Evaluating postoperative recovery in uniportal versus needlescopic video-assisted thoracoscopic surgery for primary spontaneous pneumothorax: a comparable study.

Objectives: Primary spontaneous pneumothorax (PSP) is a common disease in young and thin male. Operation has been regarded as definitive treatment for it. However, the operative methods for those patients are under dispute. This study aims to directly compare the outcomes of uniportal VATS vs. needlescopic VATS in the treatment of PSP, focusing on postoperative pain and safety outcomes. Methods: From July 2013 to December 2017, the patients who underwent video-assisted thoracic surgery for pneumothorax in National Taiwan University Hospital were retrospectively collected. The preoperative condition, surgical results, and postoperative outcomes was analyzed. Results: There were 60 patients undergoing needlescopic VATS and 91 undergoing uniportal VATS during the study period. There was no significant difference between the patients who underwent needlescopic VATS and those who underwent uniportal VATS in their demographic and clinical characteristics. The post-operative pain score was significantly lower in the uniportal VATS group compared to the needlescopic VATS group at day 1 (2.65 ± 1.59 vs. 1.74 ± 1.35, p = 0.001). Conclusion: Uniportal VATS offers an effective, safe alternative for PSP treatment, with benefits including reduced post-operative pain. Our findings support the use of uniportal VATS, supplemented by a wound protector, as a viable option for PSP patients.

Sequential multimodal treatments with chemotherapy and surgery for advanced soft tissue sarcoma may be associated with better survival than chemotherapy.

BACKGROUND: In patients with advanced soft tissue sarcoma (STS), surgery had been reported to be associated with superior overall survival (OS). Chemotherapy details for such patients were less reported, and whether multimodal treatment with surgery and chemotherapy provides extra survival benefit remains unclear. METHODS: We retrospectively reviewed patients with newly diagnosed advanced STS treated at National Taiwan University Hospital from January 1, 2011, to December 31, 2017. OS was calculated from the day of diagnosis of advanced STS to the day of death or last follow-up. Baseline patient characteristics and details regarding surgery and chemotherapy were recorded. RESULTS: A total of 545 patients were diagnosed with STS from 2011 to 2017, of which 226 patients had advanced STS. The median age was 54.7 years, and 54% of patients were women. Approximately 38% of patients with advanced STS underwent surgery and exhibited a trend of longer OS compared with who did not (median = 18.6 vs. 11.9 months, p = 0.083). In the chemotherapy subgroup, the benefit of surgery was more prominent (median = 21.9 vs. 16.5 months, p = 0.037). Patients who received chemotherapy prior to surgery exhibited numerically longer OS than those who underwent surgery first (median = 33.9 vs. 18.3 months, p = 0.155). After adjusting other clinical factors, chemotherapy remained an independent factor associated with favourable OS. CONCLUSION: Surgery may be more beneficial for the patients who receive chemotherapy. Our results support evaluation of sequential multimodal treatments strategy including surgery and chemotherapy in patients with advanced STS.

Prognostication and optimal criteria of circumferential margin involvement for esophageal cancer after chemoradiation and esophagectomy.

Purpose: Circumferential radial margin (CRM) involvement by tumor after resection for esophageal cancer has been suggested as a significant prognostic factor. However, the prognostic value of CRM involvement after surgery with neoadjuvant concurrent chemoradiotherapy (CCRT) is unclear. This study aimed to evaluate the prognostic value of and survival outcomes in CRM involvement as defined by the Royal College of Pathologists (RCP) and the College of American Pathologists (CAP) for patients with esophageal cancer undergoing neoadjuvant CCRT and esophagectomy. Methods: A total of 299 patients with esophageal cancer who underwent neoadjuvant CCRT followed by esophagectomy between 2006 and 2016 were enrolled in our study. The CRM status of the specimens obtained was determined pathologically according to both the CAP and RCP criteria. Survival analyses were performed and compared according to the two criteria. Results: Positive CRM was found in 102 (34.1%) and 40 (13.3%) patients according to RCP and CAP criteria, respectively. The overall and progression-free survival rates were significantly lower in the CRM-positive group than in the CRM-negative group according to both the RCP and CAP criteria. However, under multivariate analysis, in addition to pathological T and N staging of the tumor, only CAP-defined CRM positivity was a significant prognostic factor with adjusted hazard ratios of 2.64 (1.56-4.46) and 2.25 (1.34-3.78) for overall and progression-free survival, respectively (P < 0.001). Conclusion: In patients with esophageal cancer undergoing neoadjuvant CRT followed by esophagectomy, CAP-defined CRM positivity is an independent predictor of survival. Adjuvant therapy should be offered to patients with positive CRM.

