chemotherapy and is well without recurrence for 10 months after the surgery.

[Long survival case of resected lung cancer after chemotherapy with gefitinib].

In another hospital, a 71-year-old man had been pointed out to have an abnormal shadow in the left lung field on chest radiograph at a medical checkup. Computed tomography( CT) scan revealed a mass both in the S1+2 and in the S10 of the left lung. The mass in the S1+2 was diagnosed as squamous cell carcinoma by bronchoscopy. CT scan revealed a swelling lymph node at the opposite side. He was diagnosed as having lung cancer (cT2N3M1:stage IV) and was given chemotherapy. The S1+2-mass showed a partial response and the S10-nodule was stable disease. He was then changed to gefitinib administration due to severe side effect of the chemotherapy. The side of S10-nodule once reduced, however, it grew up again after 16 months treatment with gefitinib. He was then referred to our hospital for surgery, and bisegmentectomy with mediastinal dissection was performed. He had no complications after the operation, and is well without recurrence for 8 years after the operation.

[Thoracoscopic surgery for traumatic mediastinal hematoma].

We report a rare case of traumatic mediastinal hematoma treated by thoracoscopic surgery. A 78-year-old man accidentally fell down from the roof, and he was urgently transferred to our hospital. Soon after the arrival, he showed breathlessness followed by cardiopulmonary arrest, necessitating tracheal intubation and resuscitation. Computed tomography (CT) showed a large cervical hematoma extending to the tracheal bifurcation level of mediastinum, causing tracheal obstruction. Five days later, the large mediastinal hematoma was removed by thoracoscopic surgery. The patient recovered without any complications after our treatments.

[Minimally invasive cardiac surgery with the aid of three-dimensional computed tomography(3DCT) image projection on the body surface].

Port-access minimally invasive cardiac surgery (MICS) is complicated by limited skin incision and surgical field. In order to optimize the set-up and port placement in this surgery, we have employed image overlay technique prior to operation consisted of three-dimentional computed tomography (3DCT)image projection on the patient surface. With the aid of this technique, we successfully performed port-access MICS in 12 patients and mitral valve replacement in 1 patient with severe mediastinal displacement after previous pneumonectomy. Image overlay projection could allow surgeons to view underlying anatomical structures virtually and obtain a good operative field. Our proposed technique would be expected to make port-access MICS easier and probably safer in this particular circumstance.

Combined basilar subsegmentectomy for intralobar sequestration via uniportal VATS: a case report.

BACKGROUND: Combined basilar subsegmentectomy via uniportal video-assisted thoracoscopic surgery is an extremely complex surgery. Moreover, no the existing reports describe the procedure and technique. Here, we present the technique of combined basilar subsegmentectomy that was successfully performed via uniportal video-assisted thoracoscopic surgery to treat intralobar pulmonary sequestration in an adult patient. CASE PRESENTATION: A 57-year-old man underwent surgery for oropharyngeal carcinoma. Preoperative computed tomography showed several cystic lesions in the right lower lobe. Subsequent enhanced computed tomography revealed an anomalous artery branching from the abdominal aorta and a normal pulmonary vein. The patient with diagnosed with Pryce type III intralobar pulmonary sequestration and underwent right S7 posterior + 10bc combined basilar segmentectomy via uniportal video-assisted thoracoscopic surgery. The postoperative course was uneventful, and the patient was discharged 4 days after surgery. At the 8-month follow-up, computed tomography showed no abnormalities. CONCLUSIONS: We successfully performed combined basilar subsegmentectomy via uniportal video-assisted thoracoscopic surgery. This surgical approach is useful for the treatment of intralobar pulmonary sequestration occurring at the basal segment of the lung.

Thoracoscopic Lateral Basal Segmentectomy Based on Dissection Along the Intersegmental Veins.

In the conventional method of lateral basal (S9) segmentectomy, the intersegmental plane is first divided between the superior segment and the anterior segment, then the S9 segment is removed from the other basilar segments. We show here our modified method of thoracoscopic S9 segmentectomy based on dissection along the intersegmental veins. Our technique is unique in that we do not divide the intersegmental plane between the superior segment and the anterior segment. The merits are that it avoids additional parenchymal splitting from the superior segment and that it may be used when an incomplete interlobar fissure is present.