Short-term outcomes of robotic subxiphoid-optical thymectomy.

PURPOSE: To evaluate the usefulness of robotic subxiphoid-optical thymectomy (RST). METHODS: Thirty-seven procedures (thymoma, n = 19; thymic carcinoma, n = 1; myasthenia gravis, n = 3; and others, n = 14) performed between October 2020 and December 2023 were included. The right and left 6th intercostal midclavicular lines and subxiphoid, with an assistant port placed in the right third intercostal anterior axillary line, were adapted. Postoperative pain was assessed using a numerical rating scale (NRS). RESULTS: A good view of the surgical field is obtained. The median console time was 113 min and the time to roll-in was 30 min. The body mass index (BMI) was 21.6. One patient with thymic carcinoma required combined resection of the left phrenic nerve and left brachiocephalic vein without conversion to thoracotomy, and 1 patient had post-pericardiotomy syndrome with bilateral pleural effusion. There was a correlation between the prolonged time to roll-in and BMI (ρ = 0.439; p = 0.007). Pain was controlled with oral medication on postoperative day 1 and significantly decreased at discharge and at the first outpatient visit without epidural anesthesia (median NRS scores: 4, 1, and 1, respectively). CONCLUSION: RST is a safe procedure that provides surgeons with a sufficient view of the anterior mediastinum and causes minimal postoperative pain.

Inter-prefectural and urban-rural regional disparities in lung cancer surgery: a Japanese nationwide population-based cohort study from 2017 to 2019.

PURPOSE: To investigate regional disparities in lung cancer surgery in Japan. METHODS: The annual incidence of lung cancer, lung cancer surgery, and the number of board-certified thoracic surgeons in Japan during 2014-2019 were investigated using a national open database. Lung cancer surgeries were categorized by procedure (wedge resection, segmentectomy, lobectomy, pneumonectomy) and approach (open, thoracoscopic). Disparities in 47 prefectures and urban-rural disparities during 2017-2019 were evaluated using the Gini coefficient and an unpaired t-test. Correlation was assessed using Pearson's correlation method. RESULTS: The national annual average incidences of lung cancer and lung cancer surgery were 121,106 and 50,959, respectively, in 2014-2019. The use of the thoracoscopic approach increased over time in all procedures, except pneumonectomies. The Gini coefficients of lung cancer, thoracoscopic surgery, and board-certified thoracic surgeons indicated low inequality across prefectures; however, those of open surgery indicated high inequality. Open surgery was more common in urban areas than in rural areas. The number of thoracoscopic surgeries and board-certified thoracic surgeons by prefecture were moderately correlated. CONCLUSION: The thoracoscopic approach is becoming more common in lung cancer surgery, with little inter-prefectural regional disparity in the incidence of lung cancer, thoracoscopic surgeries, or the number of board-certified thoracic surgeons.

Non-stapling thoracoscopic surgery for spontaneous pneumothorax in young patients.

OBJECTIVES: Spontaneous pneumothorax in young patients has a high recurrence rate, even after surgical treatment, and bulla neogenesis around stapled lesions has been reported as a cause of postoperative recurrence. We investigate the clinical safety and long-term outcome of non-stapling thoracoscopic surgery for spontaneous pneumothorax in young patients. METHODS: Twenty-seven non-stapling thoracoscopic surgeries for pneumothorax in 24 patients younger than 25 years were retrospectively reviewed. The non-stapling surgical techniques used to treat bullae included thoracoscopic suture plication, soft-coagulation, covering, and ligation. Long-term follow-up was conducted by telephone or by a mailed questionnaire. RESULTS: In 22 (81.5%) operations, suture plication, soft-coagulation, and covering procedures were used in combination. The median number of bullae treated in one operation was 2 (range, 0-6). The median operative time was 97 min, and the median postoperative drainage and postoperative hospital stay periods were 1 and 3 days, respectively. No complications of grade 2 or higher were observed. Patients were followed for at least 30 (median, 37) months. The postoperative recurrence rate was 3.7%, with one case of recurrence due to bulla neogenesis at a distant site. CONCLUSION: Non-stapling thoracoscopic surgery with covering procedure for pneumothorax in young patients might reduce postoperative recurrence.

