Minimally invasive approaches for en-bloc anatomical lung and chest wall resection.

Background: The aim of this study was to evaluate the feasibility of en-bloc anatomical lung and chest wall resection via minimally invasive surgery. Methods: Between January 2013 and December 2021, a total of 22 patients (18 males, 4 females; mean age: 63±6.9 years; range, 48 to 78 years) who underwent anatomical lung and chest wall resection using minimally invasive surgery for non-small cell lung cancer were retrospectively analyzed. Demographic, clinical, intra- and postoperative data of the patients, recurrence, metastasis, mortality, and overall survival rates were recorded. Results: The surgical technique was robot-assisted thoracic surgery in two, multiport video-assisted thoracoscopic surgery in 18, and uniport video-assisted thoracoscopic surgery in two patients. Upper lobectomy was performed in 17 (77.3%) patients, lower lobectomy in three (13.6%) patients, and upper lobe segmentectomy in two (9.1%) patients. Five different techniques were used for chest wall resection. Nine (40.9%) patients had one, eight (36.4%) patients had two, four (18.2%) patients had three, and one (4.5%) patient had four rib resections. Chest wall reconstruction was necessary for only one of the patients. The mean operation time was 114±36.8 min. Complete resection was achieved in all patients. Complications were observed in seven (31.8%) patients without mortality. The mean follow-up was 24.4±17.9 months. The five-year overall survival rate was 55.3%. Conclusion: Segmentectomy/lobectomy and chest wall resection with minimally invasive surgery are safe and feasible in patients with nonsmall cell lung cancer. In addition, the localization of the area where chest wall resection would be performed should be considered the most crucial criterion in selecting the ideal technique.

Intercostal Nerve Reconstruction for Severe Compensatory Hyperhidrosis: The Gebitekin Technique.

Compensatory sweating (CS) is the most common and disabling complication of endoscopic thoracic sympathectomy and represents an unmet clinical challenge. Our surgical hypothesis is to generate a parallel pathway to the damaged part of the sympathetic nerve, similar to the Kuntz nerve, by reconstructing the 2 healthy intercostal nerves, thus treating CS. Here, we present a novel videothoracoscopic technique involving bilateral intercostal nerve reconstruction in patients with severe CS after endoscopic thoracic sympathectomy.

Comparison of survival results of patients with T0 and T1-2-3 in pathological T staging in patients with non-small cell lung cancer who underwent surgery after neoadjuvant treatment.

AIM: In this study, we aimed to compare the survival results of patients who underwent neoadjuvant treatment with NSCLC between March 1997 and August 2014 and were found to have T0N0 and T1-2-3/N0. MATERIAL AND METHODS: A hundred ninety-five patients who had complete neoadjuvant therapy, complete lung resection and lymph node dissection, and pathologically diagnosed as T0 or T1-2-3/N0, M0 were included in the study. RESULTS: Of the 195 patients included in the study, 181 were male, 14 were female and the mean age of the patients was 57.9. The mean age of the groups was as follows: group 1: 58.1, group 2: 57.7, group 3: 59.7 and group 4: 56.8. In our series the most common complication was atelectasis (n = 19). Others were prolonged air leak (n = 16), pneumonia (n = 12), apical pleural space (n = 6), wound infection (n = 3), cardiac problems (n = 3), hematoma (n = 3), bronchopleural fistula (n = 3), empyema (n = 2), chylothorax (n = 1). The 5-year survival rate for patients in the T0N0 group was 76.3%. This rate was 71.8% in group 2, 63.6% in group 3 and 44.1% in group 4. CONCLUSIONS: Survival was found to be better in patients who underwent surgery after neoadjuvant therapy and had a complete pathological response. We believe that we can provide better results with the increase in the number of cases detected as TxN0 after the neoadjuvant treatment and prolongation of the follow-up period.

Pathological complete response after neoadjuvant/induction treatment: where is its place in the lung cancer staging system?†.