Stripping Massage and Literature Review in Post-Thoracoscopic Chest Pain Management.

The aim of this randomized study was to investigate whether stripping massage (SM) of myofascial trigger points in the lower rhomboid muscle could alleviate chest pain in patients following thoracoscopic surgery. In addition, a literature review was conducted to assess the effectiveness of various pain management techniques. Sixty adult patients who reported a visual analog scale (VAS) score of 4 or higher were randomly assigned to receive conventional analgesics alone (conventional group) or combined with SM twice daily for 2 weeks (SM group). VAS scores and the use of additional analgesics were evaluated on postoperative days 1, 3, 7, 14, and 30. Using the PubMed and Cochrane Library databases, a review of current pain management techniques was carried out up to January 31, 2022. A subgroup analysis was also performed to examine the treatment effect during different surgical periods and techniques. Results showed that the SM group had significantly lower VAS scores on postoperative days 3, 7, 14, and 30 (p < 0.001), as well as a shorter hospitalization duration and reduced need for additional analgesics (p < 0.001). The literature review included a total of 20 studies (2,342 cases of chest pain relief after thoracoscopic surgery), which indicated that serratus anterior plane (SAP) blocks were commonly used as a perioperative approach to reduce pain and opioid consumption. SM and SAP can both serve as adjuvant treatments for chest pain in patients following thoracoscopic surgery, with SM being a safe and noninvasive pain control option after hospital discharge.

Robotic-Assisted Thoracoscopic (RATS) Enucleation of Esophageal Mesenchymal Tumors and Foregut Cysts.

Background: Esophageal mesenchymal tumors and foregut cysts are mostly benign lesions of the esophagus. Tumor enucleation is recommended for lesions with a risk of malignancy, or for the relief of clinical symptoms. Although robotic-assisted thoracoscopic enucleation of esophageal tumors and cysts has been demonstrated in sporadic case reports, its clinical role is yet to be elucidated. Methods: This study aimed to present the first case series in the literature for the perioperative and long-term clinical outcomes of robotic-assisted thoracoscopic enucleation. Results: A total of 19 patients who underwent robotic-assisted thoracoscopic enucleation of esophageal tumors and cysts from 2012 to 2019 were included in the study. The mean tumor/cyst size was 5.5 cm (1.5-22 cm). There were two cases shifting to minimally invasive esophagectomy (10.5%) due to intraoperative pathological confirmation of malignant gastrointestinal stromal tumors with mucosal invasion. Perioperative complication was detected in three (15.8%) cases, without 30-day or surgical mortality. There was no recurrence of tumor or symptoms in all patients during the clinical follow-up period (mean = 35 months). Conclusions: Robotic-assisted thoracoscopic enucleation of esophageal submucosal benign tumors is technically feasible and effective. Given its advantage in overcoming spatial limitations, it can become a widely accepted surgical option for such diseases.

Selection of minimally invasive surgical approaches for treating esophageal cancer.

Minimally invasive esophagectomy has gradually been accepted as an active treatment option for surgery of esophageal cancer. However, there is no consensus about how to perform the procedures in the thoracic and abdominal phase including anastomosis in the neck (McKeown) or chest (Ivor Lewis), VATS, robotic-assisted or reduced port approaches or various endoscopic abrasion techniques. Further studies to investigate the roles of these novel techniques are required to treat the various patient populations.

The management of postoperative upper alimentary tract fistulas: A single-center experience of endoscopic tissue glue repair and recommendations of a systematic review.