The consecutive impact of COVID-19 on thoracic surgical procedures in Japan: an analysis of data from the National Clinical Database.

PURPOSE: The current study was designed to analyze the impact of the COVID-19 pandemic on general thoracic surgeries in Japan. METHODS: Changes in surgeries for lung cancer and metastatic lung tumors were evaluated based on National Clinical Database data regarding cancer screening. RESULTS: In 2021, surgeries for primary lung cancer increased by 3.4% compared to 2020, which, given the increase from 2014 to 2019, indicates an overall 11.1% decrease. In contrast, surgeries for metastatic lung tumors in 2021 decreased by 5.8% compared to 2020, which, given the increase from 2014 to 2020, indicates an overall 9.2% decrease. Half of the primary diseases for metastatic lung tumor were cases of colorectal cancer. Low anterior resection procedures in 2020 decreased by 5.5% compared to 2019. Lung and colon cancer screening examinees in 2021 were increased compared to 2020; however, they still showed respective decreases of 11% and 9.0% compared to 2019. CONCLUSIONS: Surgeries for primary lung cancer still decreased substantially during the COVID-19 pandemic. The continued stagnation of screening was responsible for this decrease. Surgeries for metastatic lung tumors decreased profoundly, and the decrease in screening for primary tumors was responsible for this reduction. Our findings emphasize the significance of maintaining cancer screening efforts, even during a pandemic.

A Case of Jejunal Artery Aneurysm Successfully Treated with Endovascular Embolization.

Jejunal artery aneurysms are extremely rare; only 58 cases have been reported up to 2022. The high rupture rate necessitates a curative treatment. Only four cases of true jejunal artery aneurysms treated with endovascular embolization were reported. We report a case of a 75-year-old man with a true jejunal artery aneurysm who was successfully treated with endovascular embolization. The aneurysm was located in the third jejunal branch. The proximal and distal distance to the superior mesenteric artery and the first bifurcation of the third jejunal branch, respectively, were too short to perform isolation. First, we performed packing in the aneurysm, followed by secondary parent artery embolization. Finally, we achieved total occlusion of the aneurysm and its parent artery with preserved distal intestinal blood flow.

A Case of Refractory Esophageal Varices Caused by an Inferior Mesenteric Arteriovenous Malformation with All Portal System Occlusion Successfully Treated via Transarterial Embolization.

Inferior mesenteric arteriovenous fistulas/malformations are rare, reported in only 40 cases as of 2021. Their main manifestations include portal hypertension and ischemic bowel disease. We report the case of a 50-year-old man with refractory esophageal varices caused by this condition that was successfully treated with transarterial embolization. Computed tomography revealed an inferior mesenteric arteriovenous malformation and ascending blood flow into the esophageal varices through a remarkably dilated marginal vein. All portal systems were occluded, possibly because of the myointimal hyperplasia of the inferior mesenteric vein. The patient recovered without hemorrhagic events after transarterial embolization and endoscopic injection sclerotherapy. This is the first report of an inferior mesenteric arteriovenous malformation resulting in refractory esophageal varices with all-portal system occlusion successfully treated with transarterial embolization.

Characteristic differences in the abundance of tumor-infiltrating lymphocytes and intratumoral developing T cells in thymoma, with special reference to PD-1 expression.