OBJECTIVES: Prognosis for patients with non-small-cell lung cancer (NSCLC) who, after neoadjuvant/induction and surgery, have a pathological complete response (pCR) is expected to be improved. However, the place of the pCR patients in the context of the tumour, lymph node and metastasis (TNM) staging system is still not defined. The aim of this study is to investigate the long-term survival of NSCLC patients with pCR and to find their appropriate staging category within the TNM staging system. METHODS: We retrospectively reviewed the prospectively recorded data of 1076 patients undergoing surgery (segmentectomy or more) for NSCLC between 1996 and 2016. Patients were divided into 2 groups. Group 1: clinical early-stage patients who underwent direct surgical resection (n = 660); group 2: patients who received neoadjuvant/induction treatment before surgical resection for locally advanced NSCLC (n = 416). Morbidity, mortality, survival rates and prognostic factors were analysed and compared. RESULTS: Postoperative histopathological evaluation revealed pCR in 72 (17%) patients in group 2. Overall 5-year survival was 58.7% (group 1 = 62.3%, group 2 = 52.8%, P = 0.001). Of note, 5-year survival was 72.2% for pCRs. In addition, 5-year survival for stage 1a disease was 82.6% in group 1 and 63.2% in group 2 (P = 0.008); 70.3% in group 1 and 60.5% in group 2 for stage 1b (P = 0.08). Patients with stage II had a 5-year survival of 53.9% in group 1 and 51.1% in group 2 (P = 0.36). CONCLUSIONS: This study shows that patients with locally advanced NSCLC developing a pCR after neoadjuvant/induction treatment have the best long-term survival and survival similar that of to stage Ib patients.

Thymic tumors and results of radiotherapy.

AIM: The aim of this study was to evaluate thymic epithelial tumors (TETs) for treatment outcomes and prognostic factors on survival. BACKGROUND: TETs are very rare neoplasms and multidisciplinary approach is recommended according to prognostic factors. MATERIALS AND METHODS: Between 1995 and 2013, 31 patients were treated with median 5400 cGy (range: 1620-6596 cGy) radiotherapy (RT). Eleven patients received adjuvant or concurrent chemotherapy. There were 25 thymomas, 4 thymic carcinomas and 2 thymic neuroendocrin carcinomas. According to Masaoka, staging and WHO classification, cases were divided to good (n: 10), moderate (n: 9) and poor (n: 12) prognostic risk groups. Survival was calculated from diagnosis. RESULTS: In January 2016, 22 cases were alive with median 51.5 months (range: 2-170.5) follow-up. Recurrences were observed in 29% of patients in median 29.5 months (range: 6.5-105). Local control, mean overall (OS) and disease-free survival (DFS) rates were 86%, 119 and 116 months, respectively. There was a significant difference for R0 vs. R+ resection (81% vs. 43%, p = 0.06, and 69% vs. 46%, p = 0.05), Masaoka stage I-II vs. III-IV (75% vs. 52%, p = 0.001, and 75% vs. 37%, p < 0.001), and also prognostic risk groups (100% vs. 89% vs. 48%, p = 0.003, and 100% vs. 87% vs. 27%, p = 0.004) in terms of 5-year OS and DFS, respectively. CONCLUSION: In our study, prognostic risk stratification was shown to be a significant predictor of survival. There is a need to investigate subgroups that may or may not benefit from adjuvant RT.

The success of surgery in the first 24 hours in patients with esophageal perforation.

OBJECTIVE: Esophageal perforation (EP) is a critical and potentially life-threatening condition with considerable rates of morbidity and mortality. Despite many advances in thoracic surgery, the management of patients with EP is still controversial. MATERIALS AND METHODS: We retrospectively reviewed 34 patients treated for EP, 62% male, mean age 53.9 years. Sixty-two percent of the EPs were iatrogenic. Spontaneous and traumatic EP rates were 26% and 6%, respectively. Three patients had EP in the cervical esophagus and 31 in the thoracic esophagus. RESULTS: Mean time to initial treatment was 34.2 hours. Twenty patients comprised the early group <24 h) and 14 patients the late group (>24 h). Management of the EP included primary closure in 30 patients, non-surgical treatment in two, stent in one and resection in one. Mortality occurred in nine of the 34 patients (26%). Mortality was EP-related in four patients. Three of the nine patients that died were in the early group (p<0.05). Mean hospital stay was 13.4 days. CONCLUSION: EP remains a potentially fatal condition and requires early diagnosis and accurate treatment to prevent the morbidity and mortality.

