Current situation of management of spontaneous pneumothorax in Japan: A cross-sectional cohort study.

BACKGROUND: Limited epidemiological information is available on spontaneous pneumothorax. To address this gap, the Japan Society for Pneumothorax and Cystic Lung Disease (JSPCLD) conducted a nationwide retrospective survey to investigate the current epidemiology of spontaneous pneumothorax in Japan. METHODS: In this study, we conducted a retrospective cross-sectional cohort study to demonstrate the clinical features of spontaneous pneumothorax in one year from April 2019 to March 2020, compare patient characteristics and treatment outcomes between primary (PSP) and secondary spontaneous pneumothorax (SSP), and investigate the risk factors associated with in-hospital mortality among patients with SSP. RESULTS: A total of 1784 patients from 28 institutions were enrolled in the study, with PSP observed in 956 cases (53.6%) and SSP in 817 cases (45.8%). The age distribution showed a biphasic peak caused by the different peaks between PSP and SSP. In-hospital mortality occurred in 42 cases (2.4%) among all patients, with 0 cases (0%) in PSP and 42 cases (5.1%) in SSP. Multivariable analyses revealed that interstitial pneumonia as an underlying disease (odds ratio: 2.4700, 95% confidence interval: 1.1100 to 5.4800, p = 0.0269), performance status≧3 (odds ratio: 7.3900, 95% confidence interval: 3.1900 to 17.2000, p < 0.0001), and lower value of serum albumin on admission (odds ratio: 0.4060, 95% confidence interval: 0.2140 to 0.7690, p = 0.0057) were significantly associated with in-hospital mortality among patients with SSP. CONCLUSIONS: SSP patients with poor baseline conditions are at a higher risk for in-hospital mortality. It is crucial to provide close and meticulous management for SSP patients with compromised conditions.

Uniportal thoracoscopic mediastinal lymphadenectomy using appropriate surgical steps.

Background: Although lymphadenectomies play an important role in the surgical treatment of patients with non-small cell lung cancer (NSCLC), the quality of lymphadenectomies via a uniportal approach has only been evaluated in a few studies. We describe the surgical steps for a mediastinal lymphadenectomy via uniportal video-assisted thoracoscopic surgery (uVATS) and compare the quality of mediastinal lymphadenectomies using uVATS versus multiportal video-assisted thoracoscopic surgery (mVATS). Methods: Between April 2017 and January 2023, we analyzed data from 304 patients with NSCLC who underwent (bi-)lobectomy with nodal dissection (ND)2a-1 or greater lymphadenectomy via uVATS or mVATS. We compared patient characteristics and perioperative results, including the number of harvested lymph nodes (LNs), between the two approaches. In addition, the factors associated with N-upstage were identified. Results: No significant differences in the total number of harvested LNs were detected between the two approaches. Significantly more LN#2R/4R zone LNs were harvested in the uVATS group compared with the number harvested in the mVATS group [uVATS group: 8.5, interquartile range (IQR), 5-12.3; mVATS group: 7, IQR, 5-9, P=0.0177], while no significant differences in total nodes or nodes harvested in other zones were detected. Multivariable analysis revealed that pathologic invasion size [odds ratio: 1.0200, 95% confidence interval (CI): 1.0100-1.0400, P=0.0050], but not approach (uVATS, odds ratio: 0.6240, 95% CI: 0.3160-1.2300, P=0.1750), significantly contributed to N factor upstages. Conclusions: The use of appropriate surgical steps enabled us to achieve similar quality lymphadenectomies via mVATS or uVATS.

Two cases of lower lobe segmentectomy (left and right) using the lung-inverted approach in a robotic operation.