PURPOSE: Though programmed cell death-1 (PD-1) inhibitors mainly target tumor-infiltrating lymphocytes (TILs) expressing PD-1, developing T cells in thymus also express PD-1 in their process of maturation. To predict the therapeutic effect of PD-1 inhibitors for thymoma, it is necessary to clarify the proportions of TILs and intratumoral developing T cells. METHODS: The expressions of CD4, CD8, and PD-1 on T cells were analyzed by flow cytometry in 31 thymomas. The amount of T cell receptor excision circles (TRECs), which can be detected in newly formed naïve T cells in the thymus, was evaluated using sorted lymphocytes from thymomas by quantitative PCR. The expressions of granzyme B (GZMB) and lymphocyte activation gene-3 (LAG-3) in PD-1 + CD8 T cells were analyzed by image cytometry using multiplex immunohistochemistry. RESULTS: The PD-1 + rate in both CD4 and CD8 T cells was significantly higher in type AB/B1/B2 than in type A/B3 thymomas. The amounts of TRECs in CD4 and CD8 T cells were significantly higher in type AB/B1/B2 than in type A/B3 thymomas and comparable to normal thymus. PD-1 expression at each stage of T cell development of type AB/B1/B2 thymomas was comparable to that of normal thymus. Both the percentages and cell densities of PD-1 + CD8 T cells expressing GZMB or LAG-3, which are known to contain tumor-reactive T cells, were significantly lower in type AB/B1/B2 thymomas. CONCLUSION: Most PD-1 + T cells in type AB/B1/B2 thymomas are intratumoral developing T cells and are not TILs.

Perioperative outcomes of minimally invasive surgery for large malignant thymic epithelial tumors and for total thymectomy.

PURPOSE: Minimally invasive surgery (MIS) for thymic tumors is now accepted widely, in line with improved surgical techniques; however, we occasionally encounter complicated cases of large tumors or of total thymectomy requiring prolonged operative duration or conversion to an open procedure (OP). We reviewed patients registered in a nationwide database to identify the technical feasibility of MIS for thymic epithelial tumors. METHODS: Data on patients treated surgically between 2017 and 2019 were extracted from the National Clinical Database of Japan. Clinical factors and operative outcomes were calculated by tumor diameter using trend analyses. Perioperative outcomes of MIS for non-invasive thymoma were investigated using propensity score-matched analyses. RESULTS: MIS was performed in 46.2% of the patients. The operative duration and conversion rate increased with the tumor diameter (p < .001). After propensity score-matching, operative duration and postoperative hospital stay were shorter (p < .001), and the transfusion rate was lower (p = .007) in patients who underwent MIS than in those who underwent OP for thymomas ≥ 5 cm. Among patients who underwent total thymectomy, blood loss was less (p < .001) and the postoperative hospital stay was shorter (p < .001) in those who underwent MIS than in those who underwent OP. There were no significant differences in postoperative complications and mortality. CONCLUSIONS: MIS is technically feasible even for large non-invasive thymomas or for total thymectomy, although the operative duration and open conversion rate increase with the tumor diameter.

[Robot-assisted Segmentectomy for Lung Cancer].

The role of segmentectomy for lung cancer is expected to increase owing to the results of Japan Clinical Oncology Group (JCOG) 0802. Moreover, the major advantage of robot-assisted thoracic surgery (RATS) is that it allows high precision of dissection. The surgical approach comprised the placement of four robotic ports on the lower intercostal space with an assistant hole. While performing robotic surgery without haptic sensation, it is considered safe to dissect the bronchus first followed by the interlobar and intersegmental plane dissection at the end. In our institution, 52 lung cancer segmentectomies were performed between April 2020 and April 2022, out of which 8 (15.4%)were robot-assisted. The median operating time and console time for RATS were 233 and 182 minutes, respectively, showing a trend towards significantly longer operating time as compared to thoracoscopic segmentectomy( 184 vs. 233 minutes, p=0.007). There were no significant differences in the time to drain removal, the incidence of complications, or pain scores at discharge. Although robotic surgery provides the surgeon with better view and greater precision, it does not decrease the operation time and pain. However, robot-assisted surgery is expected to deliver greater benefits to the patient with technological advances in devices and surgical techniques.

The diagnostic challenge of non-traumatic bladder rupture: a pictorial essay.