BACKGROUND/PURPOSE: The appropriate management of postoperative upper alimentary tract fistula (UATF) remains uncertain. The efficacy of esophagogastroduodenoscopy (EGD) tissue glue repair in the treatment of patients with postoperative UATF was explored. We also conducted a systematic review of the literature regarding the inpatient management of UATF. METHODS: Totally 24 patients received EGD tissue glue repair for postoperative UATF at our institute from April 2014 to April 2020. Independent characteristics of size of fistula, location of the UATF, complications, and recurrences were analyzed. PubMed and Cochrane Library databases were reviewed. A pooled analysis was performed, and subgroup analysis was conducted separately for different anatomic locations and techniques. RESULTS: With a mean follow-up of 40 months, the fistula failed to close with EGD tissue glue repair in 2 of 24 patients (8.3%). Eight patients required repeated EGD tissue glue repair, which was more frequent in oral or thoracic UATF (p = 0.053), but all achieved a successful seal in the EGD tissue after glue repair alone (n = 22). The fistula size was correlated with the demand for repeated EGD tissue glue repair (p = 0.017). Besides, a total of 30 studies regarding 2356 cases of postoperative UATF between 2010 and 2021 were retrieved and analyzed. Several non-operative methods were generally accepted as the initial approach, with a non-inferior success rate compared to operative techniques. CONCLUSION: The results suggest that no single approach toward UATF is superior in terms of success rate and healing time. The potential advantages of EGD tissue glue repair after drainage were more suitable for patients with postoperative UATF and multiple comorbidities.

Comparison of perioperative outcomes between intubated and nonintubated thoracoscopic surgery in children.

BACKGROUND/PURPOSE: This study aimed to compare our experiences of nonintubated video-assisted thoracoscopic surgery (VATS) for pneumothorax and lung tumor resections with that of intubated VATS in pediatric patients. METHODS: In total, 17 nonintubated and 64 intubated pediatric VATS were performed between January 2012 and December 2018. Patient characteristics, operation period, comorbidities, precedent lung surgery, diagnosis, type of anesthesia, side and type of procedure, and perioperative outcomes were collected from medical records. Perioperative outcome data included induction time, operation time, postoperative chest tube drainage duration, and length of stay. Simple linear regression and multiple linear regression analyses were used to determine the influence of selected variables on perioperative outcomes. RESULTS: The mean age was 16.2 years in the intubated group and 15.2 years in the nonintubated group. Comorbidities including malignancy and asthma were noted in 9 intubated patients and 6 nonintubated patients. Nonintubated VATS was performed in 9 pneumothorax surgeries and 8 lung tumor resections. Five patients breathed oxygen through a face mask, 3 patients through a high-flow nasal cannula, and 9 patients through a laryngeal mask airway. No patient required tracheal intubation or thoracotomy. No major operative complications were noted in either group. After adjustments for statistically relevant confounders, the multiple regression analysis showed that the nonintubated technique influenced the length of stay, leading to a reduction of 0.75 days. CONCLUSION: Nonintubated VATS is feasible and safe in selected children undergoing bullectomy or wedge resections for lung tumors. The nonintubated approach might enhance postoperative recovery.

Drainless Thoracoscopic Lobectomy for Lung Cancer.

OBJECTIVES: Drainless video-assisted thoracoscopic (VATS) wedge resection has been demonstrated as feasible in treating various lung diseases. However, it remains unknown whether this surgical technique can be effectively applied to lobectomy. In the current study, we evaluated the perioperative outcome of drainless, minimally invasive lobectomy in patients with lung cancer. METHODS: A total of 26 lung cancer patients who received surgery-performed pulmonary lobectomy were enrolled. The perioperative outcomes were analyzed based on a propensity score matching a comparison with those who had chest drainage. RESULTS: No major surgical morbidity and mortality was noted during the perioperative period. The mean of postoperative hospital stay was 5.08 ± 2.48 days. There was no significant difference in postoperative hospital stay between the two groups of patients. However, the presence of significant postoperative pain (VAS score > 30) on the first day after surgery was less in the drainless group (34.6% vs. 3.8%; p = 0.005). CONCLUSIONS: Our results demonstrated that drainless, minimally invasive lobectomy for selected lung cancer patients is feasible. Further evaluation of its impact on short- and long-term surgical outcomes is required in the future.

The Long-Term Clinical Impact of Thoracic Endovascular Aortic Repair (TEVAR) for Advanced Esophageal Cancer Invading Aorta.

