Outcomes of minimally invasive surgery for pulmonary metastasis: who benefits the most?

Introduction: Metastatic disease is one of the main causes of death and factors affecting overall survival. It is known that selected patients with pulmonary oligometastases whose primary tumor is under control and who have adequate respiratory capacity may benefit from metastasectomy by resecting all detected lesions. Aim: To report our findings on the use of video-assisted thoracoscopic surgery (VATS) for pulmonary metastasectomy, with a focus on identifying suitable candidates. Material and methods: Between August 2010 and 2023 a total of 532 pulmonary metastasectomy procedures were performed in our institution. Metastasectomy was performed with VATS for 281 of those patients. Results: VATS metastasectomy was performed in 131 patients with a single lesion on preoperative imaging, while 110 patients underwent metastasectomy for multiple lesions. The rate was significantly (p < 0.05) lower in the group with multiple lesions removed during surgery (38 months) than in the group with only one lesion removed during surgery (60 months). The predicted survival time in the group with other tumor histology (79 months) was significantly (p < 0.05) higher than in the groups with tumor histology carcinoma (41.4 months) and sarcoma (55.5 months). Conclusions: The best prognosis after metastasectomy is provided in cases with a single nodule. Grade is also an important prognostic factor affecting survival, particularly for grade 1 tumor. The histopathological type of the primary tumor is also a significant prognostic factor affecting survival after pulmonary metastasectomy in secondary pulmonary neoplasms, particularly for sarcoma and carcinoma.

Post bar removal results of pectus deformity patients who underwent minimally invasive correction.

Introduction: The most common chest wall deformities are pectus excavatum and pectus carinatum. Surgical repair of these deformities via minimally invasive technique using pectus bars is commonly preferred by numerous thoracic surgeons. Despite this common choice for treatment, the duration of the bar stay, the bar removal process, the possible complications and ways to prevent them have been debated over the years and still there is no single decision. Aim: To determine the decision making, surgical outcomes and negative factors in the bar removal process. Material and methods: There were 1032 patients underwent bar removal between 2006-2020 and their data was recorded prospectively. We analyzed patients' demographics, family history, Haller index, bar count, body mass index, stabilizer and wire usage, length of hospital stay, time until bar removal, incision side and complications retrospectively. Results: There was no significant correlation between BMI and surgery time (p = 0.748). There was no statistically significant correlation between the age groups and the number of pectus bars removed. The other factors showed no significant difference. The surgery time was found to be significantly longer in those with callus tissue (p = 0.002). Conclusions: These findings suggest that pectus bars can be left in place for a shorter time than the standard 3-year interval without any additional recurrence risk and without compromising quality of life. As a result, patients with persistent pain after pectus repair should be well evaluated for the possibility of life-threatening complications during bar removal.

Can postoperative complications be reduced by the application of ERAS protocols in operated non-small cell lung cancer patients?

Background: In our study, we aimed to evaluate the length of hospital stay and complication rate of patients before and after application o f t he E nhanced R ecovery A fter S urgery ( ERAS) protocols. Methods: Between January 2001 and January 2021, a total of 845 patients (687 males, 158 females; mean age: 55±11 years; range, 19 to 89 years) who were operated with the diagnosis of non-small cell lung carcinoma were retrospectively analyzed. The patients were divided into three groups as follows: patients between 2001 and 2010 were evaluated as pre-ERAS (Group 1, n=285), patients between 2011 and 2015 as preparation for ERAS period (Group 2, n=269), and patients who had resection between 2016 and 2021 as the ERAS period (Group 3, n=291). Results: All three groups were similar in terms of clinical, surgical and demographic characteristics. Smoking history was statistically significantly less in Group 3 (p=0.005). The forced expiratory volume in 1 sec/forced vital capacity and albumin levels were statistically significantly higher in Group 3 (p<0.001 and p=0.019, respectively). The leukocyte count and tumor maximum standardized uptake value were statistically significantly higher in Group 1 (p=0.018 and p=0.014, respectively). Postoperative hospitalization day, complication rate, and intensive care hospitalization rates were statistically significantly lower in Group 3 (p<0.001). The rate of additional disease was statistically significantly higher in Group 1 (p=0.030). Albumin level (<2.8 g/dL), lymphocyte/monocyte ratio (<1.35), and hemoglobin level (<8.3 g/dL) were found to be significant predictors of complication development. Conclusion: With the application of ERAS protocols, length of postoperative hospital stay, complication rate, and the need for intensive care hospitalization decrease. Preoperative hemoglobin level, albumin level, and lymphocyte/monocyte ratio are the predictors of complication development. Increasing hemoglobin and albumin levels before operation may reduce postoperative complications.

