Multicentre randomized clinical trial on robot-assisted versus video-assisted thoracoscopic oesophagectomy (REVATE trial).

BACKGROUND: Surgery for oesophageal squamous cell carcinoma involves dissecting lymph nodes along the recurrent laryngeal nerve. This is technically challenging and injury to the recurrent laryngeal nerve may lead to vocal cord palsy, which increases the risk of pulmonary complications. The aim of this study was to compare the efficacy and safety of robot-assisted oesophagectomy (RAO) versus video-assisted thoracoscopic oesophagectomy (VAO) for dissection of lymph nodes along the left RLN. METHODS: Patients with oesophageal squamous cell carcinoma who were scheduled for minimally invasive McKeown oesophagectomy were allocated randomly to RAO or VAO, stratified by centre. The primary endpoint was the success rate of left recurrent laryngeal nerve lymph node dissection. Success was defined as the removal of at least one lymph node without causing nerve damage lasting longer than 6 months. Secondary endpoints were perioperative and oncological outcomes. RESULTS: From June 2018 to March 2022, 212 patients from 3 centres in Asia were randomized, and 203 were included in the analysis (RAO group 103; VAO group 100). Successful left recurrent laryngeal nerve lymph node dissection was achieved in 88.3% of the RAO group and 69% of the VAO group (P < 0.001). The rate of removal of at least one lymph node according to pathology was 94.2% for the RAO and 86% for the VAO group (P = 0.051). At 1 week after surgery, the RAO group had a lower incidence of left recurrent laryngeal nerve palsy than the VAO group (20.4 versus 34%; P = 0.029); permanent recurrent laryngeal nerve palsy rates at 6 months were 5.8 and 20% respectively (P = 0.003). More mediastinal lymph nodes were dissected in the RAO group (median 16 (i.q.r. 12-22) versus 14 (10-20); P = 0.035). Postoperative complication rates were comparable between the two groups and there were no in-hospital deaths. CONCLUSION: In patients with oesophageal squamous cell carcinoma, RAO leads to more successful left recurrent laryngeal nerve lymph node dissection than VAO, including a lower rate of short- and long-term recurrent laryngeal nerve injury. Registration number: NCT03713749 (http://www.clinicaltrials.gov).

Oesophageal cancer often requires complex surgery. Recently, minimally invasive techniques like robot- and video-assisted surgery have emerged to improve outcomes. This study compared robot- and video-assisted surgery for oesophageal cancer, focusing on removing lymph nodes near a critical nerve. Patients with a specific oesophageal cancer type were assigned randomly to robot- or video-assisted surgery at three Asian hospitals. Robot-assisted surgery had a higher success rate in removing lymph nodes near the important nerve without permanent damage. It also had shorter operating times, more lymph nodes removed, and faster drain removal after surgery. In summary, for oesophageal cancer surgery, the robotic approach may provide better lymph node removal and less nerve injury than video-assisted techniques.

Temporal Trends in Survival Outcomes for Patients with Esophageal Cancer Following Neoadjuvant Chemoradiotherapy: A 14-Year Analysis.

BACKGROUND: The prognosis for patients with esophageal cancer who received neoadjuvant chemoradiotherapy (nCRT) followed by surgery has shown improvement in recent years. We sought to identify the critical factors contributing to enhanced survival outcomes. PATIENTS AND METHODS: We retrospectively examined 427 patients with esophageal cancer treated with nCRT and esophagectomy across two periods: P1 (from 1 January 2004 to 31 December 2011) and P2 (from 1 January 2012 to 31 December 2017). The introduction of the CROSS regimen and total meso-esophagectomy in P2 prompted an evaluation of their effects on perioperative outcomes and overall survival (OS). RESULTS: During P2, the occurrence of recurrent laryngeal nerve palsy increased significantly from 3.9 to 16.8% (p < 0.001), while pneumonia and in-hospital mortality rates remained unchanged. The median OS improved from 19.2 to 29.2 months (p < 0.001) between P1 and P2. Multivariable analysis identified higher nodal yields and the achievement of major response as favorable prognostic factors. Conversely, an involved circumferential resection margin (CRM), an advanced ypN stage, and pneumonia were independently associated with poor outcomes. Patients treated during P2 had a lower prevalence of involved CRM (10% vs. 25.1%, p < 0.001), a higher rate of major response (52.7% vs. 34.8%, p < 0.01), and a greater nodal yield (27.8 vs. 10.9, p < 0.001). CONCLUSIONS: The clinical outcomes following nCRT and surgery have improved significantly over time. This progress can be attributed to multiple factors, with the primary drivers being the refinement of nCRT protocols and the application of radical surgery.