In pulmonary segmentectomy, the dominant pulmonary arteries are conventionally divided at the fissure. However, this approach sometimes leads to accidental injury of the pulmonary artery and prolonged air leaks when the fissure is fused. To overcome these problems, we have adopted the lung-inverted approach without dissection of a fissure for segmentectomy, taking advantage of the good view provided by robotic surgery. We have successfully performed a robotic left S10 or right S6 segmentectomy using the lung-inverted approach. In addition to a good postoperative course, the console time was 72 minutes for the left S10 segmentectomy and 110 minutes for the right S6 segmentectomy; these times were considered relatively short. This approach did not require repeated rotation of the lung, which may have contributed to the short operating time. A clear understanding of the anatomy was required to properly implement this approach, because each branch of the pulmonary vessels and of the bronchi was treated at the hilum. Preoperative 3-dimensional computed tomography broncho-angiography was considered useful because it allowed us to recognize the relative positions of the dominant pulmonary vessels, bronchi and other preserved structures.

Robotic upper division segmentectomy of the left upper lobe without turning the lung.

The fissureless technique in lobectomy or the unidirectional dissection technique in segmentectomy is considered useful to avoid a postoperative prolonged air leak if a fissure is fused because it is not dissected. Another advantage of this technique is that it does not require repeated rotation of the lung to obtain a good surgical view, which may result in a shorter operating time. We believe that this technique is suitable for a robotic approach because we sometimes find it difficult to rotate the lung parenchyma in the limited rigid thoracic cavity when using the robotic approach. We demonstrate a robotic upper division segmentectomy of the left upper lobe with an explanation of the nuances of its performance. The console time was 74 minutes with minimal blood loss. The patient's postoperative course was uneventful. On the day of the operation, we removed the chest tube because we found no air leak. The patient was discharged on postoperative day (POD) 2. The final pathology report showed that a sufficient surgical margin was achieved. These good perioperative results indicate the feasibility of this technique.

A robotic left S1+2c subsegmentectomy using preoperative simulation.

Although there are reports describing segmentectomy by a robotic approach, reports describing robotic subsegmentectomy are rare because this procedure requires more precise anatomical knowledge and exposure of subsegmental pulmonary vessels and bronchi. However, the robotic approach has several advantages, including a high-definition 3-dimensional surgical view and precise motion without tremor, which may allow us to perform the subsegmentectomy more easily. Considering these advantages of the robotic approach, we successfully performed a robotic left S1+2c segmentectomy with a short console time and a good postoperative course. We present the surgical steps of this procedure. In addition, the preoperative simulation method was useful to ensure a sufficient surgical margin. Because the robotic approach lacked tactile feedback, it was difficult to locate the target tumour intraoperatively by palpation compared with the conventional thoracoscopic approach. Finally, in this case, we obtained an adequate surgical margin using this preoperative simulation method.

A robotic anterior (S3) segmentectomy of the left upper lobe.

A robotic approach might be more suitable for pulmonary segmentectomy than the conventional thoracoscopic approach, because the high-definition 3-dimensional surgical view and precise motion without tremor allow us to dissect pulmonary vessels and bronchi to the periphery. However, among several types of segmentectomies, the anterior segmentectomy (S3) of the left upper lobe may be one of the most difficult to achieve in the robotic approach because the dissected hilar region tends to be obstructed by the lung parenchyma in the "looking-up" view. We offer two technical tips to achieve robotic left S3 segmentectomy. The first is the proper retraction of the upper lobe using straw gauze, which allows us to get a good surgical view in the dissected hilar area where pulmonary vessels and bronchi are located. Second, when the intersegmental plane is divided by robotic staplers, the lung should be moved to the dividing line because the angulation of the inserted stapler is limited. Taking these two tips into consideration, we have successfully performed a robotic left S3 segmentectomy. We show the surgical steps of this procedure.

Anatomy of the lung revisited by 3D-CT imaging.

The anatomy of the lung was originally described based on data acquired from cadaveric studies and surgical findings. Over time, computed tomography (CT) and three-dimensional (3D) imaging techniques have been developed, allowing for reconstruction and understanding of lung anatomy in a more intuitive way. The wide adoption of 3D-CT imaging technology has led to a variety of anatomical studies performed not only by anatomists but also by surgeons and radiologists. Such studies have led to new or modified classification systems, shed light on lung anatomy from a useful surgical viewpoint, and enabled us to analyze lung anatomy with a focus on particular anatomical features. 3D images also allow for enhanced pre- and intra-operative simulation, improved surgical safety, enhanced educational utility, and the capacity to perform large-scale anatomical studies in shorter time frames. We will review here the key features of 3D-CT imaging of the lung, along with representative anatomical studies regarding (I) general lung anatomy, (II) anatomy of the right and left lobes, and (III) features of interlobar vessels. The current surge of 3D imaging analysis shows that the field is growing, with the technology continuing to improve. Future studies using these new and innovative methodologies will continue to refine our understanding of lung anatomy while enhancing our ability to perform safe and effective surgical resections.

