[Improving the procedures of video-assisted thoracoscopic surgery bronchial sleeve lobectomy for lung cancers].

OBJECTIVE: To modify and improve the procedures of video-assisted thoracoscopic surgery (VATS) bronchial sleeve lobectomy for lung cancers. METHODS: From December 2010 to July 2012, 11 patients with nonsmall cell lung cancers underwent VATS bronchial sleeve lobectomy in our department, which included 7 cases of right upper lobectomy, 3 cases of left upper lobectomy and 1 case of left lower lobectomy. We modified the surgical procedures in relation to the distribution of VATS ports, the techniques of dissecting hilar structures and the method of bronchial reconstruction. The position of incisions for the left side differed from the right side. The lobe was resected with the technique of "hollow out" and the bronchus was reconstructed using a running prolene stitch. RESULTS: Blood loss of these 11 patients ranged from 50-400 (median 200) mL. The operations were completed within 200-320 (median 235) minutes and the duration needed for bronchial reconstruction ranged from 35 to 60 (median 50) minutes. A total of 8-28 (median 15) lymph nodes were dissected. There was no conversion to thoracotomy or blood transfusion. Chest drainage tubes were removed within 2-12 (median 3) days after surgery. The patency of bronchial anastomosis was confirmed by bronchoscopy. Postoperative complications occurred in three patients, which included one case of bronchial pleural fistula (BPF) and two cases of pneumonia. The patient suffered from BPF died 49 days after surgery from intrabronchial bleeding. The postoperative hospital stay of those patients ranged from 8 to 49 (median 8) days. The reconstructed bronchus continued to work well during the three month follow-up visits. CONCLUSION: VATS bronchial sleeve lobectomy is feasible and safe. The modifications of the surgical procedures may promote the use of this complex operation.

[Length of operation with video-assisted thoracoscopic lobectomy].

OBJECTIVE: To determine the duration of the resection of pulmonary lobe (RPL) and the effect of video-assisted thoracoscopic surgery (VATS) procedure on the duration of RPL. METHODS: The records of 126 patients who had VATS lobectomy from October 2009 to October 2010 with a single-direction thoracoscopic procedure in one hospital were reviewed. RESULTS: The patients included 65 (52%) men and 61 (48%) women with a mean age of 56 years (range, 15 years to 82 years). Four cases were excluded because of intraoperative complication. The average length of operation of RPL in the 122 patients without intraoperative complications was 38.98 min +/- 13.243 min (range, 17 min to 100 min), and the average length of the entire operation was 153.36 min +/- 39.64 min (range, 70 min to 245 min). Regardless which lobes, the average length of a single RPL remained the same (P > 0.05). The RPL of bilobectomies took longer than a single lobectomy (P < 0.05). However, no significant differences in the length of the entire operations were found between bilobectomy and single lobectomy (P > 0.05). CONCLUSION: The length of RPL reflects the difficulties of the core step of thoracoscopic lobectomy. Single-direction thoracoscopic lobectomy is an easy procedure to manipulate.

[Immune functions of patients following lobectomy for lung cancers: a comparative study between video-assisted thoracoscopic surgery and posterolateral thoracotomy].

OBJECTIVE: To compare acute inflammatory responses and immunosuppression to lobectomy in lung cancer patients with video-assisted thoracoscopic surgery (VATS) and posterolateral thoracotomy (PLT). METHODS: A total of 103 patients who underwent either a VATS (n = 51) or a PLT (n = 52) lobectomy for early non-small cell lung cancers (NSCLC, stage I ) were recruited for this study. Blood samples of the participants were taken preoperatively and at 24 h and 72 h post-operatively for analyses of C-reactive protein (CRP), interleukin (IL)-6, IL-2 receptors (IL-2R), and serum amyloid A (SAA). Blood samples taken pre-operatively and at 2 d and 7 d post operations were also analyzed for total lymphocytes, NK cells, CD4+ T, and CD8+ T. RESULTS: Patients in the VATS group lost significantly less blood than those in the PLT group (P = 0.001). Patients in the PLT group had significantly higher serum SAA than those in the VATS group (P = 0. 006). Significant reduction of CD8+ T was found in the patients with PLT after operations (P < 0.01). Patients in the PLT group had significantly lower at CD8+ T 7 d post operations than those in the VATS group (P = 0.015). CONCLUSION: VATS pulmonary lobectomy is associated with reduced acute inflammatory responses and immunosuppression compared with the PLT approach.

