Subcarinal lymph node dissection facilitated by applying suture passer in uniportal video-assisted thoracoscopic surgery.

With the advancement of surgical skills and instrumentation, uniportal video-assisted thoracoscopic surgery (UniVATS) has become a popular option for the treatment of early stage lung cancer surgery. However, performing subcarinal lymph node dissection remains technically challenging under UniVATS view. We introduce a novel technique that utilized a suture passer to improve the exposure of the subcarinal area and simplify lymph node dissection, which has the potential for widespread adoption in clinical practice. There were 13 lung cancer patients who underwent UniVATS lobectomy with mediastinal lymphadenectomy in our institution from July to August 2022. Clinical data of the patients were documented and reviewed. The study population consisted of nine females and four males, with an average age of 57.5 ± 9.1 years. UniVATS lobectomy with mediastinal lymphadectomy was successfully performed in all patients without conversion to open surgery. The mean operation time was 90.7 ± 36.0 min (53-178 min), intraoperative blood loss was 73.1 ± 43.8 mL (50-200 mL), and postoperative hospital stay was 2.9 ± 0.3 days (2-3 days). No complications related to lymph node dissection, such as chylothorax, occurred. Our novel method of using a suture passer could simplify the procedure of subcarinal lymph node dissection during UniVATS in initial clinical practice. Further comparative studies are warranted in the future.

The efficacy and safety of uniportal video-assisted thoracic surgery on the treatment for stage II-III tuberculous empyema: a single-arm clinical retrospective study from 2016 to 2021 in a thoracic surgery center in China.

BACKGROUND: Surgery is an important adjuvant treatment for tuberculous empyema(TE). We thus conducted a single arm-clinical retrospective study of stage II-III TE patients who underwent uniportal video-assisted thoracic surgery (Uni-VATS) over a 5-year period to evaluate the efficacy and safety of surgery on TE, so as to provide the evidence for the optimal clinical strategies. METHODS: Patients diagnosed as TE with withdrawal of anti-tuberculosis-VATS were retrospectively enrolled from January 2016 to December 2021. All patients were followed up untill 12 months after withdrawal of anti-tuberculosis treatment (ATT). Clinical characteristics and surgical details were observed and analyzed to evaluate the efficacy and safety of the minimally invasive surgery. RESULTS: Totally 439 cases met included criteria were enrolled, no deaths were reported. The mean operative time was 2.6 (1.9, 4.3) hours and the mean intraoperative blood loss was 356 (240, 940) ml. Blood transfusion was performed in 20.50% (90/439) of patients and additional pneumonectomy was occurred in 9.89%(37/439)of patients .The mean postoperative drainage time was 12 (7, 49) days and the mean hospital stay was 6 (4,12) days. All stage II TE achieved complete lung re-expansion after surgery while 84.22%(315/374) of stage III achieved complete lung re-expansion, p 0.00. 15.78% (59/374) of stage III TE achieved incomplete re-expansion, 4 of which underwent a second decortication by Uni-VATS. Recurrences rate was 2.96% (13/439), including 11 cases of early recurrence and 2 cases of late recurrence at TE stage III, 5 of which underwent a second decortication by Uni-VATS. CONCLUSION: Uni-VATS is highly effective safe and minimally invasive for patients with TE, which could be recommended as the mainstream operation in areas with high TB burden.

Video-assisted subtotal parietal pleurectomy: an effective procedure for recurrent refractory pneumothorax.

BACKGROUND: Refractory pneumothorax combined with diffuse emphysematous changes is an intractable problem requiring surgical treatment. Traditional bullectomy may result in long-term air leakage and has a risk of early recurrence. Pleurectomy is an effective pleurodesis procedure, which appears to be more suitable for these cases. We conducted this study to present our experience with this procedure. METHODS: We collected the clinical data of 14 patients who underwent subtotal pleurectomy via video-assisted thoracic surgery (VATS) in our institution from November 2016 to October 2021. All patients had undergone complete preoperative examinations and met the indications for pleurectomy. Regular follow-up was conducted after surgery. RESULTS: The study population was composed of 11 males and 3 females, with an average age of 52.4 ± 19.0 years. Subtotal pleurectomy via VATS was successfully performed in all patients, with no conversion to open surgery. The average operation time was 82.5 ± 23.4 min (range 45-120 min), intraoperative blood loss was 92.9 ± 37.1 mL (range 50-200 mL), postoperative hospital stay was 5.0 ± 4.8 days (range 2-19 days), and chest tube duration time was 22.1 ± 13.0 days (range 5-49 days). No major complication occurred except for one case in which reoperation was performed due to massive postoperative hemorrhage. The mean follow-up time was 24.8 ± 17.0 months (range 6-60 months); no recurrence was noted. CONCLUSIONS: Subtotal pleurectomy via VATS is a satisfactorily effective procedure for preventing pneumothorax recurrence.