Can Thoracic Sympathetic Nerve Damage Be Reversed?

BACKGROUND: Function of the thoracic sympathetic chain (TSC) reportedly recovers after surgical clips are removed. Hence, this study was designed to study nerve regeneration after unclipping the TSC. METHODS: The bilateral TSCs of six goats were studied; the goats were separated into three groups (groups I, II, and III) during excision, clipping, and unclipping. During surgery, the TSCs were excised with a scalpel in group I and clipped in groups II and III. In group III, the clips were removed 1 month postoperatively and observed for possible nerve healing for 1 month. All TSCs were examined histologically following en block resection at 1 month postoperatively in groups I and II and at 2 months postoperatively in group III. RESULTS: Inflammation in nerve sections was noted following clip removal. Furthermore, there was significant degeneration and cell infiltration in the nerve fibers of the clipped regions. The Schwann cells around the peripheral nerve endings in the unclipped regions facilitated nerve transmission by reconstitution of myelin. CONCLUSION: Clipping the TSC can cause histologic degeneration; however, histologic nerve regeneration occurs after unclipping.

Molecular markers for patients with thymic malignancies: not feasible at present?

BACKGROUND: Thymomas and thymic carcinomas are rare malignancies and devising clinically effective molecular targeted therapies is a major clinical challenge. The aim of the study was to analyze BLC2 and vascular endothelial growth factor receptor (VEGFR) expression and KRAS and EGFR mutational status and to correlate them with the clinical characteristics of patients with thymomas and thymic carcinomas. MATERIALS AND METHODS: A total of 62 patients (mean age: 50.4 ± 13.2 years) with thymomas and thymic carcinomas were enrolled. The expression of BLC2 and VEGFR in tumor cells and normal tissues was evaluated by RT-PCR. The mutational status of the KRAS and EGFR genes was investigated by PCR with sequence specific primers. RESULTS: The BLC2 and VEGFR expression levels did not differ significantly between tumor and normal tissues. Moreover, there were no clearly pathogenic mutations in KRAS or EGFR genes in any tumor. None of the molecular markers were significantly related to clinical outcomes. CONCLUSIONS: Changes in levels of expression of BLC2 and VEGFR do not appear to be involved in thymic tumorigenesis. Moreover, our data suggest that KRAS and EGFR mutations do not play a major role in the pathogenesis of thymomas and thymic carcinomas.

European guidelines on structure and qualification of general thoracic surgery.

OBJECTIVE: To update the recommendations for the structural characteristics of general thoracic surgery (GTS) in Europe in order to provide a document that can be used as a guide for harmonizing the general thoracic surgical practice in Europe. METHODS: A task force was created to set the structural, procedural and qualification characteristics of a European GTS unit. These criteria were endorsed by the Executive Committee of the European Society of Thoracic Surgeons and by the Thoracic Domain of the European Association for Cardio-Thoracic Surgery and were validated by the European Board of Thoracic Surgery at European Union of Medical Specialists. RESULTS: Criteria regarding definition and scope of GTS, structure and qualification of GTS unit, training and education and recommendations for subjects of particular interest (lung transplant, oesophageal surgery, minimally invasive thoracic surgery, quality surveillance) were developed. CONCLUSIONS: This document will hopefully represent the first step of a process of revision of the modern thoracic surgeons' curricula, which need to be qualitatively rethought in the setting of the qualification process. The structural criteria highlighted in the present document are meant to help and tackle the challenge of cultural and language barriers as well as of widely varying national training programmes.

Clinical outcomes of lung metastasectomy in patients with colorectal cancer.