Learning curve for uniportal thoracoscopic pulmonary segmentectomy: how many procedures are required to acquire expertise?

Background: Minimally invasive surgeries are increasingly being performed. However, few studies have evaluated the learning curve for uniportal thoracoscopic segmentectomies. Therefore, we investigated the learning curve for uniportal thoracoscopic segmentectomy in our department. Methods: We retrospectively reviewed the clinical data of consecutive patients who underwent uniportal thoracoscopic segmentectomy at our institution between February 2019 and January 2022. Two senior surgeons [Hitoshi Igai (H.I.) and Natsumi Matsuura (N.M.)] performed all of the surgeries. H.I. introduced uniportal thoracoscopic segmentectomy in our department and supervised N.M. performing this operation. Resident surgeons participated in the operations as assistants. The learning curve for uniportal thoracoscopic segmentectomy was evaluated on the basis of operative time and cumulative sum (CUSUMOT). Results: The entire team, including resident surgeons, completed the learning curve by performing 60 surgeries. The learning curve consisted of three phases: initial learning (60 surgeries), accumulation of competence (16 surgeries), and acquisition of expertise (17 surgeries), respectively. The operative time, blood loss, postoperative drainage, and postoperative hospitalization time significantly improved across the phases. N.M. completed the initial learning curve faster than H.I. (16 and 29 surgeries, respectively). Conclusions: Under supervision by an experienced surgeon, a team successfully completed the learning curve for uniportal thoracoscopic segmentectomy and achieved good perioperative outcomes, which indicates the importance of appropriate supervision for acquiring expertise for this surgery.

A robotic fissureless left lower lobectomy.

The fissureless technique is considered one of several useful techniques for patients with a fused fissure to avoid postoperative prolonged air leak. When performing the fissureless technique for a lower lobectomy, we consider two important points necessary to perform this technique safely and appropriately. The first is not to injure the pulmonary artery behind the lower bronchus when encircling or dividing it. The second is to accurately identify the pulmonary artery branches to be divided. To achieve these goals, we chose a robotic approach, which yielded successful perioperative results.

Early chest drain removal on the day of uniportal thoracoscopic segmentectomy.

OBJECTIVE: Although early removal of postoperative chest drains can facilitate recovery, it can be difficult to achieve in segmentectomy due to the management of air leakage in intersegmental planes. This study prospectively examined the feasibility of drain removal on the same day of uniportal thoracoscopic segmentectomy. METHODS: Twenty patients who underwent uniportal thoracoscopic segmentectomy between July 2021 and May 2022 were enrolled in this prospective study. The indications for drain removal on the day of surgery were absence of air leakage in an intraoperative sealing test, radiographic evidence of lung expansion, and continuous absence of air leakage via a drainage bottle for 4 h after the operation. The primary endpoint was rate of the patients who required re-drainage after the postoperative drainage tube was removed on the day of surgery. The secondary end points were postoperative pain evaluated using a numerical rating scale on postoperative days 1, 7, and 28; morbidity; and postoperative hospitalization period. RESULTS: Fifteen patients successfully underwent drain removal on the day of surgery. None required re-drainage. The mean postoperative hospitalization period was 2.3 ± 1.7 days. Overall, 12 of the 15 (80%) patients were discharged on postoperative day 1 or 2. The mean numerical rating scale scores were 1.2 ± 1.6, 0.4 ± 0.7, and 0.4 ± 1.5 on postoperative days 1, 7, and 28, respectively. CONCLUSION: In uniportal thoracoscopic segmentectomy, drain removal on the day of surgery is feasible and may reduce pain on postoperative day 1.