Non-traumatic bladder rupture (NTBR) is relative rare pathology including spontaneous rupture and iatrogenic injury. As increasing the medical intervention for the pelvic malignancy or elderly population, NTBR will be encountered more frequently. There are few previous studies summarizing the imaging features of NTBR. We reviewed imaging characteristics of 18 previous cases of NTBR experienced. In addition, 3 presentative cases that can be a pitfall to differentiate from NTBR. The aim of this article is to clarify the key CT findings of NTBR and its pitfalls.

Thymic Hyperplasia With Lymphoepithelial Sialadenitis-Like Features Arising in a Patient With Immunoglobulin G4-Related Disorders: A Case Report.

Thymic hyperplasia with lymphoepithelial sialadenitis-like features is characterized by thymic hyperplasia with lymphocytic infiltrates in the thymic epithelium. The lesion differs from other forms of thymic hyperplasia, including true and follicular thymic hyperplasia, in that it presents at an advanced age and has been reported to be unassociated with autoimmune diseases. We report a case of thymic hyperplasia with lymphoepithelial sialadenitis-like features in a 55-year-old male patient with a history of an immunoglobulin G4 (IgG4)-related disorder. Histologically, the resected mediastinal mass showed features consistent with those of thymic hyperplasia with lymphoepithelial sialadenitis-like features. In addition, the IgG4/IgG ratio was elevated in the polyclonal plasmacytoid infiltration. Thymic hyperplasia with lymphoepithelial sialadenitis-like features has not been reported to be associated with IgG4-related disorders; however, as shown in our report, it is crucial to include it in the differential diagnosis of a mediastinal mass in a patient with IgG4-related disorders.

Usefulness of free pericardial fat pads as pledgets for air leaks in pulmonary resection.

PURPOSE: Intraoperative control of air leaks is important for preventing prolonged air leaks after surgery. The usefulness of suturing free pericardial fat pads (FPFPs) as pledgets for repairing air leaks was investigated. METHODS: A total of 111 patients who underwent anatomical lung resection and required suture repair for intraoperative air leaks were retrospectively reviewed. Mattress sutures were performed using polyglycolic acid (PGA) sheets (PGA group; n = 60) in the early period (April 2014 to March 2018) and FPFPs (FPFP group; n = 51) in the late period (April 2018 to March 2021) as pledgets. RESULTS: More patients had a history of smoking in the FPFP group than in the PGA group. The duration of air leakage was significantly shorter (mean 1.2 vs. 3.5 days, p = 0.002) and prolonged air leakage (> 5 days) was less frequently observed (23.3% vs. 5.9%, p = 0.016) in the FPFP group than in the PGA group. The FPFP group had fewer cases requiring pleurodesis and with recurrent air leaks than in the PGA group. In one case in the FPFP group, fat necrosis with fibrosis and fibrous adhesion to the visceral pleura was found on a pathological examination. CONCLUSION: Parenchymal repair using FPFPs as pledgets can reduce prolonged air leaks after surgery.

Surgical intervention for non-small-cell lung cancer with minimal malignant pleural effusion.

PURPOSE: We assessed the clinical significance of minimal malignant pleural effusion (MPE) using liquid-based cytology (LBC) and immunocytochemistry and reviewed the postoperative outcomes of patients with non-small-cell lung cancer (NSCLC). METHODS: We reviewed 240 patients with cM0 NSCLC who underwent lobectomy. Carcinoembryonic antigen (CEA) immunocytochemistry was performed with LBC to aid in the diagnosis of minimal MPE. We assessed the efficacy of this diagnostic method, relevant clinical factors, and postoperative outcomes. RESULTS: LBC showed positive results in two patients and suspicious results in 21. Of the 21 patients, immunocytochemistry showed minimal MPE in 10 (47.6%); therefore, a total of 12 patients (5%) showed minimal MPE. Minimal MPE is associated with an older age, increased consolidation tumor ratio, and adenocarcinoma histology. The 12 patients with minimal MPE had a 3-year overall survival rate of 90%. Postoperative recurrence was observed in seven patients (58.3%), four of whom were treated with epidermal growth factor receptor-tyrosine kinase inhibitors or immune checkpoint inhibitors, while three are still undergoing treatment, with a survival of 2.2, 2.5 and 5.5 years. CONCLUSIONS: CEA immunocytochemistry offers high sensitivity for the diagnosis of minimal MPE. Surgical intervention may be considered for select patients with NSCLC showing minimal MPE.