[Complete video-assisted thoracoscopic anatomic segmentectomy for pulmonary diseases: the early experiences].

OBJECTIVE: To evaluate the safety and feasibility of video-assisted thoracic surgery (VATS) anatomic segmentectomy for pulmonary diseases. METHODS: Between November 2009 and July 2011, 20 patients received consecutive VATS anatomic segmentectomy by single surgical group. There were 3 male and 17 female, aging from 32 to 81 years with a mean of 53 years. The patients included 12 cases of non-small cell lung cancer (NSCLC) (5 cases of bronchioloalveolar carcinoma, 6 cases of adenocarcinoma, and 1 case of squamous cell carcinoma), 7 cases of benign diseases (3 cases of bronchiectasis, 2 cases of inflammatory pseudotumor, 1 case of tuberculosis, and 1 case of sclerosing hemangioma) and 1 case of metastasis tumor. The locations of resected segments included 1 anterior segment, 3 posterior segments, 4 apical segments, and 2 superior segments in the right side; and 5 lingular segments, 3 trisegments, and 2 superior segments in the left side. Simultaneously, 3 patients with bronchiectasis underwent segmentectomy and lobectomy, 1 of 6 patients with adenocarcinoma underwent lingulectomy and thymectomy. The pathological TNM stages of 12 NSCLC patients were 9 cases of T1aN0M0, 1 case of T1bN0M0 and 2 cases of T2aN0M0. RESULTS: Of these 20 patients, the median operative time was 155 minutes (range, 120 to 235 minutes), the median blood loss was 50 ml (range, 10 to 600 ml), the median drainage duration was 3 d (range, 1 to 6 d), and the median hospital stay was 6 d (range, 3 to 9 d). One patient who had undergone lingulectomy had a 600 ml intraoperative bleeding from lingular artery, and the bleeding was controlled by suturing the rupture under VATS. Bloody sputum occurred in 2 patients, prolonged air leak occurred in one patient for 5 days, and one patient developed subcutaneous emphysema that spontaneously resolved. No mortality was observed for 30 days after the surgery. CONCLUSIONS: VATS anatomic segmentectomy is a feasible and safe technique with acceptable operative time, less blood loss, fewer complications, and shorter hospital stay.

[Surgical treatment of invasive thymoma: a prognostic retrospective study].

OBJECTIVES: To observe the clinical outcome of invasive thymoma, and analyze how the surgical methods, Masaoka staging, adjuvant radiotherapy and/or chemotherapy affect the prognosis. METHODS: The clinical data of 59 surgical patients with invasive thymoma and conducted follow-up from January 2000 to December 2009 was analyzed retrospectively. There were 34 male and 25 female, aged from 18 to 72 years with a mean age of 49 years. Forty-four cases underwent radical resection while the other 15 cases underwent palliative resection or biopsy. Masaoka staging: 18 cases with stage II, 30 cases with stage III, 11 cases with stage IV. Patients with stage II didn't undergo further adjuvant radiotherapy or chemotherapy after surgery. Among the patients with stage III and stage IV, 26 patients received adjuvant radiotherapy and/or chemotherapy after surgery, while the other 15 patients did not receive any further therapy. The relationship between the prognosis and the different surgical methods, Masaoka staging, adjuvant radiotherapy and or chemotherapy was evaluated. RESULTS: Fifty-nine patients had been followed up for 1 to 111 months with an average of 54 months. Three cases were lost with the rate of 6.1%. Nineteen patients suffered local recurrence or systemic metastasis, and 14 of them died. The 3-year and 5-year survival rates were 86.8% and 70.8% respectively. Univariate analysis indicated that patients with early Masaoka staging and who received radical resection, adjuvant radiotherapy and/or chemotherapy after surgery had better survival (P < 0.05). Multivariate analysis indicated that radical resection, adjuvant radiotherapy and or chemotherapy were the most significant prognostic factors which could remarkably improve the survival of patients (P < 0.05). For patients with resectable recurrence, reoperation could also improve survival. CONCLUSIONS: The Masaoka staging is related to the prognosis of patients with invasive thymoma. Radical resection, adjuvant radiotherapy, chemotherapy can significantly improve the survival of patients with invasive thymoma. Reoperation can improve the survival of some patients with recurrence.