Immune infiltration landscape and immune-marker molecular typing of pulmonary fibrosis with pulmonary hypertension.

BACKGROUND: Pulmonary arterial hypertension (PH) secondary to pulmonary fibrosis (PF) is one of the most common complications in PF patients, it causes severe disease and usually have a poor prognosis. Whether the combination of PH and PF is a unique disease phenotype is unclear. We aimed to screen the key modules associated with PH-PF immune infiltration based on WGCNA and identify the hub genes for molecular typing. METHOD: Using the gene expression profile GSE24988 of PF patients with or without PH from the Gene Expression Omnibus (GEO) database, we evaluated immune cell infiltration using Cibersortx and immune cell gene signature files. Different immune cell types were screened using the Wilcoxon test; differentially expressed genes were screened using samr. The molecular pathways implicated in these differential responses were identified using Gene Ontology and Kyoto Encyclopedia of Genes and Genomes functional enrichment analyses. A weighted co-expression network of the differential genes was constructed, relevant co-expression modules were identified, and relationships between modules and differential immune cell infiltration were calculated. The modules most relevant to this disease were identified using weighted correlation network analysis. From these, we constructed a co-expression network; using the STRING database, we integrated the values into the human protein-protein interaction network before constructing a co-expression interaction subnet, screening genes associated with immunity and unsupervised molecular typing, and analyzing the immune cell infiltration and expression of key genes in each disease type. RESULTS: Of the 22 immune cell types from the PF GEO data, 20 different immune cell types were identified. There were 1622 differentially expressed genes (295 upregulated and 1327 downregulated). The resulting weighted co-expression network identified six co-expression modules. These were screened to identify the modules most relevant to the disease phenotype (the green module). By calculating the correlations between modules and the differentially infiltrated immune cells, extracting the green module co-expression network (46 genes), extracting 25 key genes using gene significance and module-membership thresholds, and combining these with the 10 key genes in the human protein-protein interaction network, we identified five immune cell-related marker genes that might be applied as biomarkers. Using these marker genes, we evaluated these disease samples using unsupervised clustering molecular typing. CONCLUSION: Our results demonstrated that all PF combined with PH samples belonged to four categories. Studies on the five key genes are required to validate their diagnostic and prognostic value.

Uniportal video-assisted versus open pneumonectomy: a propensity score-matched comparative analysis with short-term outcomes.

OBJECTIVES: Uniportal (U-VATS) pneumonectomy in lung cancer patients remains disputed in terms of oncological outcomes, and has not been compared to open approaches previously. We evaluated U-VATS versus open pneumonectomy at a high-volume centre. METHODS: Patients undergoing pneumonectomy for lung cancer between 2014 and 2018 were retrospectively reviewed and divided into two groups based on surgical approach. Propensity-score matching was performed (1:1), and intention-to-treat analysis applied. Overall survival, operative time, intraoperative blood loss, hospital-stay and readmission, pain, time to adjuvant therapy, morbidity and mortality were tested. Statistical analysis was performed using SAS version 9.4 (SAS Institute Inc. NC) RESULTS: 341 patients underwent pneumonectomy; 23 patients with small-cell lung cancer were excluded, thus 318 patients were submitted to surgery by either U-VATS (n = 54) or open (n = 264). After matching, 52 patients were selected from each group. Five patients (9.2%) in the uniportal group required conversion. There was no significant difference in intraoperative outcomes, complication rates, readmission rates or mortality. The U-VATS group experienced significantly shorter hospital stay (mean ± SD; 6.7 ± 2.7 vs 9.1 ± 2.3 days, p < 0.001) and reported less pain postoperatively (p < 0.0001). Adjuvant chemotherapy was initiated sooner after U-VATS (38.1 ± 8.4 vs 50.8 ± 11.5 days, p < 0.0001). Overall survival appeared to be superior in U-VATS when pathology stage was aligned (p = 0.001). CONCLUSIONS: Uniportal VATS is a safe and effective alternative approach to open surgery for pneumonectomy in lung cancer. Complications and oncologic outcomes were comparatively similar. U-VATS showed lower postoperative pain, shorter hospital stay and superior overall survival. The study is a preliminary analysis.

Bronchial Sleeve Resection with Complete Pulmonary Preservation: A Single-Center Experience.