Anterior unidirectional approach in a uniportal thoracoscopic anterior segmentectomy (S3) of the right upper lobe for a dense fissure.

Most types of segmentectomies require dissection of a fissure to expose the pulmonary arteries, which is considered a conventional technique. Therefore, it is necessary to deal with a dense fissure in a pulmonary segmentectomy as well as in a lobectomy. Nevertheless, only a few reports describe the operative technique for managing a dense fissure in a pulmonary segmentectomy. Although a dense fissure is frequently found between the right upper and the middle lobes, only one previous report has described an anterior segmentectomy (S3) of the right upper lobe without the dissection of a dense fissure between the right upper and middle lobes. In this video tutorial, we show the appropriate surgical steps for a right S3 segmentectomy using an anterior unidirectional approach via uniportal thoracoscopy for a patient with a dense fissure.

Right basal bronchial fistula due to amebic infection: a case report.

BACKGROUND: Pleuropulmonary amebiasis is the second most common form of extraintestinal invasive amebiasis, but cases that include bronchopleural fistula are rare. CASE PRESENTATION: A 43-year-old male was referred to our hospital for liver abscess, right pleural effusion, and body weight loss. He was diagnosed with a bronchopleural fistula caused by invasive pleuropulmonary amebiasis and human immunodeficiency virus (HIV) infection. After initial medical treatment for HIV infection and invasive amebiasis, he underwent pulmonary resection of the invaded lobe. Intraoperative inspection revealed a fistula of the right basal bronchus in the perforated lung abscess cavity, but the diaphragm was intact. The patient was discharged on postoperative day 3 and was in good condition at the 1-year follow-up. CONCLUSIONS: Clinicians should be aware that pleuropulmonary amebiasis can cause a bronchopleural fistula although it is very rare.

A uniportal thoracoscopic fissureless lingual segmentectomy for a patient with a dense fissure.

Postoperative prolonged air leak is one of the most common morbidities in general thoracic surgery, and a dense fissure is considered to be one of the main causes of prolonged air leak. In a patient with a dense fissure, the fissureless technique is considered one of the most useful options to avoid prolonged air leak, which has been reported in several previous articles after a lobectomy. However, there are few reports describing the operative technique to treat a dense fissure via a pulmonary segmentectomy, although the management of a dense fissure is necessary in a pulmonary segmentectomy as well as in a lobectomy. In this video tutorial, we show the successful results of a left lingual segmentectomy using the fissureless technique via a uniportal thoracoscopy in a patient with a dense fissure. Special emphasis was placed on how to divide the dominant pulmonary vessels and bronchus given the limited angulation of the inserted stapler.

Supervision by an experienced surgeon can reduce the learning curve of uniportal thoracoscopic lobectomy.

Background: This retrospective study was performed to investigate the learning curve of uniportal thoracoscopic lobectomy with ND2a-1 or greater lymphadenectomy for two senior surgeons, and to evaluate how supervision affected the learning curve. Methods: Between February 2019 and January 2022, 140 patients with primary lung cancer underwent uniportal thoracoscopic lobectomy with ND2a-1 or greater lymphadenectomy in our department. Two senior surgeons (HI and NM) performed most of the operations, with junior surgeons performing the rest. HI initiated this surgical method in our department and supervised all operations performed by other surgeons. Patient characteristics and perioperative outcomes were reviewed, and the learning curve was evaluated based on operative time and the cumulative sum method (CUSUMOT). Results: No significant differences were observed in patient characteristics or perioperative outcomes between groups. Three distinct learning curve phases were identified for each senior surgeon: HI, cases 1-21, cases 22-40, cases 41-71; NM cases 1-16, cases 17-30, cases 31-49. For HI, the rate of conversion to thoracotomy was significantly higher in the initial phase (14.3%, P=0.04) although other perioperative outcomes were equivalent between phases. For NM, while the duration of postoperative drainage was significantly shorter in phase 2 and phase 3 (P=0.026), other perioperative outcomes, including conversion rate (5.3-7.1%), were equivalent between phases. Conclusions: Supervision by an experienced surgeon was important for avoiding conversion to thoracotomy during the initial period, and facilitated the surgeon rapidly gaining proficiency with the surgical method.