[The learning curve of single-direction complete video-assisted thoracoscopic surgery for lung cancer].

OBJECTIVE: To analyze the learning curve of single-direction complete video-assisted thoracoscopic surgery (cVATS) for lung cancer. METHODS: From May 2006 to April 2009, 125 cases of cVATS for lung cancer were performed by two dedicated surgeons. Clinical data were collected prospectively and analyzed retrospectively. The patients operated by different surgeon were divided into 2 groups (group A, n = 24; group B, n = 101), and group B was further divided sequentially into 4 subgroups (B1, B2, B3 and B4) by the number of patients. The patients in group A and B were operated by the surgeons with 2-year and 5-year experience of VATS respectively. The operating time, blood loss, number of resected lymph nodes (NLN), rate of thoracotomy conversion (RTC) and postoperative complications (POC) were compared. RESULTS: Compared with group B, the operating time of group A was significantly prolonged [(237 ± 85) min vs. (187 ± 43) min, P = 0.013], but there were no significant differences in blood loss, NLN, RTC and POC. Comparing group A with B1, the same results were got. From group B1 to B4, the operating time was gradually reduced and blood loss decreased, but the difference was not statistically significant. And in group B, there was a significant reduction of blood loss for the last 51 cases compared to the first 50 cases [(122 ± 141) ml vs. (87 ± 81) ml, P = 0.009]. CONCLUSIONS: At the early stage of cVATS resection of lung cancer, the duration of operation was longer, which it was more significant for the surgeons with short carrier of thoracoscopic experience. But the morbidity of operation related complications did not increase. The indicator of proficiency in this operation is achievement of 50 cases of complete thoracoscopic resection of lung cancer.

[The feasibility study in the treatment of benign pulmonary diseases by single-direction complete video-assisted thoracoscopic lobectomy].

OBJECTIVE: To explore the feasibility and safety of single-direction video-assisted thoracoscopic lobectomy in the treatment of benign pulmonary diseases. METHODS: From May 2006 to Dec 2009, 60 patients with benign pulmonary diseases were treated by single-direction complete video-assisted thoracoscopic lobectomy. Nine cases were bronchiectasis, 7 bronchial cyst, 7 tuberculoma, 11 inflammatory pseudotumor, 6 sclerosing hemangioma, 4 hamartoma, 2 atelectasis with bronchial stenosis, 2 pulmonary aspergillosis, 2 pulmonary sequestration, 8 multiple bullae and 2 cases of mid-lobe syndrome. In the 60 patients, there were 18 cases received right upper lobectomy, and right middle lobectomy in 11 cases, right lower lobectomy in 7 cases, left upper lobectomy in 6 cases, left lower lobectomy in 18 cases. RESULTS: There was one conversion to open surgery. One patient died of postoperative pneumonia. The average operation time was 169 min (range, 70-265 min), average blood loss was 125 mL (range, 10-70 mL), average drainage was 860 mL (range, 20-3500 mL) and average duration of drainage was 4 days (range, 2-16 days). The average postoperative hospital stay was 7.9 days (range, 4-19 days). CONCLUSION: Single-direction complete video-assisted thoracoscopic lobectomy is feasible and safe in the treatment of benign pulmonary diseases.

Predictive Value of Excision Repair Cross-Complementation Group 1 in the Response to Platinum-Based Chemotherapy in Esophageal Cancer: A Meta-Analysis.