PURPOSE: Bronchial sleeve resection with complete pulmonary preservation (BSRCPP) is a classic surgical method for the treatment of benign or low-grade bronchial tumors. For elderly patients and patients with poor cardiopulmonary function, BSRCPP is particularly advantageous because some of these patients may not tolerate lobectomy or pneumonectomy. We retrospectively reviewed the clinical data of 20 patients who underwent BSRCPP during the past 7 years. This report presents the experience with BSRCPP in our department. PATIENTS AND METHODS: We collected the data of 20 patients who underwent BSRCPP. Of these 20 patients, 17 underwent thoracotomy and 3 underwent video-assisted thoracoscopic surgery (VATS). The study cohort comprised 7 male and 13 female patients with an average age of 44 years (range, 4-71 years). All patients underwent a systematic preoperative examination to confirm the surgical indications and methods. Regular follow-up was conducted after the operation. RESULTS: All patients survived and remained clinically well. Two of the 20 patients (10%) were re-admitted to the hospital because of pulmonary air leakage, which was resolved after thoracic drainage. No patients developed tumor recurrence. CONCLUSION: BSRCPP may be an effective treatment for selected patients with bronchial tumors. Notably, however, many technical key points require improvement, especially in VATS. Therefore, thoracoscopic minimally invasive treatment requires more practice and exploration.

Subxiphoid versus intercostal uniportal video-assisted thoracoscopic surgery for bilateral lung resections: a single-institution experience.

OBJECTIVES: Subxiphoid uniportal video-assisted thoracoscopic surgery (SUVATS) is a technically difficult and challenging operation that can help decrease pain around the incision after traditional intercostal uniportal video-assisted thoracoscopic surgery (IUVATS), and can also treat bilateral lesions through the same incision. We aimed to compare perioperative outcomes and pain scores after SUVATS and IUVATS in patients receiving synchronous treatment of bilateral lung lesions. METHODS: Patients who received SUVATS and IUVATS bilateral lung resections from September 2014 to February 2018 were analysed. Ultimately a total of 381 cases were analysed after using one-to-one propensity score matching to match baseline characteristics between the 2 groups. RESULTS: The 381 patients included 56 with SUVATS and 325 with IUVATS. After matching, 54 SUVATS and 54 IUVATS cases were analysed. The 2 groups had similar preoperative factors and did not differ with respect to duration of chest tube placement, length of stay in hospital and incidence of postoperative complications. SUVATS was associated with a significantly longer operative time (212.3 vs 154.6 min, P < 0.001) and more blood loss (190.9 vs 72.7 ml, P < 0.001), lower pain score on the first day after operation (2.6 vs 3.0, P = 0.03) and before discharge (0.8 vs 1.4, P < 0.001). Furthermore, less patients in group SUVATS requested for additional analgesic therapy (P = 0.03). CONCLUSIONS: Compared with IUVATS, despite the longer operative time and greater blood loss, SUVATS for bilateral lung lesions is a safe surgical procedure associated with significantly less postoperative pain and a similar incidence of postoperative complications in selected patients.

Comparison of Double Sleeve Lobectomy by Uniportal Video-Assisted Thoracic Surgery (VATS) and Thoracotomy for NSCLC Treatment.

BACKGROUND: With the development of the surgical technique and experience of surgeons, uniportal VATS has been used in double sleeve lobectomy to treat non-small cell lung cancer (NSCLC). This retrospective study aims to evaluate the efficacy and safety of uniportal VATS in NSCLC treatment. METHODS: We reviewed 42 NSCLC patients who underwent double sleeve lobectomy in Shanghai Pulmonary Hospital from June 2015 to November 2017. 21 patients received double sleeve lobectomy through uniportal VATS and 21 through conventional thoracotomy with large incision. RESULTS: The characteristics of patients were similar between the two groups. The operation time was longer in the uniportal VATS group (p=0.021) and the drainage on postoperation day 1 was significantly less in the uniportal VATS group (p=0.004). Patients reported a lower postoperative pain level in the uniportal VATS group than in the thoracotomy group (p=0.002). No statistically significant difference showed in other aspects. CONCLUSION: Uniportal VATS double sleeve lobectomy for NSCLC treatment is safe and effective. Lower postoperative pain level was found in the uniportal VATS group. Its complication rate and postoperation survival were similar to the conventional thoracotomy approach with large incision. But a large randomized clinical trial is still necessary for further investigation.

Lung cancers associated with cystic airspaces: CT features and pathologic correlation.

