Prediction of visceral pleural invasion of clinical stage I lung adenocarcinoma using thoracoscopic images and deep learning.

PURPOSE: To develop deep learning models using thoracoscopic images to identify visceral pleural invasion (VPI) in patients with clinical stage I lung adenocarcinoma, and to verify if these models can be applied clinically. METHODS: Two deep learning models, one based on a convolutional neural network (CNN) and the other based on a vision transformer (ViT), were applied and trained via 463 images (VPI negative: 269 images, VPI positive: 194 images) captured from surgical videos of 81 patients. Model performances were validated via an independent test dataset containing 46 images (VPI negative: 28 images, VPI positive: 18 images) from 46 test patients. RESULTS: The areas under the receiver operating characteristic curves of the CNN-based and ViT-based models were 0.77 and 0.84 (p = 0.304), respectively. The accuracy, sensitivity, specificity, and positive and negative predictive values were 73.91, 83.33, 67.86, 62.50, and 86.36% for the CNN-based model and 78.26, 77.78, 78.57, 70.00, and 84.62% for the ViT-based model, respectively. These models' diagnostic abilities were comparable to those of board-certified thoracic surgeons and tended to be superior to those of non-board-certified thoracic surgeons. CONCLUSION: The deep learning model systems can be utilized in clinical applications via data expansion.

Lymphoid follicular hyperplasia arising from the chest wall presenting as a substantial mass.

Lymphoid follicular hyperplasia (LFH) is a benign lymphoproliferative disease. Although it can occur within the thoracic cavity, LFH originating from the chest wall has not been reported. A 79-year-old woman was incidentally found to have a well-defined mass on the left posterior chest wall during a preoperative examination for aortic valve replacement. The mass had slowly grown over 6 years. Thoracoscopic surgical resection was performed without complications. Pathological examination ruled out lymphoproliferative diseases, such as Castleman disease or malignant lymphoma, and a diagnosis of LFH was made. Although LFH generally has a good prognosis, surgical resection is recommended for diagnostic and therapeutic purposes owing to the possibility of malignancy masquerading as a reactive lesion. This is the first report of an LFH arising from the chest wall with imaging findings similar to other benign tumours. Its potential as a differential diagnosis for tumours with similar imaging findings is highlighted.

Predictive factors of early autologous blood pleurodesis for postoperative air leak.

BACKGROUND: The usefulness of autologous blood pleurodesis for air leak after pulmonary resection is well known; however, factors predicting the therapeutic efficacy are poorly understood. Herein, we aimed to examine the predictors of early autologous blood pleurodesis for air leak following pulmonary resection. METHODS: Patients who underwent pulmonary resection and autologous blood pleurodesis with thrombin for postoperative air leak between January 2016 and October 2022 were retrospectively analyzed. Patients received 50-100 mL of autologous blood and 20,000 units of thrombin on postoperative days 1-4. If necessary, the same procedure or pleurodesis with other chemical agents was repeated until the air leak stopped. Patients were divided into single-dose and multiple-dose groups based on the number of times pleurodesis had occurred before the air leak stopped and were statistically analyzed. Logistic regression analysis was performed to identify predictors of treatment efficacy. RESULTS: Of the 922 patients who underwent pulmonary resection, 57 patients (6.2%) were included and divided into single-dose (n = 38) and multiple-dose (n = 19) groups. The amount of air leaks was identified as a significant predictor of multiple dosing, with a cutoff of 60 mL/min, in multivariate logistic regression analyses (odds ratio 1.13, 95% CI 1.03-1.24, p = 0.0065). The multiple-dose group showed a significantly higher recurrence of air leak (p = 0.0417). CONCLUSIONS: The amount of air leaks after pulmonary resection is the only significant factor predicting whether multiple autologous blood pleurodesis is required, and the recurrence rate of pneumothorax is significantly higher in such cases.

Early chest tube removal within 6 hours after thoracic surgery results in improved postoperative prognosis and no adverse effects.