BACKGROUND: Advanced esophageal cancer invading the aorta is considered unsuitable for surgery with definitive chemotherapy or chemoradiation as the treatments of choice. In the current study, we evaluated the long-term clinical impact of combining thoracic endovascular aortic repair (TEVAR) with multimodality treatment in caring for such patients. METHODS: We evaluated 48 patients who had advanced esophageal cancer with aortic invasion. The oncological outcome, including overall survival (OS) and progression-free survival (PFS), after multimodality treatment with or without TEVAR is evaluated for these patients. RESULTS: Overall, 25/48 patients (52.1%) received a TEVAR procedure. There was no significant difference in OS (p = 0.223) between patients who did or did not receive TEVAR; however, patients who received TEVAR had significantly less local tumor recurrence (p = 0.020) and longer PFS (p = 0.019). This impact was most evident in patients who received both TEVAR and esophagectomy, with an incremental increase in hazard ratio (HR) for disease progression of 2.89 (95% confidence interval [CI] 0.86-9.96) and 4.37 (95% CI 1.33-14.33) observed under multivariable analysis, respectively, in comparison with patients who underwent only one or neither of these procedures (p = 0.005 for trend test). CONCLUSION: TEVAR is a feasible procedure for esophageal cancers invading the aorta and can be used for curative-intent resection to improve local tumor control and PFS.

The genetic effect and molecular function of the SOCS5 in the prognosis of esophageal squamous cell carcinoma.

Expression of cytokines and growth factors have been shown to be highly correlated with the prognosis of esophageal squamous cell carcinoma (ESCC), a deadly disease with poor prognosis. The suppressor of cytokine signaling (SOCS) family of proteins are key factors in regulating cytokines and growth factors. Yet the role of the SOCS proteins in ESCC is hardly investigated. We currently investigated the prognostic role of SOCS5 in ESCC. We analyzed the prognostic effects of 16 single nucleotide polymorphisms (SNPs) within the SOCS genes in 632 ESCC patients. We repeatedly observed that the 3 SNPs in SOCS5, SOCS5:rs3814039, SOCS5:rs3738890, and SOCS5: rs3768720, were significantly correlated with both overall (OS) and progression-free survival (PFS) of ESCC patients (rs3814039, p=0.032 for OS and p=0.009 for PFS; rs3738890, p=0.016 for OS, and p=0.008 for PFS; rs3768720, p=0.005 for OS and p=0.002 for PFS). SOCS5: rs3768720 was also significantly associated with distant metastasis (Ptrend=0.028). The luciferase assay revealed that SOCS5:rs3814039 and SOCS5: rs3768720 might influence the prognosis by regulating SOCS5 expression. Functional analysis demonstrated SOCS5 was able to regulate epidermal growth factor receptor (EGFR) expression and migration activity of ESCC cells. Furthermore, Patients with strong SOCS5 in normal tissues exhibited significantly better PFS (P=0.049) and reduced risk of distant metastasis (P=0.004) compared to those with weak SOCS5 expression. Overall, our study demonstrates the novel function of SOCS5 in ESCC prognosis. The genetic polymorphisms and expression of SOCS5 could serve as a novel therapeutic biomarker for improving the prognosis of ESCC.

Comparison of several alternatives for the management of severe pectus excavatum in the Nuss procedure.

BACKGROUND: The aim of this study was to assess the safety of several modified Nuss procedures for severe pectus excavatum (PE). METHODS: Thirty-four patients with severe PE underwent the Nuss procedure: 10 underwent slanting-directed bar insertion (group A); 11 underwent standard Nuss procedure (group B); and 13 underwent Nuss procedure with subxiphoid assistance (group C). All the patients met the criteria of having a Haller index greater than 4.5, assessed from chest computed tomography. Besides, the transverse length of the most depressed point and the 2-intercostal left slant length between the heart and the anterior chest wall were measured. RESULTS: All patients were followed up for 6-45 months (mean 31.4 ± 11.38 months). None of the patients suffered from injuries to the pericardium, heart or lungs. There were no significant differences in age, Haller's index, operation time and postoperative stay among the three groups. However, two patients in group B experienced bar rotation and subsequently required reoperation vs the other two groups (p < 0.001). The length of contact between the heart and the chest wall was shorter in the left slant axis (5.8 ± 0.33 cm) than in the transverse axis (7.3 ± 0.37 cm) in group A (p = 0.001). CONCLUSION: A modified Nuss procedure of slanting steel bar insertion has shown to be a safe and effective approach for the correction of severe PE.

Tracheal reconstruction with nail grafts: A novel approach.