INTRODUCTION: Platinum is widely used in the treatment of esophageal cancer. In clinical practice, it is significant to distinguish patients who respond to platinum from those who do not. Excision repair cross-complementation group 1 (ERCC1) is thought to be the key in the resistance to platinum. However, whether it is related to the platinum-based chemotherapy response on real esophageal cancer patients is controversial. We conducted this meta-analysis to explore the association between ERCC1 polymorphisms, its expression levels and platinum-based chemotherapy response, and identify the most sensitive genotypes. METHODS: The study was carried out according to the Cochrane handbook for systemic reviews of intervention. The study protocol has been registered on PROSPERO. RESULTS: Three studies were included in the analysis of C8092A polymorphisms, 5 in the C118T, and another 6 in ERCC1 expression levels. In C118T polymorphisms, compared to wild genotype, patients with mutant genotypes had a significantly higher response rate. As for C8092A polymorphisms, the mutant genotypes also presented a better response than the wild genotype. The pooled analysis indicated a significantly higher response rate in patients with a low expression of ERCC1. CONCLUSIONS: ERCC1 is a valuable biomarker for platinum-based chemotherapy in esophageal cancer. Patients with ERCC1 mutations or low-level ERCC1 expression are more sensitive to platinum-based chemotherapy.

Fixed in the neck or pushed back into the thorax?-Impact of cervical anastomosis position on anastomosis healing.

BACKGROUND: Cervical anastomotic leakage remains a great challenge for thoracic surgeons in the surgical treatment of esophageal cancer. Among the factors affecting cervical anastomosis healing, the surgical technique is the key controllable element. This study aimed to identify the risk factors of cervical anastomotic leakage after McKeown esophagectomy, especially those controllable surgical factors. METHODS: A retrospective review of patients who underwent McKeown esophagectomy in the past eight years in West China Hospital was performed. Patients with cervical anastomotic leakage were assigned to leakage group (LG) while the left was enrolled in the none-leakage group (NLG). Multivariate logistic regression analysis was used to identify independent risk factors of anastomotic leakage. RESULTS: A total of 518 patients were enrolled in the final analysis. In the baseline comparison, the difference in fixation of anastomosis in the neck, anastomosis mode, diabetes, and hypertension between the LG and NLG reached statistically significant. Moreover, the statistical difference of cervical fixation, anastomosis mode, and hypertension remained significant in the multivariate logistic regression analysis. CONCLUSIONS: The cervical anastomosis fixation, anastomosis mode, and hypertension are independent risk factors of gastroesophageal cervical anastomotic leakage.

Role of everolimus in the treatment of advanced neuroendocrine tumor: a meta-analysis of randomized trials.

PURPOSE: There are two fundamentally groups of neuroendocrine neoplasms: neuroendocrine tumors (NETs) and neuroendocrine carcinomas (NECs). Target therapy plays a quite important role in the treatment of NETs. However, whether everolimus (mTOR inhibitor) could improve the overall survival (OS) of NETs is contradictory and the efficacy of the agent in NETs from specific organ is lacking analysis. This meta-analysis enrolled the relevant published trials to see the results in a large sample size and further analyzed the efficacy of everolimus according to the tumor origin. METHODS: A systemic search was performed on four major medical databases and related studies were screened out of the result. All the works were done by two reviewers independently and then checked with each other. RESULTS: Finally, 5 articles and 4 conference abstracts from 3 trials were included. All of the trials indicated a statistically significant difference of progression free survival (PFS) in patients receiving everolimus. And the statistic difference remained significant when it came to the NETs from specific organ (overall HR=0.42, 95%CI 0.35, 0.51). As for OS, all the three trials showed no statistically significant difference between the experimental group (patients receiving everolimus) and control group (patients receiving placebo) and the pooled analysis also indicated no significant difference (HR=0.95, 95%CI 0.71,1.25, p=0.695). CONCLUSION: Everolimus is effective in improving the PFS of NETs and the statistical difference remained significant when it came to the NETs from specific organs.

Preoperative thromboprophylactic administration of low-molecular-weight-heparin significantly decreased the risk of intraoperative bleeding compared with heparin in patients undergoing video-assisted lobectomy for lung cancer.