Standardization of intra- and peri-operative management to reduce postoperative drainage time after major thoracoscopic pulmonary resections.

Background: It is important to reduce the postoperative drainage time after thoracic surgery to relieve postoperative pain and facilitate patient mobilization. We standardized intra- and peri-operative management of major, thoracoscopic pulmonary resections in February 2019. In this study, we investigated whether this standardization reduced the postoperative drainage time. Moreover, we examined how such management affected re-admission within 30 days after operation (because of pleural complications). Methods: Between May 2012 and February 2022, 815 patients with malignant or benign disease underwent major thoracoscopic pulmonary resections in our department. The patients were classified into two groups: those who received standardized management (n=352) and those who did not (n=463). After propensity score-matching, we compared characteristics and perioperative results between the two groups (n=234 in each group) by univariate analysis. The factors affecting postoperative drainage time and re-admission within 30 days after operation (because of pleural complications) were evaluated via multivariate analysis. Standardized management was as follows: (I) intraoperatively, any dense fissures were left untreated to avoid postoperative air leakage. A fissureless or unidirectional dissection technique served as an alternative; pulmonary vessels and bronchi were divided at the hilum in patients with dense fissures. (II) The chest drain was removed when air leakage ceased, regardless of the fluid volume or surgeon's preference. Results: The standardized management group evidenced superior results in terms of operative time (P<0.0001) and postoperative drainage time (P<0.0001). There were no significant differences in the remaining perioperative parameters. Moreover, standardized management significantly reduced postoperative drainage time, as revealed by multivariate analysis [estimated regression coefficient: -0.47; 95% confidence interval (CI): -0.78 to -0.16; P=0.003]. Moreover, standardized management did not significantly increase re-admission (because of pleural complications) [odds ratio (OR) =1.76; 95% CI: 0.557 to 5.58; P=0.34]. Conclusions: Standardized intra- and peri-operative management significantly reduced the postoperative drainage time after major thoracoscopic pulmonary resections, without increasing re-admissions within 30 days among patients with pleural complications caused by insufficient drainage. Surgeons must master a fissureless or a unidirectional dissection technique, avoid dissection of fused fissures, and apply standardized perioperative drainage management.

[Gefitinib Monotherapy Afforded Long-Term Survival of an Octogenarian Patient with a Postoperative Recurrence of a Pulmonary Adenocarcinoma-A Case Report].

An 83-year-old(at the time of postoperative recurrence)female clinically diagnosed with primary lung cancer underwent right upper lobectomy and lymph node dissection(ND2a-2). Postoperative pathological staging revealed a Stage ⅠB (pT2aN0M0)adenocarcinoma that was EGFR mutation-positive(exon 21: L858R). Fifty-one months after surgery, the patient developed a mediastinal lymph node metastasis, and radiotherapy was delivered. Next, gefitinib(250 mg daily)was prescribed as first-line therapy. She developed mild anemia but we took a wait-and-see approach. A complete response was evident after 58 months of monotherapy. However, she then developed grade 3 anemia(Hb 6.2 g/dL)and gefitinib was discontinued. She requested(and received)follow-up computed tomography. No progressive disease was evident, but she died of non-cancer disease 16 months after discontinuation of gefitinib(thus 125 months after surgery and 74 months after the postoperative recurrence). Thus, we here present an unusual case. Gefitinib monotherapy afforded long-term survival of an octogenarian patient with a postoperative recurrence of a pulmonary adenocarcinoma.

A retrospective multi-institutional survey of characteristics of surgically treated spontaneous hemopneumothorax patients.