Safety and feasibility comparison between three different CT-guided localization techniques under systemic approach algorithm.

INTRODUCTION: In the era of lung cancer screening, more and more sub-centimeter indeterminate lung lesions are being identified. It is difficult to approach these lesions and obtain tissue to confirm diagnosis. CT-guided navigation followed by surgical resection is the best way to overcome this difficulty. The aim of this study is to compare the safety and feasibility of wire and dye-tattoo CT-guided localization techniques. MATERIALS AND METHODS: From September 2019 to August 2021, 418 patients who presented with single lung lesion and received single CT-guided localization were included in this study. Procedure details, navigation results, and related complications were compared. RESULTS: For patients who received wire localization, majority (98.3 %) had perihilar lesions. In addition, 68 (57.1 %) patients received tangential approach because of lesions were blocked by bony or vital structure, abutting major fissure, or previous approach failure. The characteristics of lesion location was quite different than dye-tattooing technique (p = 0.033). As regards persistence of the target lesion localization, the interval between localization and surgery using ICG tattooing was 829.0 ± 552.9 min; much longer than the other two navigation techniques (p < 0.0001). As regards safety, patients who received wire localization had a higher rate of pneumothorax (p = 0.042) and pulmonary hemorrhage (p < 0.001) than the dye-tattooing techniques. DISCUSSION: CT-guided navigation techniques are safe and feasible. Wire localization is suitable for centrally located lesions but the wire needs to be fixed properly and symptomatic pneumothorax monitored for. Dye-tattooing is more suitable for peripheral lesions, while ICG localization persists longer than other techniques.

The impact of surgical learning curve on short-term outcomes after bilateral lung transplantation: results from a multidisciplinary surgical team.

OBJECTIVES: The aim of this study was to examine the impact of surgical learning curve on short-term clinical outcomes of patients after bilateral lung transplantation (LTx) performed by a surgical multidisciplinary team (MDT). METHODS: Forty-two patients underwent double LTx from December 2016 to October 2021. All procedures were performed by a surgical MDT in a newly established LTx program. The time required for bronchial, left atrial cuff and pulmonary artery anastomoses was the main end point to assess surgical proficiency. The associations between the surgeon's experience and procedural duration were examined by linear regression analysis. We employed the simple moving average technique to generate learning curves and evaluated short-term outcomes before and after achieving surgical proficiency. RESULTS: Both total operating time and total anastomosis time were inversely associated with the surgeon's experience. On analysing the learning curve for bronchial, left atrial cuff and pulmonary artery anastomoses using moving averages, the inflection points occurred at 20, 15 and 10 cases, respectively. To assess the learning curve effect, the study cohort was divided into early (cases 1-20) and late (cases 21-42) groups. Short-term outcomes-including intensive care unit stay, in-hospital stay and severe complications-were significantly more favourable in the late group. Furthermore, there was a notable tendency for patients in the late group to experience a decreased duration of mechanical ventilation along with reduced instances of grade 3 primary graft dysfunction. CONCLUSIONS: A surgical MDT can perform double LTx safely after 20 procedures.

Tracheal reconstruction with pedicled tandem grafts engineered by a radial stretch bioreactor.

The engineering of tracheal substitutes is pivotal in improving tracheal reconstruction. In this study, we aimed to investigate the effects of biomechanical stimulation on tissue engineering tracheal cartilage by mimicking the trachea motion through a novel radial stretching bioreactor, which enables to dynamically change the diameter of the hollow cylindrical implants. Applying our bioreactor, we demonstrated that chondrocytes seeded on the surface of Poly (ε-caprolactone) scaffold respond to mechanical stimulation by improvement of infiltration into implants and upregulation of cartilage-specific genes. Further, the mechanical stimulation enhanced the accumulation of cartilage neo-tissues and cartilage-specific extracellular macromolecules in the muscle flap-remodeled implants and reconstructed trachea. Nevertheless, the invasion of fibrous tissues in the reconstructed trachea was suppressed upon mechanical loading.

Puf-A promotes cancer progression by interacting with nucleophosmin in nucleolus.