AIM: To investigate prognostic factors of survival following curative, non-palliative surgical removal of lung metastases secondary to colorectal cancer (CRC). METHODS: Between 1999 and 2009, a radical metastasectomy with curative intent was performed on lung metastases in 21 patients with CRC (15 male and 6 female; mean age: 57.4 ± 11.8 years; age range: 29-74 years) who had already undergone primary tumour resection. RESULTS: The mean number of lung metastases ranged from one to five. The mean overall survival was 71 ± 35 mo (median: 25 mo). After adjusting for potential confounders, multivariable Cox regression analyses predicted only the number of lung metastases (1 vs ≥ 2; hazard ratio: 7.60, 95% confidence interval: 1.18-17.2, P = 0.03) as an independent predictor of poor survival following lung resection for metastatic CRC. CONCLUSION: Resection of lung metastases is a safe and effective treatment in selected CRC patients with single lung metastases.

Pericardial cysts: an analysis of 12 cases.

BACKGROUND: Pericardial cysts are usually asymtomatic, benign, congenital mediastinal lesions but may also be acquired after cardiothoracic surgery. The purpose of the study was to evaluate surgical approach and results of our experience with pericardial cysts. PATIENTS AND METHODS: A total of 12 patients who had undergone surgical treatment for pericardial cyst between February 1999 and August 2010 were retrospectively evaluated. All patients were analyzed according to the symptoms, method for the diagnosis, cyst location, management, and outcomes. RESULTS: The mean age was 50.4±17 years (range, 23-68 years) with a female-to-male ratio of 8:4. Pericardial cyst were located in the right hemithorax in 8 (67%) patients and left hemithorax in 4 (33%) patients. The cysts were resected by thoracotomy in 4 (33%) patients and by video-assisted thoracic surgery in 8 (67%) patients. There was an excellent long-term follow-up with no morbidity or mortality. CONCLUSION: Videothoracoscopic surgical removal of pericardial cysts is an excellent surgical intervention without serious morbidity and mortality.

Rib approximation without intercostal nerve compression reduces post-thoracotomy pain: a prospective randomized study.

OBJECTIVE: One of the most important considerations in the care of thoracic surgery patients is the control of pain, which leads to increased morbidity and relevant mortality. METHODS: Between February and May 2009, 60 patients undergoing full muscle-sparing posterior minithoracotomy were prospectively randomized into two groups, according to the thoracotomy closure techniques. In the first group (group A), two holes were drilled into the sixth rib using a hand perforator, and sutures were passed through the holes in the sixth rib and were circled from the upper edge of the fifth rib, thereby compressing the intercostal nerve underneath the fifth rib. In the second group (group B), the intercostal muscle underneath the fifth rib was partially dissected along with the intercostal nerve, corresponding to the holes on the sixth rib. Two 1/0 polyglactin (Vicyrl) sutures were passed through the holes in the sixth rib and above the intercostal nerve. RESULTS: There were 30 patients in each group. The visual analog score, observer verbal ranking scale (OVRS) scores for pain, and Ramsay sedation scores were used to follow-up on postoperative analgesia and sedation. The von Frey hair test was used to evaluate hyperalgesia of the patients. The patients in group B had lower visual analog scores at rest and during coughing. The patients in group B had lower OVRS scores than group A patients. The groups were not statistically different in terms of the Ramsay sedation scores and von Frey hair tests. CONCLUSIONS: Thoracotomy closure by a technique that avoids intercostal nerve compression significantly decreases post-thoracotomy pain.

What are the considerations in the surgical approach in pulmonary metastasectomy?