OBJECTIVE: The Japan Society for Pneumothorax and Cystic Lung Disease conducted a nationwide retrospective survey to identify correlations between the timing of surgical intervention and the incidence of transfusion, and to examine the factors contributing to the need for transfusion among clinical features in surgically treated spontaneous hemopneumothorax (SHP) patients. METHODS: We analyzed the characteristics and perioperative results of patients with SHP who underwent thoracoscopy or thoracotomy between April 2009 and March 2019. RESULTS: From 17 institutions, 171 cases were enrolled in this study. Receiver-operating characteristic curve analyses for the incidence of transfusion and waiting time before the operation revealed an area under the curve of 0.54 (95% confidence interval [CI] 0.44-0.64). Therefore, we did not compare the clinical features using a cutoff value of waiting time before the operation. More than 80% of the patients underwent surgical treatment within 24 h from admission. Multivariate analysis revealed that the total volume of hemorrhage was the only significant factor contributing to the incidence of transfusion (p = 0.00011, odds ratio: 0.03, 95% CI 0.0051-0.18). Moreover, multivariate analyses revealed that the waiting time before the operation was a contributing factor for prolonged total hospitalization (p < 0.0001, estimated regression coefficient: 0.036, 95% CI 0.027-0.045). CONCLUSION: In SHP patients, a reduction in the waiting time before the operation significantly contributed to not the avoidance of transfusion but a reduction in total hospitalization time. In addition, transfusion was performed depending on the volume of blood loss.

Feasibility of tubeless thoracoscopic bullectomy in primary spontaneous pneumothorax patients.

OBJECTIVES: Although early removal of postoperative chest drains can facilitate postoperative recovery, there are risks of undetected bleeding and a need for re-drainage to treat delayed pulmonary air leaks. In this study, we aimed to prospectively examine the feasibility of tubeless thoracoscopic bullectomy in primary spontaneous pneumothorax (PSP) patients. METHODS: Between January 2021 and November 2021, 30 PSP patients were enrolled in this prospective study. The absence of air leakage was confirmed and radiographic evidence of lung expansion was acquired; the tube was then removed in the operating room. The primary endpoint was postoperative air leakage requiring re-drainage among patients who underwent tube removal in the operating room. The secondary endpoints were postoperative pain (numerical rating scale) on postoperative days (PODs) 1, 7, and 28, morbidity, and postoperative hospitalization time. RESULTS: Four (13.3%) patients were excluded because of underlying pulmonary disease (n = 2) and air leaks (n = 2) detected in the operating room. Chest drainage tubes were removed in the operating room for the remaining 26 patients; none of them required re-drainage. The mean postoperative hospitalization time was 1.2 ± 0.4 days. The mean numerical rating scale scores were 4.2 ± 2 (median: 4.5), 1.6 ± 1.6 (median: 1), and 0.4 ± 0.8 (median: 0) on PODs 1, 7, and 28, respectively. Only one case of hemoptysis occurred as a postoperative complication. CONCLUSIONS: Tubeless thoracoscopic bullectomy for PSP is feasible and may reduce the postoperative hospitalization time; however, it does not significantly reduce pain on POD1.

Comparison of the Learning Curve between Uniportal and Robotic Thoracoscopic Approaches in Pulmonary Segmentectomy during the Implementation Period Using Cumulative Sum Analysis.

BACKGROUND: The aim of this retrospective study was to compare the learning curve and perioperative outcomes between the two approaches uVATS and RATS during their implementation periods. METHODS: The uVATS group included 77 consecutive uVATS segmentectomies performed by HI between February 2019 and June 2022, while the RATS group included 30 between July 2022 and September 2023. The patient characteristics, perioperative outcomes, and learning curves were compared between the two groups. The learning curve was evaluated using operative time and cumulative sum (CUSUMOT) analysis. RESULTS: Most patient characteristics and perioperative outcomes were equivalent between the two groups. In the uVATS group, after a positive slope was observed until the 14th case (initial period), a plateau was observed until the 38th case (stable period). Finally, a negative slope was observed after the 38th case (proficiency period). In the RATS group, after a positive slope was observed until the 16th case (initial period), a plateau was observed until the 22nd case (stable period). Finally, a negative slope was observed after the 22nd case (proficiency period). CONCLUSIONS: In segmentectomy, a surgeon reached the proficiency period earlier in RATS than in uVATS, although the trends to the stable period were similar.