Previously, we identified Puf-A as a novel member of Puf-family RNA-binding proteins; however, its biological functions remain obscure. Analysis of tumor samples of non-small cell lung cancer (NSCLC) showed that high Puf-A expression correlated with high histology grade and abnormal p53 status. Kaplan-Meier curve for overall survival revealed high expression of Puf-A to predict poor prognosis in stage I NSCLC. Among patients with colorectal cancer, high Puf-A expression also showed an adverse impact on overall survival. In lung cancer cell lines, downregulation of p53 increased Puf-A expression, and upregulation of p53 dampened its expression. However, luciferase reporter assays indicated that PUF-A locus harbored the p53-response element, but regulated Puf-A transcription indirectly. In vivo suppression of p53 in CCSP-rtTA/TetO-Cre/LSL-KrasG12D/p53flox/flox conditional mutant mice accelerated the progression of the KrasG12D-driven lung cancer, along with enhanced expression of Puf-A. Importantly, intranasal delivery of shPuf-A to the inducible KrasG12D/p53flox/flox mice suppressed tumor progression. Puf-A silencing led to marked decreases in the 80S ribosomes, along with decrease in S6 and L5 in the cytoplasm and accumulation in the nucleolus. Based on immunofluorescence staining and immunoprecipitation studies, Puf-A interacted with NPM1 in nucleolus. Puf-A silencing resulted in NPM1 translocation from nucleolus to nucleoplasm and this disruption of NPM1 localization was reversed by a rescue experiment. Mechanistically, Puf-A silencing altered NPM1 localization, leading to the retention of ribosomal proteins in nucleolus and diminished ribosome biogenesis, followed by cell-cycle arrest/cell death. Puf-A is a potential theranostic target for cancer therapy and an important player in cancer progression.

Puestow's Procedure Performed During Gastric Conduit Harvesting.

Esophageal cancer survival has improved as a result of improvements in surgical techniques and preoperative chemoradiation. Excessive alcohol consumption is a shared risk factor for esophageal cancer and chronic alcoholic pancreatitis. Puestow's procedure is a treatment choice for pain relief and pancreatic duct decompression. It is logical to perform Puestow's procedure in patients undergoing esophagectomy with underlying chronic pancreatitis to preserve pancreatic function and restore quality of life in the setting of improved overall survival of patients with esophageal cancer. This report describes a preliminary experience with 2 patients who underwent both procedures during the same operation and achieved acceptable outcomes.

Malignancy Prediction Capacity and Possible Prediction Model of Circulating Tumor Cells for Suspicious Pulmonary Lesions.

More and more undetermined lung lesions are being identified in routine lung cancer screening. The aim of this study was to try to establish a malignancy prediction model according to the tumor presentations. From January 2017 to December 2018, 50 consecutive patients who were identified with suspicious lung lesions were enrolled into this study. Medical records were reviewed and tumor macroscopic and microscopic presentations were collected for analysis. Circulating tumor cells (CTC) were found to differ between benign and malignant lesions (p = 0.03) and also constituted the highest area under the receiver operation curve other than tumor presentations (p = 0.001). Since tumor size showed the highest sensitivity and CTC revealed the best specificity, a malignancy prediction model was proposed. Akaike information criterion (A.I.C.) of the combined malignancy prediction model was 26.73, which was lower than for tumor size or CTCs alone. Logistic regression revealed that the combined malignancy prediction model showed marginal statistical trends (p = 0.0518). In addition, the 95% confidence interval of combined malignancy prediction model showed less wide range than tumor size ≥ 0.7 cm alone. The calculated probability of malignancy in patients with tumor size ≥ 0.7 cm and CTC > 3 was 97.9%. By contrast, the probability of malignancy in patients whose tumor size was < 0.7 cm, and CTC ≤ 3 was 22.5%. A combined malignancy prediction model involving tumor size followed by the CTC count may provide additional information to assist decision making. For patients who present with tumor size ≥ 0.7 cm and CTC counts > 3, aggressive management should be considered, since the calculated probability of malignancy was 97.9%.

Long-Term Results of a Standard Algorithm for Intravenous Port Implantation.

Intravenous ports serve as vascular access and are indispensable in cancer treatment. Most studies are not based on a systematic and standardized approach. Hence, the aim of this study was to demonstrate long-term results of port implantation following a standard algorithm. A total of 2950 patients who underwent intravenous port implantation between March 2012 and December 2018 were included. Data of patients managed following a standard algorithm were analyzed for safety and long-term outcomes. The cephalic vein was the predominant choice of entry vessel. In female patients, wire assistance without use of puncture sheath was less likely and echo-guided puncture via internal jugular vein (IJV) with use of puncture sheath was more likely to be performed, compared to male patients (p < 0.0001). The procedure-related complication rate was 0.07%, and no pneumothorax, hematoma, catheter kinking, catheter fracture, or pocket erosion was reported. Catheter implantations by echo-guided puncture via IJV notably declined from 4.67% to 0.99% (p = 0.027). Mean operative time gradually declined from 37.88 min in 2012 to 23.20 min in 2018. The proposed standard algorithm for port implantation reduced the need for IJV echo-guided approach and eliminated procedure-related catastrophic complications. In addition, it shortened operative time and demonstrated good functional results.