There are four matters of uncertainty considered in this working group report, which are distilled into four clinical questions: (1) What is the evidence for the need for palpation of the lung in modern era of imaging? (2) Is there evidence of a difference in outcome for an open versus a closed approach? (3) Is there evidence of a difference in outcome for an initial policy of bilateral versus unilateral exploration? (4) In patients with known bilateral disease, is there a difference in outcome with a simultaneous versus a staged approach?We searched the literature formally and supplemented this with knowledge from all other sources. We provide evidence tables on the first two questions by relying on a group consensus and frame recommendations for the other two.There are no randomized trials to guide us but there are comparative studies addressing the need for palpation and the need to and open operation in all cases. The evidence is equivocal, and opinions are divided in the literature.Palpation of the lung is still seen as necessary in a therapeutic metastasectomy as opposed to a diagnostic procedure when videothoracoscopy is adequate. However, the importance of palpation becomes less clear with advances in imaging. Routine bilateral exploration for unilateral disease was not favored. For bilateral disease, an initial median sternotomy has a place for some cases but sequenced thoracotomy was preferred.

[Therapeutic approach in hemodynamically stable transmediastinal gunshot wounds]. / Hemodinamisi stabil transmediastinal atesli silah yaralanmalarinda tedavi yaklasimi.

Transmediastinal gunshot wounds may result in damage to the heart, large blood vessels, esophagus or lung. In hemodynamically stable patients, diagnostic examinations have critical importance and the preferred therapies still have unresolved points. In this paper, we present our experience with five patients, three of whom were operated for transmediastinal gunshot wounds after diagnostic tests; all were hemodynamically stable. Before deciding on operation, diagnostic tests should be performed in hemodynamically stable patients with transmediastinal gunshot wounds.

[Thoracoscopic bullectomy and pleural abrasion in the treatment of primary spontaneous pneumothorax]. / Primer spontan pnömotoraks tedavisinde torakoskopik büllektomi ve plevral abrazyon.

Although spontaneous pneumothorax is the most common problem seen by the thoracic surgeon, there is no universal agreement in its management. Thoracoscopic bullectomy is preferred to open bullectomy because of minimal trauma, less pain, early recovery and discharge with comparable results. Seventy thoracoscopic bullectomy and apical pleural abrasion in 65 patients with spontaneous pneumothorax were retrospectively reviewed. All but 8 (13%) patients were male with a mean age of 24 years (range 17-55). Only the patients who had a prolonged air leak (> 4 days), reccurence/bilateral pneumothorax occupational reasons and bilateral pneumothorax were the indications for surgical treatment. The patients who had conversion to open thoracotomy were not included in the study. Computerized tomography was performed in all cases prior to the surgery. Endo-GIA 45-60 mm (4.8) staplers (Auto Suture, Tyco, USA) were used for bullectomy using three port access. The apical pleural abrasion following thoracoscopic bullectomy was performed in all cases. One patient developed haematoma on the first postoperative day and underwent open thoracotomy and evacuation of the haematoma. The median hospital stay was 3 (1-11) days. Recurrent pneumothorax was observed in 5 (7.1%) patients. Although thoracoscopic bullectomy is an expensive procedure that requires experience, however reduced pain, shorter hospital stay and early recovery makes it preferred method in such cases.

Pleurovenous shunt for treating refractory benign pleural effusion.

We report the case of a 63-year-old female with hepatic cirrhosis due to chronic hepatitis C, successfully treated for refractory nonmalignant hepatic hydrothorax by using a long-term pleurovenous shunt (PVS). After failure of conventional treatment by mechanical pleurodesis, a PVS was inserted to drain the pleural fluid into the right subclavian vein. After 8 months of follow-up, the effusion is well controlled, and the shunt remains patent.

Comparison of different bronchial closure techniques following pneumonectomy in dogs.