Background: Advances in minimally invasive surgery and drainage systems have caused earlier chest-tube-removal. This retrospective study aimed to assess the safety of early chest tube removal using the institution's new criteria 6 hours after thoracic surgery. Methods: Elective thoracic surgery patients from 2017 to 2023 were reviewed for meeting or not meeting the newer institutional requirement for early chest tube removal; (I) no air leak detected under the digital drainage device observation; (II) no fluid drainage of ≥100 mL/h; (III) no ≥3 combined risks [male, chronic obstructive pulmonary disease (COPD), body mass index (BMI) of <18.5 kg/m2, severe pleural adhesion, upper lobe lobectomy, or left upper division segmentectomy]. The incidence of adverse events, including chest tube replacement, subcutaneous tube placement, and postoperative thoracentesis, were investigated for 1 month postoperatively. Perioperative outcomes and factors involved in conventional chest tube removal were also assessed. Results: Of the 942 patient charts reviewed, 244 (25.9%) met the criteria for chest tube removal within 6 hours postoperatively. This patient group did not experience adverse events. They also demonstrated shorter postoperative hospital stay (4 vs. 6 days, P<0.001), and lesser postoperative complications (7.4% vs. 25.6%, P<0.001) compared to those for whom early chest tube removal was not done. A correlation with thoracotomy, COPD, and steroid and/or immunosuppressant use was observed for patients in the conventional chest tube removal group. Conclusions: Early chest tube removal after 6 postoperative hours was deemed safe for a selected group of patients who met the criteria for early chest tube removal. This study would support the potential expansion of our early removal criteria.

Experiences of novel cotton device for uniportal video-assisted thoracoscopic surgery: CS Two-Way HandleTM.

In Japan, cotton is commonly used in thoracic surgery for the gentle handling of organs as well as obtaining a good surgical field. While uniportal video-assisted thoracoscopic surgery is being recognized as a major surgical approach, use of cotton is not noted in this technique. Uniportal video-assisted thoracoscopic surgery needs curved instruments because they are effective in preventing the interference of instruments. Thus, we developed a novel curved cotton instrument, known as the "CS Two-Way HandleTM", for uniportal video-assisted thoracoscopic surgery. The CS Two-Way HandleTM can be used not only as a cotton bar but also as a suction aid. Moreover, surgical smoke can be suctioned with the insertion of cotton. This instrument was introduced in our institution in September 2019, along with some other prototypes. When anatomical lung resection using uniportal video-assisted thoracoscopic surgery was first introduced, there were some instances of conversion to conventional multiportal video-assisted thoracoscopic surgery. However, after the CS Two-Way HandleTM introduction, the procedure has become easy to perform and the need for conversion to conventional methods has reduced. The main uses of the CS Two-Way HandleTM are: (I) exposure of the surgical view, (II) lymph node dissection, (III) bleeding control, (IV) suction, and (V) evacuation of surgical smoke. We present our experiences using the CS Two-Way HandleTM in uniportal video-assisted thoracoscopic surgery.

Metachronous bilateral immunoglobulin G4-related pleuritis: A case report and literature review.

Immunoglobulin G4-related disease (IgG4-RD) is a newly recognized disease, and therefore its clinical features are not yet fully understood. Here, we describe a surgical case of metachronous bilateral IgG4-related pleuritis and postoperative chylothorax. This case could provide key insights into the pathology of IgG4-RD from a surgical perspective. We present a 70-year-old woman who had a right pleural mass. Video-assisted thoracoscopic pleural mass resection was performed, and the patient was diagnosed with right-sided IgG4-related pleuritis. Two years later, she was also diagnosed with left-sided IgG4-related pleuritis. We suspected the presence of IgG4-positive plasma cell infiltration. Additionally, she experienced a complicated postoperative chylothorax on the left side. It is important to consider the altered course of lymphatic vessels when extensively removing the pleura near the right thoracic duct. The occurrence of metachronous bilateral IgG4-associated pleuritis has not been previously reported, making this case particularly significant for understanding the pathology of IgG4-RD from a surgical standpoint.

Decreased postoperative complications, neuropathic pain and epidural anesthesia-free effect of uniportal video-assisted thoracoscopic anatomical lung resection: a single-center initial experience of 100 cases.

Background: We aimed to analyze perioperative complications, postoperative neuropathic pain, and the necessity of epidural anesthesia in uniportal video-assisted thoracoscopic surgery (U-VATS) compared to conventional multiportal VATS (M-VATS) for anatomical lung resection. Methods: This retrospective study included all patients who underwent elective VATS lobectomy and segmentectomy between April 2016 and December 2019. The exclusion criteria were as follows: age ≤19 years, planned thoracotomy, re-operation in thoracic surgery, median sternotomy, robot-assisted thoracic surgery, simultaneous resection of extrathoracic organs, locally invasive lung tumor with bronchoplasty or angioplasty, past or current neuropathic pain, and a large tumor with a minimum diameter ≥5 cm. M-VATS had 4 ports approach. U-VATS port positions were placed by extending the thoracoscope port of M-VATS. Results: U-VATS patients showed significant differences compared to M-VATS patients: smaller intraoperative bleeding (1 vs. 30 mL; P=0.0010), shorter operative time (141 vs. 183 min; P<0.0001), post-hospitalization (5 vs. 8 days; P=0.0002), fewer complications (23.9% vs. 40.9%; P=0.048), less acute pain, less postoperative neuropathic pain (32.4% vs. 52.1%; P=0.027) and shorter duration of neuropathic pain (30 vs. 60 days; P=0.041). For the postoperative neuropathic pain and pain score until postoperative day 5, there were no differences between the groups with and without epidural anesthesia. Conclusions: As a single-center initial experience, U-VATS lobectomy and segmentectomy seemed safe and minimally invasive based on not only postoperative neuropathic pain and complications but also time management. U-VATS would provide better pain control, without epidural anesthesia.