Spread through air spaces is a powerful prognostic predictor in patients with completely resected pathological stage I lung adenocarcinoma.

PURPOSE: To evaluate the frequency of spread through air spaces (STAS) in patients with early-stage primary lung cancer and to elucidate the association between STAS and various clinicopathological factors. METHODS: We retrospectively reviewed data from a total of 265 consecutive patients who underwent lobectomy and mediastinal lymph node dissection (172 patients) or sublobar resection (93 patients) for completely resected pathological stage I lung adenocarcinoma. We evaluated clinical variables, including the preoperative serum carcinoembryonic antigen (CEA) level, tumour size, consolidation tumour ratio (CTR), maximum standardized uptake value (SUVmax) on FDG-PET, histological results, presence of STAS and vascular and lymphatic invasion. RESULTS: The median follow-up time after surgery was 49 months. Eighty-seven patients (32.8 %) had STAS. The overall survival rates of patients in the STAS-positive and STAS-negative groups were 92.7 % and 97.1 % at 3 years, respectively (p = 0.1255), and the recurrence-free survival rates were 82.1 % and 95.9 % at 3 years, respectively (p = 0.0001). STAS was found in 73 patients (42.4 %) in the lobectomy group, which was a significantly higher proportion than the 14 patients (15.1 %) in the sublobar resection group. The STAS-positive group had significantly larger areas of invasion, higher CTRs, preoperative CEA and SUVmax levels, and more lymphatic and vascular invasion. STAS also correlated significantly with large consolidation sizes, larger invasive size, higher CTRs and the presence of a micropapillary pattern. Cox regression analysis after adjustment for important prognostic factors revealed that the presence of STAS was an independent predictor associated with postoperative recurrence, most of which was observed locoregionally. CONCLUSIONS: STAS was an independent factor associated with postoperative recurrence after lung resection for stage I lung adenocarcinoma. Among stage IA patients, the postoperative outcomes of STAS-positive patients were worse than those of STAS-negative patients and were similar to those of stage IB patients.

Clinical significance of spread of lipiodol marking for pulmonary nodules and its influence on surgery.

OBJECTIVE: Computed tomography (CT)-guided lipiodol marking is one of the targeting methods for resecting small pulmonary nodules or ground-glass nodules in video-assisted thoracic surgery (VATS). However, lipiodol spreading during marking has not been assessed, practically. In this study, we examined the clinical significance and the influence of lipiodol spreading on surgery. METHODS: From April 2010 to March 2021, 176 pulmonary nodules in 167 patients were marked with lipiodol under CT guided before VATS. The marking images after lipiodol injection were classified into "Spread" and "non-Spread." Lung resection was sequentially performed on the same day. RESULTS: All target nodules were successfully resected in VATS. In the classification of marking images, Spread was 32 (18%), non-Spread was 144 (82%). There was a significant difference in duration of surgery (mean; 138.7 min vs. 118.3 min, p = 0.0496) and amount of bleeding (mean; 32.7 g vs. 11.2 g, p = 0.0173). Provided that limited to the data of wedge resections without intrathoracic pleural adhesion (n = 117), there was no significant difference in duration of surgery (mean; 104.8 min vs. 99.6 min, p = 0.48), amount of bleeding (mean; 4.9 g vs. 5.3 g, p = 0.58). In the multivariate logistic regression analysis, the risk factor of lipiodol spreading was intrathoracic pleural adhesion (odds ratio: 3.16, 95% confidence interval: 1.12-8.97, p = 0.03). There was no relationship between marking image and complication rate. CONCLUSIONS: Lipiodol spreading did not directly influence surgery and complication. However, it was a sign of intrathoracic pleural adhesion, which could lead to increased duration of surgery and amount of bleeding.