An intrapericardial thymoma resected by uniportal video-assisted thoracoscopic surgery.

Thymomas are usually located in the normal location of the thymus in the anterior mediastinum. It is very rare for thymomas to arise primarily intrapericardially. A 76-year-old male patient with a known human immunodeficiency virus positivity and has been under close follow-up for five years was admitted to our clinic. Thoracic computed tomography revealed an intrapericardial mass. Uniportal video-assisted thoracoscopic surgery was performed for the resection of the intrapericardial mass. Pathological examination revealed a type AB thymoma with a 3x3x2.5-cm dimensions (Stage 1). He underwent adjuvant irradiation. He has been doing well without any recurrence for 41 months. In conclusion, resection of intrapericardial masses is feasible and safe. This is the first case with a purely intrapericardial thymoma that was resected via uniportal videoassisted thoracoscopic surgery in the literature.

Effect of trail C1595T variant and gene expression on the pathogenesis of non-small cell lung cancer.

It is known that disorders in apoptosis function play an important role in the pathogenesis of many types of cancer, including lung cancer. Tumor necrosis factor related apoptosis inducing ligand (TRAIL), a type II transmembrane protein, is a death ligand capable of inducing apoptosis by activating distinctive death receptor. Our purpose in this study is to investigate the gene polymorphisms in TRAIL molecular pathway and TRAIL gene expression levels in non-small cell lung cancer (NSCLC) patients in terms of pathogenesis and prognosis of the disease. In this study, TRAIL C1595T polymorphism was genotyped using polymerase chain reaction-restriction fragment length polymorphism analysis in 158 patients with NSCLC and 98 healthy individuals. Surgically resected tissues were examined and classified histopathologically. In addition, TRAIL gene expression levels in tumor tissue and tumor surrounding tissue samples of 48 patients with NSCLC were determined using real-time polymerase chain reaction. TRAIL gene expression levels of NSCLC patients were detected significantly 28.8 fold decrease in the tumor tissue group compared to the control group (p=0.026). When patients were compared to tumor stage, expression of TRAIL gene in advanced tumor stage was found to be significantly 7.86 fold higher than early tumor stage [p=0.028]. No significant relationship was found between NSCLC predisposition and prognostic parameters of NSCLC with TRAIL genotypes, but the frequency of TRAIL gene 1595 CT genotype was observed to be lower in the patients compared to the other genotypes, and the difference was found to be very close to statistical significance (p=0.07). It can be suggested that TRAIL may play an important role in the development of NSCLC and may be an effective prognostic factor in tumor progression.: It is known that disorders in apoptosis function play an important role in the pathogenesis of many types of cancer, including lung cancer. Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL), a type II transmembrane protein, is a death ligand capable of inducing apoptosis by activating distinctive death receptor. Our purpose in this study is to investigate the gene polymorphisms in TRAIL molecular pathway and TRAIL gene expression levels in non-small cell lung cancer (NSCLC) patients in terms of pathogenesis and prognosis of the disease.

Comparative study of video-assisted thoracoscopic surgery versus open thymectomy for thymoma and myasthenia gravis.