BACKGROUND: The replacement of tracheal defects has been a challenge for investigators worldwide. We aimed to develop autologous nail grafts for the reconstruction of anterior tracheal defects. METHODS: Toenail grafts were implanted to improve the structural integrity of the trachea in patients with tracheal diseases. We clinically applied these grafts for the partial replacement of the cervical tracheal cartilage. Data on graft construction details, clinical outcomes, bronchoscopy, and 3-dimensional computed tomography examinations were collected. RESULTS: The nail grafts were implanted in 4 patients. The trachea was successfully reconstructed in all cases. Bronchoscopy was performed 3 times to document healing: immediately, 1 month, and 3 months after surgery. All grafts were well vascularized and incorporated into the tracheal wall and were covered with the respiratory mucosa. Three of the patients survived during the study period, but 1 patient died of progressive lung cancer. CONCLUSIONS: Toenail grafts potentially may be used as an alternative strategy for the closure of small defects during tracheal reconstruction.

Vicryl Mesh Coverage Reduced Recurrence After Bullectomy for Primary Spontaneous Pneumothorax.

BACKGROUND: Although thoracoscopic stapled bullectomy is a standard procedure for primary spontaneous pneumothorax (PSP), the postoperative recurrence rate is high. We investigated whether using a Vicryl (Ethicon, Somerville, NJ) mesh to cover the staple line after bullectomy reduces the postoperative recurrence rate. METHODS: Our single-blind, parallel-group, prospective, randomized controlled trial at 2 medical centers in Taiwan studied patients with PSP who were aged 15 to 50 years and required thoracoscopic bullectomy. On the day of operation, patients were randomly assigned (1:1) to receive Vicryl mesh (mesh group) or not (control group) after thoracoscopic bullectomy with linear stapling and mechanical apical pleural abrasion. Randomization was achieved using computer-generated random numbers in sealed envelopes. Our primary end point was the pneumothorax recurrence rate within 1 year after the operation (clinicaltrials.gov number, NCT01848860.) RESULTS: Between June 2013 and March 2016, 102 patients were assigned to the mesh group and 102 to the control group. Within 1 year after operation, recurrent pneumothorax was diagnosed in 3 patients (2.9%) in the mesh group compared with 16 (15.7%) in the control group (P = .005). The short-term postoperative results and hospitalization duration were comparable between the groups. CONCLUSIONS: For thoracoscopic bullectomy with linear stapling and mechanical apical pleural abrasion, the use of a Vicryl mesh to cover the staple line is effective for reducing the postoperative recurrence of pneumothorax. Vicryl mesh coverage can be considered an optimal adjunct to the standard surgical procedure for PSP.

Robotic-assisted single-incision gastric mobilization for minimally invasive oesophagectomy for oesophageal cancer: preliminary results.

OBJECTIVES: With the gradual acceptance of robotic-assisted surgery to treat oesophageal cancer and the application of a single-port approach in several abdominal procedures, we adopted a single-port technique in robotic-assisted minimally invasive oesophagectomy during the abdominal phase for gastric mobilization and abdominal lymph node dissection. METHODS: Robotic-assisted oesophagectomy and mediastinal lymph node dissection in the chest were followed by robotic-assisted gastric mobilization and conduit creation with abdominal lymph node dissection, which were performed via a periumbilicus single incision. The oesophagogastrostomy was accomplished either in the chest (Ivor Lewis procedure) or neck (McKeown procedure) depending on the status of the proximal resection margin. RESULTS: The procedure was successfully performed on 11 patients with oesophageal cancer from January 2017 to December 2018 in our institute. No surgical or in-hospital deaths occurred, though we had one case each of anastomotic leakage, pneumonia and hiatal hernia (9%). CONCLUSIONS: Robotic single-incision gastric mobilization for minimally invasive oesophagectomy for treating oesophageal cancer seems feasible. Its value in terms of perioperative outcome and long-term survival results awaits future evaluation.

Recent advances and controversies in surgical intervention of nontuberculous mycobacterial lung disease: A literature review.

The prevalence of nontuberculous mycobacterial lung disease (NTM-LD) has increased in Western and Asian nations in recent decades. While surgery may improve the outcome of more complex cases, many inconsistencies exist in the current literature regarding the management, growing emergence, and challenges of drug-resistant forms of NTM-LD, the indications and timing of surgical treatment, and perioperative multimodal therapy of NTM-LD. Moreover, data regarding the comparative treatments, risk factors of pulmonary resection for NTM-LD, and the long-term outcomes of microbiological recurrence are limited. This review will focus on outlining the outcomes of recently optimized surgical approaches, as well as providing an overview of the roles of perioperative multimodalities therapies in the treatment of NTM-LD.