The comparison of the histologic healing and bronchopleural fistula (BPF) complications encountered with three different BS closure techniques (manual suture, stapler and manual suture plus tissue flab) after pneumonectomy in dogs was investigated for a one-month period. The dogs were separated into two groups: group I (GI) (n = 9) and group II (GII) (n = 9). Right and left pneumonectomies were performed on the animals in GI and GII, respectively. Each group was further divided into three subgroups according to BS closure technique: subgroup I (SGI) (n = 3), manual suture; subgroup II (SGII) (n = 3), stapler; and subgroup III (SGIII) (n = 3), manual suture plus tissue flab. The dogs were sacrificed after one month of observation, and the bronchial stumps were removed for histological examination. The complications observed during a one-month period following pneumonectomy in nine dogs (n = 9) were: BPF (n = 5), peri-operative cardiac arrest (n = 1), post-operative respiratory arrest (n = 1), post-operative cardiac failure (n = 1) and cardio-pulmonary failure (n = 1). Histological healing was classified as complete or incomplete healing. Histological healing and BPF complications in the subgroups were analyzed statistically. There was no significant difference in histological healing between SGI and SGIII (p = 1.00; p > 0.05), nor between SGII and SGIII (p = 1.00; p > 0.05). Similarly, no significant difference was observed between the subgroups in terms of BPF (p = 0.945; p > 0.05). The results of the statistical analysis indicated that manual suture, stapler or manual suture plus tissue flab could be alternative methods for BS closure following pneumonectomy in dogs.

Low frequency of p53 and k-ras codon 12 mutations in non-small cell lung carcinoma (NSCLC) tumors and surgical margins.

AIMS AND BACKGROUND: Lung cancer is one of the most common cancers and has became a predominant cause of cancer-related death throughout the world. The k-ras codon 12 mutation, which is the most common lung cancer mutation, is found in 15 to 30% of all lung cancers. Furthermore, the p53 gene has a very important role in the biological properties of tumor cells, and it is mutated in about 50% of non-small cell lung cancers. Residual tumor cells remain in surgical margins diagnosed as tumor free by histopathological techniques, and they can play a role in forming any local recurrence. Molecular methods may be exploited that are sensitive enough to detect small numbers of tumor cells. METHODS: In the present study, we examined p53 gene mutations and k-ras codon 12 mutations from the tumor samples and surgical margins of 34 non-small-cell lung cancer patients. P53 gene mutations were analyzed by single strand conformational polymorphism analysis, heterodublex analysis and DNA sequencing. K-ras codon 12 mutations were analyzed by the mutagenic PCR-restricted fragment length polymorphism method. RESULTS: A p53 mutation was detected only in primary tumors of 3 out of 34 patients (8.82%). These mutations were clustered in exon 5. Moreover, a k-ras codon 12 mutation was detected in both the primary tumor and the surgical margin tissues of 2 out of 34 patients (5.88%). CONCLUSIONS: The detected mutation rate was low, in the range given in the literature. We think that different mechanisms related to other genes and individual genetic differences might play a role in cancer formation in our study group. We believe that molecular studies are necessary to identify biomarkers and to determine genetic alterations in histopathologically normal surgical margins.

Basic interrupted versus continuous suturing techniques in bronchial anastomosis following sleeve lobectomy in dogs.

OBJECTIVE: Sleeve resection with or without lung resection is a valid conservative operation for patients with benign or malignant tumors; it enables the preservation of lung parenchyma. The aim of this prospective randomized study was to compare complications, operating time, and bronchial healing between the techniques of interrupted and continuous suturing for bronchial anastomosis in dogs. METHODS: Twenty adult mongrel dogs each weighing 18-22 kg (average: 20 kg) were divided into two groups according to the anastomosis technique performed: group A, interrupted suturing and group B, continuous suturing. Each group comprised of 10 dogs. Following right thoracotomy, sleeve resection of the right cranial lobe was performed in all dogs. Basic interrupted sutures using 4/0 Vicryl (Ethicon, USA) were used in group A, and continuous sutures were used in group B. RESULTS: The median anastomosis time was 15.2 min (range: 13-21 min) in group A and 9.6 min (range: 8-13 min) in group B. In all dogs, the anastomosis line was resected via right pneumonectomy for histopathological investigation 1 month after sleeve resection. Histopathological examination revealed that the healing of the anastomosis was not affected by the suturing technique applied. One dog from each group died on the fourth postoperative day; Fisher's exact test, p=0.763. CONCLUSIONS: Our research revealed that the healing of the anastomosis was not affected by the suturing technique performed.