INTRODUCTION: Thymectomy is the preferred standard treatment in younger non-thymoma patients with myasthenia gravis as well as in patients with early stage thymoma. Total thymectomy by median sternotomy has been the surgical approach since resection of the thymus with video-assisted thoracoscopic surgery (VATS). AIM: To compare the clinical outcomes of VATS thymectomy with conventional open thymectomy for neoplastic and non-neoplastic thymic diseases. MATERIAL AND METHODS: Forty patients underwent thymectomy between October 2012 and January 2016. Fifteen patients were male and 25 patients were female. The mean age was 40.3 ±17.7 years. Seventeen (55%) patients underwent VATS thymectomy and 23 (45%) patients underwent an open procedure. We retrospectively reviewed the data of the patients and compared these two techniques. RESULTS: The mean tumor size was 5.17 ±3.2 cm in the thymoma group (VATS 2.5 ±2.4 cm vs. open access 4.7 ±3.7 cm). None of the patients experienced a myasthenic crisis. Conversion to thoracotomy was required in 1 patient in the VATS group due to bleeding from the right internal mammary artery; therefore, the conversion rate was 2.5% among all the patients. No mortality occurred in either group. No significant difference was found in the perioperative blood loss, operative time or pain visual analogue scale scores. On the other hand, regarding postoperative drainage, duration of chest tube drainage and length of hospital stay, VATS thymectomy yielded better results and the differences were significant. CONCLUSIONS: Video-assisted thoracoscopic surgery thymectomy can be performed for both neoplastic and non-neoplastic thymic diseases with minimal morbidity and mortality.

Uniportal versus multiport video-assisted thoracoscopic surgery for anatomical lung resections: a glance at a dilemma.

INTRODUCTION: As the number of operations performed by videothoracoscopy is increasing, there is also a tendency to decrease the number of port incisions. Apart from the reduced number of surgical incisions, there are a few reports and systematic reviews that demonstrate some potential advantages of the uniportal video-assisted thoracoscopic surgery, but the impact of the reduced incisions in the clinical setting still remains uncertain. AIM: To compare uniportal video-assisted thoracoscopic surgery to multiport video-assisted thoracoscopic surgery for anatomical lung resections in patients with malignant and benign lung diseases. MATERIAL AND METHODS: From August 2010 to April 2016, a total of 102 patients with malignant and benign lung diseases underwent videothoracoscopic lobar and sublobar lung resections in our department. Comorbidities, tumor stage, tumor localization, mortality, operative time, pain visual analogue scale, length of hospital stay, perioperative blood loss, duration and amount of postoperative drainage and air leak, number of harvested lymph nodes and complication rates were analyzed. RESULTS: No significant difference was found in the duration of chest tube drainage, pain visual analogue scale score, length of hospital stay, perioperative blood loss, amount of postoperative drainage, number of harvested lymph nodes or complication rate. There was no surgical mortality in either of the two groups. However, operative time was shorter (189 min vs. 256 min, p < 0.005) in the multiport group than in the uniportal group. CONCLUSIONS: Compared with the uniportal approach, the multiport approach is associated with a significantly shorter operative time in our study.

The importance of programmed death ligand 1 gene expression, epidermal growth factor receptor gene mutations and serum epidermal growth factor receptor levels in Turkish non-small cell lung cancer patients.

BACKGROUND: This study aims to investigate the possible relationships between epidermal growth factor receptor gene mutations, serum epidermal growth factor receptor levels, programmed death ligand gene expression levels and the risks and survivals of resectable nonsmall cell lung cancer patients. METHODS: Deoxyribonucleic acid isolation was performed from peripheral blood samples and tumor tissues. The mutation analysis was performed for epidermal growth factor receptor. Programmed death ligand 1 gene expression levels were examined pathologically and histopathologically following the tissue tracing of 36 non-small cell lung cancer patients (29 males, 7 females; mean age 60.1 years; range, 41 to 79 years) and analyzed using real-time polymerase chain reaction. Epidermal growth factor receptor serum levels were assessed in all patients. RESULTS: As a result of mutation analyses in 21 patients (28.5% of all adenocarcinoma patients), epidermal growth factor receptor mutation was determined in at least one exon in six patients. In epidermal growth factor receptor mutation detected patients, programmed death ligand 1 gene expression levels were associated with lymph node metastasis (p=0.036). However, epidermal growth factor receptor mutations were not statistically significantly associated according to histopathological examination (p>0.05). Of patients carrying exon 20 (c.2303G>T) mutations, 25% had tumors with perineural invasion. There was a statistically significant association between exon 20 insertions and c.2303G>T and lymphatic invasion (p=0.02), lymph node metastasis and exon 20 insertions (p=0.03). Patients with lower serum epidermal growth factor receptor levels (<400 pg/mL) had better survival time than those with higher serum epidermal growth factor receptor levels (p=0.04). CONCLUSION: Programmed death ligand 1 gene expression and epidermal growth factor receptor mutation might have a combined effect on non-small cell lung cancer. Programmed death ligand 1 gene expression in tumor pathology may also be a significant feature for tumor progression and tumorigenesis. Serum epidermal growth factor receptor levels seem to be associated with survival.