OBJECTIVE: Lung cancer associated with cystic airspaces (LCCA) is a rare entity. The diagnosis and treatment is often delayed due to lack of comprehension of this disease. We aimed to elucidate LCCA's clinicopathological characteristics and investigate imaging features correlated with pathological invasiveness. METHOD: The preoperative computed tomographic (CT) scans of 10,835 patients diagnosed with NSCLC between January 2015 and December 2016 were reviewed by two thoracic radiologists for association with a cystic airspace. A clinicopathological and radiological feature analysis was done. RESULT: A total number of 123 LCCA patients were identified and four morphologic patterns were recognized: I, thin-walled type (n = 23, 18.7%); II, thick-walled type (n = 34, 27.6%); III, a cystic airspace with a mural nodule (CWN) type (n = 43, 35.0%); and IV, mixed type (n = 23, 18.7%). A solid component in the cyst wall predicted histological invasiveness in all four types of LCCA. The proportion of moderately/poorly (M/P)-differentiated subtype in type III (85.0%) was higher than in other three patterns (which were 50.0%, 50.0%, and 69.6%, respectively). Multivariate analysis revealed that type III pattern (odds ratio [OR], 6.5; 95% confidence interval [CI], 1.1-36.4; P = 0.035), part-solid/solid component in wall (part-solid: OR, 27.2; 95% CI, 5.6-3131.6; P < 0.001; solid: OR 614.6; 95% CI, 36.4-10,368.6; P < 0.001), and irregular inner surface of cyst (OR 7.0; 95% CI 1.9-26.2; P = 0.004) were independent risk factors for the M/P-differentiated subtype. EGFR mutations were the predominant genetic alterations in each type of LCCAs, but no significant difference was found among them. CONCLUSIONS: In LCCA, morphological patterns and wall components were two important predictors for determining pathological invasiveness.

Uniportal Subcostal Video-Assisted Thoracoscopic Surgery: A Feasible Approach for a Challenging Middle Lobectomy in an Obese Patient.

Subcostal access is a novel approach for anatomical lung resection. To perform surgery via this access, specially designed long instruments are required. Subcostal access provides excellent visualization of the mediastinum and anterior lung hilum. We exhibit here a subcostal middle lobectomy with systematic en-block mediastinal lymphadenectomy in an obese 52-year-old male patient with body mass index (BMI=37.7) performed via this single incision. The operation was completed efficiently within 30 minutes with negligible postoperative pain.

Behavior of primary tracheal glomus tumor, uncertain malignant potential subtype.

The behavior of the pathological subtypes of tracheal glomus tumor (benign, uncertain malignant potential UMP, malignant) is vague. In a 51-year-old gentleman, suffering from cough for 4 months, computed tomography scan showed a mass at lower third of the trachea and the bronchoscope revealed exophytic mass at the tracheal lumen. Segmental tracheal resection was done using special modified endotracheal tube for the distal lung ventilation. The tracheal glomus tumor was also diagnosed based on the immunohistochemical staining. The tumor was 2 cm in diameter, deeply located, mitotic phase was difficult to identify, and a diagnosis of UMP subtype was made. There was no recurrence after 2 years follow-up. This is the first reported case of UMP subtype in lower trachea and we studied the treatment options with the clinic-pathological behavior of this tumor and its sequel by regular follow-up.

[Effects of complete and incomplete sleep deprivation on immune function of mice].

AIM: To study the interaction between sleep deprivation and immune functions in mice. METHODS: To set up the uncompleted sleep deprivation of mice by means of lighting mimicked with whole day and dark box done with whole night for 2 weeks and to deprive the mice of sleep in the rotating cage for 24 h and 72 h. All mice are challenge with BSA before sleep deprivation. The spleen weight of mice was measured by analytic balance. The count of T subpopulation was detected with FACS. The levels of cytokines IL-2, IL-10 and the concentration of the specific antibody to BSA was detected by ELISA method. RESULTS: Compared with the normal control, the spleen weight of mice in all the other experimental groups was decreased (P<0.05) except those of lighting group. Decrease of CD8+ T lymphocyte was observed (P<0.01) while the ratio CD4/CD8 increased greatly. Augmentation of IL-10 was demonstrated only in the all-light group, both IL-2 and IL-10 decreased (P<0.01) in the other groups. Significant decrease of specific antibody for BSA was found in the mice of sleep deprived group (P<0.01). CONCLUSION: Complete and incomplete sleep deprivation inhibit differently the immune function of mice by triggering decrease of CD8+ T cells, inhibiting secretion of specific antibody and causing disturbance on the pattern of cytokines.