BACKGROUND: Due to the threat from venous thromboembolism (VTE) after major thoracic surgery, especially for cancers, guidelines recommend either heparin sodium (unfractionated heparin) or low-molecular-weight-heparin (LMWH) for those patients at high risk of deep vein thrombosis (DVT). However, risk of bleeding remains a major concern for pre-operative administration of anti-coagulation agents. Therefore, this study aimed to compare the bleeding risk of preoperative administration of LMWH and heparin in patients undergoing video-assisted thoracic surgery (VATS) lobectomy for lung cancer. METHODS: A retrospective, single-center study was designed. A total of 130 patients diagnosed with lung cancer were included from August 2016 to January 2018. These patients were divided into two groups. The preoperative administration of heparin group (PH group) had received heparin 5,000 IU, BID (twice a day) both pre- and post-operatively. And the LMWH group (PL group) had received LMWH 4,000 IU, QD (once a day) both pre- and post-operatively. These anticoagulants would not be ceased until patient was discharged or 24-hour postoperative chest drainage volume exceeded 500 mL. Both preoperative and postoperative coagulation parameters including platelet count (PLT), hemoglobin value (HGB), international normalized ratio (INR), prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (FIB), thrombin time (TT), postoperative drainage parameters and intraoperative bleeding volume were compared. RESULTS: A total of 62 patients were collected in PH group, while 68 patients comprised PL group. Preoperative coagulation parameters, hematologic data and demographic data were comparable. Preoperative duration of two agents (P=0.414), operation time (P=0.155), postoperative HGB (P=0.943), PLT (P=0.244), INR (P=0.469), PT (P=0.651), TT (P=0.407), FIB (P=0.151), drainage duration (P=0.800), duration of heparin and LMWH (P=0.778) were all comparable between the two groups. Compared with PL group, intraoperative bleeding volume (105.11 and 50.26, P<0.001) and postoperative mean drainage volume (251.52 and 216.90 mL, P=0.025) of PH group were significant more. Postoperative APTT (30.17 vs. 28.20 seconds, P=0.022) was significantly longer in PH group. CONCLUSIONS: Compared with preoperative administration of heparin, preoperative thromboprophylactic administration of LMWH significantly decreased the risk of intraoperative bleeding in VATS lobectomy.

Perioperative and long-term outcome of thymectomy for myasthenia gravis: comparison of surgical approaches and prognostic analysis.

BACKGROUND: Thymectomy is an established treatment for myasthenia gravis (MG), and video-assisted thoracoscopic surgery (VATS) thymectomy has become an acceptable surgical procedure. This study aimed to compare the results of VATS thymectomy and open thymectomy and to identify the prognostic factors after thymectomy. METHODS: The clinical data of 187 consecutive thymectomies performed between July 2000 and December 2009 were retrospectively reviewed; 75 open thymectomies and 112 VATS thymectomies. Clinical efficacy and variables influencing outcome were assessed by Kaplan-Meier survival curves and Cox proportional hazards regression analysis. RESULTS: The operative blood loss in the VATS group was significantly less than that in the open group ((62.14 ± 55.43) ml vs. (137.87 ± 165.25) ml, P < 0.05). The postoperative crisis rate increased with the severity of preoperative MG and the prescription dose of anticholinesterase. Complete follow-up information of patients more than 12 months after the thymectomy was obtained on 151 cases, 89 cases from the VATS group and 62 cases from the open group, with a mean follow-up period of 59.3 months, range from 12 to 117 months. Complete stable remission (CSR) was the end point for evaluation of the treatment results. The overall five-year CSR rate was 57.5%. Two good prognostic factors were identified; preoperative prescription of anticholinesterase alone (P = 0.035) and non-thymomatous MG (P = 0.003). The five-year CSR rate of the ocular type of MG reached a high level of 67.4%. CONCLUSIONS: Thymectomy can achieve good long-term CSR in MG, and VATS is an ideal alternative method. High-dose prescription of anticholinesterase and the advanced stage by Myasthenia Gravis Foundation of America (MGFA) classification have higher risks of postoperative crisis. Preoperative prescription of anticholinesterase alone and non-thymomatous MG are good prognostic factors. Thymectomy should also be considered for the ocular type of MG.