Single stage bilateral uniportal videothoracoscopic sympathicotomy for hyperhidrosis: can it be managed as an outpatient procedure?

INTRODUCTION: The videothoracoscopic approach is minimally invasive with benefits that include less postoperative pain and shorter hospital stay. It is also a safe procedure which can be performed on an outpatient basis. AIM: To determine whether videothoracoscopic sympathicotomy can be performed safely in most patients as an outpatient procedure. MATERIAL AND METHODS: Between July 2005 and October 2015, a total of 92 patients underwent bilateral and single port thoracoscopic sympathicotomy in our department on an outpatient basis. The level of sympathicotomy was T2 in 2 (2.2%) patients, T2 to T3 in 31 (33%) patients, T2 to T4 in 46 (50%) patients and T3 to T4 in 12 (13%) patients. Demographic data, length of postoperative stay, substitution index (SI), admission rate (AR) and readmission rate (RR), complications and patient satisfaction were reviewed retrospectively. RESULTS: Two (2.2%) patients suffered from chest pain, while 4 (4.3%) patients complained about pain at the port site. Mean discharge time after surgery was 5.1 h (range: 4-6 h), mean duration of hospital stay was 0.15 days (0-3 days) postoperatively and the mean operation time was 43.6 min (15-130 min). In 8 (8.6%) patients, pneumothorax was detected on postoperative chest X-ray, while 5 (5.4%) patients required chest tube drainage. Mild or moderate compensatory sweating developed in 32 (34.7%) patients. No recurrence was observed, and the satisfaction rate was 96.7%. Substitution index and admission rate were 91.3% and 11% respectively, while RR was 0%. CONCLUSIONS: Bilateral video-assisted thoracoscopic sympathicotomy can be performed safely in most patients as an outpatient procedure.

Minimally invasive repair of pectus excavatum (MIRPE) in adults: is it a proper choice?

INTRODUCTION: The Nuss procedure is suitable for prepubertal and early pubertal patients but can also be used in adult patients. AIM: To determine whether the minimally invasive technique (MIRPE) can also be performed successfully in adults. MATERIAL AND METHODS: Between July 2006 and January 2016, 836 patients (744 male, 92 female) underwent correction of pectus excavatum with the MIRPE technique at our institution. The mean age was 16.8 years (2-45 years). There were 236 adult patients (28.2%) (> 18 years) - 20 female, 216 male. The mean age among the adult patients was 23.2 years (18-45 years). The recorded data included length of hospital stay, postoperative complications, number of bars used, duration of the surgical procedure and signs of pneumothorax on the postoperative chest X-ray. RESULTS: The MIRPE was performed in 236 adult patients. The average operative time was 44.4 min (25-90 min). The median postoperative stay was 4.92 ±2.81 days (3-21 days) in adults and 4.64 ±1.58 (2-13) in younger patients. The difference was not statistically significant (p = 0.637). Two or more bars were used in 36 (15.8%) adult patients and in 44 (7.5%) younger patients. The difference was not statistically significant either (p = 0.068). Regarding the overall complications, complication rates among the adult patients and younger patients were 26.2% and 11.8% respectively. The difference was statistically significant (p = 0.007). CONCLUSIONS: MIRPE is a feasible procedure that produces good long-term results in the treatment of pectus excavatum in adults.