Effectiveness and failure factors of manual aspiration using a small needle for large pneumothorax in stable patients.

Background: Manual aspiration as the initial management of a large pneumothorax in a clinically stable patient has been reported to be safe and effective. However, the effect with smaller needles, the number of aspiration, the indication other than spontaneous pneumothorax and failure factors are unknown. We assessed the effectiveness and failure risk factors of manual aspiration up to three using a 20- or 22-gauge (G) needle in patients with a large, clinically stable pneumothorax. Methods: We included 107 clinically stable patients with large pneumothorax. Patients who were unstable, required a ventilator, underwent chest tube drainage or had an observed small pneumothorax, bilateral pneumothorax, hemopneumothorax, or postoperative pneumothorax were excluded. Up to three aspirations were performed using 20- or 22-G intravenous needles. When the aspiration volume was ≥2,500 mL or lung expansion did not occur, a chest tube was placed. Results: The first aspiration was successful in 57 patients (53.3%), the second in 16 patients (59.3%), and the third in eight patients (80.0%). No patient experienced any obvious complications or required emergent hospitalization or surgery after aspiration. Aspiration failure was correlated with an inter-pleural distance >20 mm at the level of the hilum [odds ratio (OR): 4.93; 95% confidence interval (CI): 1.49-22.71; P=0.0075], spontaneous secondary pneumothorax (OR: 3.11; 95% CI: 1.14-8.76; P=0.027), and ≤24 h from onset to presentation (OR: 2.95; 95% CI: 1.12-8.26; P=0.028). There were no significant differences in intrathoracic pressure after aspiration or plasma factor XIII levels between patients with resolved and persistent pneumothorax. Conclusions: Manual aspiration up to three times using a small needle might be one of a treatment option in clinically stable patients with any large pneumothorax. Aspiration failure was correlated with an inter-pleural distance >20 mm at the level of the hilum, spontaneous secondary pneumothorax, and ≤24 h from onset to presentation.

Adverse factors and postoperative neuropathic pain in challenging video-assisted thoracoscopic surgery.

BACKGROUND: Whether challenging video-assisted thoracoscopic surgery (VATS) is a minimal invasive surgery remains controversial. This study aimed to analyze causes of challenging conventional multiple-port VATS (CVATS) and conversion to thoracotomy and postoperative pain to provide indications for VATS. METHODS: This was a two-center retrospective study. Challenging VATS was defined as CVATS with operation time ≥5 hours and it was converted to thoracotomy. This study included patients who were admitted to Joetsu General Hospital (Joetsu, Niigata, Japan) and Toyama University Hospital (Toyama, Japan) for elective CVATS between April 2013 and March 2019. The exclusion criteria were as follows: a planned thoracotomy, uniportal VATS, robot-assisted thoracoscopic surgery, and simultaneous resection of extrathoracic organs. RESULTS: A total of 911 (91.6%) patients underwent CVATS. Of these cases, 876 (96.2%) were suitable VATS cases. On the contrary, 35 cases (3.8%) were recognized as challenging VATS. In 21 (2.3%) cases, VATS took ≥5 hours, and 14 (1.5%) VATS cases were converted to thoracotomy. The causes were severe adhesions (62.9%), air leak (45.7%), body position changes (22.9%), large tumor (14.3%), bronchoplasty or angioplasty (8.6%), and bleeding (2.9%). The minimum diameter of large tumors was 61.4 mm (53-67 mm). In 15 (71.4%) patients, VATS took ≥5 hours, and 10 (71.4%) patients who were converted to thoracotomy developed postoperative neuropathic pain. CONCLUSIONS: In this study, VATS ≥5 hours and conversion from VATS to thoracotomy were complicated by postoperative neuropathic pain. In case of bronchoplasty, angioplasty, and large tumor with minimum diameter ≥5 cm, a thoracotomy approach would be appropriate depending on the skill and experience of the surgeon. In cases of local or vascular sheath adhesion, if operation progress is delayed, it may be necessary to set a time limit and decide to convert to thoracotomy, considering patient's safety first.