Prognostic Impact of Using Combined Plasma Fibrinogen Level and Neutrophil-to-Lymphocyte Ratio in Resectable Non-small Cell Lung Cancer.

BACKGROUND: Both plasma fibrinogen level and neutrophil-to-lymphocyte ratio (NLR) are associated with malignant potential in different cancer types. The current study evaluated the use of combined plasma fibrinogen level and NLR (F-NLR) as a prognostic predictor in patients with non-small cell lung cancer (NSCLC). METHODS: Data collected from 279 patients with resectable NSCLC were retrospectively reviewed. Patients were divided into three groups based on the F-NLR score: score 2, high fibrinogen level (≥350 mg/dL) and high NLR (≥2.5); score 1, either high fibrinogen level or high NLR; and score 0, neither abnormal. Overall survival (OS) and relapse-free survival (RFS) were evaluated using the Kaplan-Meier method and log-rank test. Cox proportional hazard model was used to assess prognostic factors. RESULTS: Numbers of patients with F-NLR score of 0, 1, and 2 were 122 (43.7%), 105 (37.6%), and 52 (18.6%), respectively. The F-NLR was found to be significantly associated with age, male sex, heavy smoking history, high pT status and pathological stage, and nonadenocarcinoma. Moreover, the OS and RFS significantly differed according to the F-NLR score (P < 0.001, P = 0.003). A multivariate analysis revealed that a high F-NLR score (≥1) was an independent poor prognostic factor for OS (P = 0.027). In subgroup analyses, an adverse prognostic impact of the F-NLR score on OS was identified regardless of nodal involvement or pathological stage. CONCLUSIONS: The F-NLR score, which is based on histological inflammation and coagulability, could be a potential prognostic indicator in patients with resectable NSCLC.

Clinical significance of postoperative pulmonary complications in elderly patients with lung cancer.

OBJECTIVES: An increasing number of elderly patients with impaired immunity, malnutrition and comorbidities are considered surgical candidates. This study aimed to clarify the predictive factors and prognostic impact of postoperative pulmonary complications in elderly patients with lung cancer. METHODS: This retrospective study included 188 patients (≥75 years) who underwent complete anatomical lung resection for non-small cell lung cancer between 2005 and 2019. Postoperative pulmonary complications graded ≥II in the Clavien-Dindo classification, occurring within 30-day post-surgery were evaluated. Multivariate logistic regression analyses and Cox proportional hazard models were used to analyse predictors and prognostic impact of complications. RESULTS: Video-assisted thoracoscopic surgery was performed in 154 patients (81.9%). The 90-day mortality rate was 0.5%. Postoperative pulmonary complications including air leak, pneumonia, sputum retention, atelectasis, bronchopleural fistula and empyema occurred in 29 patients (15.4%). A lower prognostic nutritional index (<45) and longer operative time were independent predictive factors of pulmonary complications, with 33.3% of patients experiencing both factors. Following a median follow-up of 48 months, the 5-year overall and relapse-free survival rates were significantly worse in patients with pulmonary complications than in those without them (54.4% vs 81.5% and 41.2% vs 74.9%). Pulmonary complications were significantly associated with worse overall and relapse-free survival [hazard ratio (95% confidence interval): 1.97 (1.01-3.66), P = 0.047 and 2.35 (1.28-4.12), P = 0.007, respectively] along with pathologic stage and carcinoembryonic antigen levels. CONCLUSIONS: Postoperative pulmonary complications are associated with a lower prognostic nutritional index and prolonged operative time; the complications are independent adverse prognostic factors in elderly patients.

Robotic subxiphoid-optical thymectomy.

Robot-assisted thymectomy through a subxiphoid scopic approach can provide a good surgical view, similar to that of median sternotomy. We originally used the subxiphoid port only for the robotic scope to avoid instrument collision with the assistant device. This approach, robotic subxiphoid-optical thymectomy, is advantageous for the safe and accurate dissection of the bilateral phrenic nerves and the left brachiocephalic vein, which are especially needed in extended thymectomy for patients with myasthenia gravis.