Benign emptying of the postpneumonectomy space.

A drop in the air-fluid level in the postpneumonectomy space on a chest radiogram is an early sign of bronchopleural fistula (BPF). Any suspicion of BPF points to the need for urgent evaluation and appropriate management. Very rarely may this drop occur without the existence of a fistula, but such a condition is defined as benign emptying of the postpneumonectomy space. We share our successful conservative management in a case of postpneumonectomy space emptying with a suspicion of BPF.

Effect of the amount of intraoperative fluid administration on postoperative pulmonary complications following anatomic lung resections.

OBJECTIVE: Excessive fluid administration during lung resections is a risk for pulmonary injury. We analyzed the effect of intraoperative fluids on postoperative pulmonary complications (PCs). METHODS: Patients who underwent anatomic pulmonary resections during 2012 to 2013 were included. Age, weight, pulmonary function data, smoking (pack-years), the infusion rate and the total amount of intraoperative fluids (including crystalloid, colloid, and blood products), duration of anesthesia, hospital stay, PCs, and mortality were recorded. PCs were defined as acute respiratory distress syndrome, need for intubation, bronchoscopy, atelectasis, pneumonia, prolonged air leak, and failure to expand. Univariate analyses and multivariate logistic regression were performed. A Lowess curve was drawn for intraoperative fluid threshold. RESULTS: In 139 patients, types of resections were segmentectomy-lobectomy (n = 69; extended n = 37; video-assisted thoracoscopic surgery n = 19) and pneumonectomy (n = 9; extended n = 5). One hundred sixty-one PCs were observed in 76 patients (acute respiratory distress syndrome [n = 5], need for intubation [n = 9], atelectasis [n = 60], need for bronchoscopy [n = 19], pneumonia [n = 26], prolonged air leak [n = 19], and failure to expand [n = 23]). Overall mortality was 4.3% (6 out of 139 patients). Mean hospital stay was 8.5 ± 4.8 days. Univariate analyses showed that smoking, intraoperative total amount of fluids, crystalloids, blood products, and infusion rate as well as total amount of crystalloids and infusion rate during the postoperative first 48 hours were significant for PCs (P = .033, P < .0001, P = .001, P = .03, P < .0001, P = .002, and P < .0001, respectively). In multivariate logistic regression analysis intraoperative infusion rate (P < .0001) and smoking were significant (P = .023). An infusion rate of 6 mL/kg/h was found to be the threshold. CONCLUSIONS: The occurrence of postoperative PCs is seen more frequently if the intraoperative infusion rate of fluids exceeds 6 mL/kg/h.

Left-sided thoracoscopy in the prone position for surgery of distal esophageal benign pathologies.

Exposure of the distal esophagus can be achieved by a wide variety of surgical approaches. The standard procedure is mostly by laparoscopy. In cases where laparoscopy is relatively contraindicated, thoracoscopy is preferred. In this case, exposure of the distal esophagus from the aorta, heart and lung is technically challenging using thoracoscopy in the right lateral decubitus position. Surgery in the prone position for esophageal cancer has been successfully described in previous literature. We present our experience with left-sided thoracoscopy in the prone position in three patients with benign distal esophageal pathologies. This approach provided a much better exposure of the distal esophagus and enabled a successful surgery to be done in all patients with less manipulation of the lung.

Adjuvant systemic chemotherapy with or without bevacizumab in patients with resected pulmonary metastases from colorectal cancer.

INTRODUCTION: We investigated the impact of modern chemotherapy regimens and bevacizumab following pulmonary metastasectomy (PM) from metastatic colorectal cancer (CRC). METHODS: A total of 122 consecutive patients who were curatively resected for pulmonary metastases of CRC in twelve oncology centers were retrospectively analysed between January 2000 and April 2012. RESULTS: Of 122 patients, 14 did not receive any treatment following PM. The remaining 108 patients received fluoropyrimidine-based (n = 12), irinotecan-based (n = 56) and oxaliplatin-based (n = 40) chemotherapy combinations. Among these, 52 patients received bevacizumab (BEV) while 56 did not (NoBEV). Median recurrence-free survival (RFS) was 17 months and median overall survival (OS) has not been reached at a median follow-up of 25 months after PM. Three and five-year OS rates were 66% and 53%, respectively. RFS and OS were similar, irrespective of the chemotherapy regimen or BEV use. Positive pulmonary margin, KRAS mutation status, and previous liver metastasectomy were negative independent prognostic factors for RFS, while pathologically confirmed thoracic lymph node involvement was the only negative independent prognostic for OS in multivariate analysis. CONCLUSIONS: No significant RFS or OS difference was observed in respect to chemotherapy regimens with or without BEV in patients with pulmonary metastases of CRC following curative resection.

The validity of preoperative lymph node staging guidelines of European Society of Thoracic Surgeons in non-small-cell lung cancer patients.

OBJECTIVE: The European Society of Thoracic Surgeons (ESTS) has proposed preoperative lymph-node staging guidelines (LNSGs) for non-small-cell lung cancer (NSCLC) based on the introduction of new staging modalities into clinical practice. The validity of these guidelines was assessed. METHODS: Among the patients (n=185) with histologically confirmed NSCLC diagnosed between 2007 and 2009, who were suitable for thoracotomy, the 168 who underwent computed tomography (CT) of the chest and CT-integrated positron emission tomography (PET-CT) were included in the study. The preoperative mediastinal stage was confirmed by mediastinoscopy in all patients. A thoracotomy was done for mediastinoscopy-negative patients. The mediastinal staging results were adapted to the ESTS-LNSG (direct thoracotomy for T1-2 N0 tumour according to CT and PET-CT and invasive staging for others) and the validity of the guidelines was tested. RESULTS: In this series, the overall mediastinal lymph-node metastasis (MLNM) prevalence was 29.2%. If the guidelines had been applied, thoracotomy without invasive mediastinal staging would have been done in only 11 (6.5%) patients, and no MLNM would have been detected. Mediastinoscopy would have been performed in 157 patients and MLNM would have been found in 41 (26%). In the 116 mediastinoscopy-negative patients, MLNM would have been detected after thoracotomy in an additional eight patients. Thus, the sensitivity, specificity, and positive and negative predictive values of the guidelines were calculated as 84%, 100%, 100% and 94%, respectively. CONCLUSIONS: The preoperative LNSGs for NSCLC proposed by the ESTS are effective.

[The role of positron emission tomography (PET) in mediastinal staging of non-small cell lung cancer]. / Küçük hücreli disi akciger kanserinin mediastinal evrelemesinde pozitron emisyon tomografisi (PET)'nin rolü.

Mediastinal lymph node metastasis (MLNM) is the most important prognostic factor and guide to the treatment in non-small cell lung cancer (NSCLC) patients with no distant metastasis. As a non invasive method, using of positron emission tomography (PET) to evaluate NSCLC is increasing. We aimed to compare results of PET and mediastinoscopy to reveal effectiveness of PET in the mediastinal staging of NSCLC patients. PET was performed to 100 operable NSCLC patients between 2004 and 2006. Later, standard cervical mediastinoscopy was performed to all of the patients. Twenty-six patients who detected MLNM at mediastinoscopy were referred to oncology clinic for neoadjuvant or definitive chemo-radiotherapy. Other 74 patients underwent thoracotomy and performed lung resection and mediastinal lymphatic dissection. Sensitivity and specificity rates for detecting mediastinal lymphatic metastasis of PET and mediastinoscopy were compared. There were 89 male and 11 female with mean age of 59 years. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy rates were calculated as 74%, 76%, 59%, 86% and 76% respectively for PET and 83%, 100%, 100%, 93% and 95% respectively for mediastinoscopy. Accuracy rate of PET is not sufficient and mediastinoscopy is still the gold standard to evaluate mediastinal staging of NSCLC, at present.