Surgical result in non small cell lung cancer patients presenting with ground glass opacity predominant lesion less than 2 cm: Anatomic versus wedge resection.

BACKGROUND: Image characteristics of tumor, including tumor size and component are crucial for patients' survival. Patients who presented with ground glass opacity (GGO) was found less risk of intrapulmonary lymph node metastases and good survival. However, it is difficult to get tissue prove for small GGO lesion preoperatively because of its tiny size and the accuracy of intraoperation frozen section. Some patients received another operation for anatomic resection after malignancy has been confirmed and others refused reoperation and only received wedge resection. The aim of this study was tried to compare the treatment result between anatomic and wedge resection for non small cell lung cancer patients who present as small ground glass opacity (GGO) predominant lesion in pre-operation CT. METHODS: From January 2010 to May 2014, 500 non small cell lung cancer patients who underwent tumor resection were included. Patients who presented with small GGO predominant lesion in pre-operation CT were included and medical records were reviewed retrospectively. The survival status between anatomic and wedge resection was analyzed. RESULTS: 37 patients received anatomic resection (Group A) and 9 patients received wedge resection (Group B). Group B showed less staple usage (p = 0.01) and blood loss (p = 0.02). From view of pathology result, only less intrapulmonary lymph nodes was dissected was identified in group B. From view of survival, similar disease free and overall survival without statistical differences in both groups. CONCLUSION: Wedge resection may provide equivalent treatment result for patients who presented as peripheral GGO or GGO predominant lesions that less than 2 cm in size.

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.

Circulating Tumor Cells as a Tool of Minimal Residual Disease Can Predict Lung Cancer Recurrence: A longitudinal, Prospective Trial.

BACKGROUND: The role of circulating tumor cells (CTCs) for predicting the recurrence of cancer in lung cancer patients after surgery remains unclear. METHODS: A negatively selected protocol of CTC identification was applied. For all the enrolled patients, CTC testing was performed before and after surgery on the operation day (day 0), postoperative day 1, and day 3. The daily decline and trend of CTCs were analyzed to correlate with cancer relapse. The mixed model repeated measures (MMRM) adjusted by cancer characteristics was applied for statistical significance. RESULTS: Fifty patients with lung mass undergoing surgery were enrolled. Among 41 primary lung cancers, 26 (63.4%) were pathological stage Tis and I. A total of 200 CTC tests were performed. MMRM analysis indicated that surgery could contribute to a CTC decline after surgery in all patients with statistical significance (p = 0.0005). The daily decrease of CTCs was statistically different between patients with and without recurrence (p = 0.0068). An early rebound of CTC counts on postoperative days 1 and 3 was associated with recurrence months later. CONCLUSION: CTC testing can potentially serve as a tool for minimal residual disease detection in early-staged lung cancer after curative surgery.

Safety and oncological efficacy of bilateral recurrent laryngeal nerve lymph-node dissection after neoadjuvant chemoradiotherapy in esophageal squamous cell carcinoma: a propensity-matched analysis.

BACKGROUND: We sought to evaluate the safety and oncological efficacy of bilateral recurrent laryngeal nerve (RLN) lymph-node dissection (LND) in patients with esophageal squamous cell carcinoma (ESCC) who had undergone neoadjuvant chemoradiotherapy (nCRT). METHODS: We retrospectively examined the records of ESCC patients who were judged to be ycN-RLN(-) following nCRT. Patients were divided into two groups according to the extent of LND [standard two-field LND (STL group) versus total two-field LND (TTL group)]. Only lower mediastinal and upper abdominal lymph nodes were removed in the STL group. In addition to the standard procedure, patients in the TTL group underwent resection of upper mediastinal lymph nodes located along the bilateral RLN. Using propensity score matching, 29 pairs were identified and compared with regard to perioperative complications, lymph-node metastases rates, overall survival (OS), and disease-specific survival (DSS). RESULTS: No significant intergroup differences were identified in terms of in-hospital mortality and morbidity. Metastases to the RLN lymph nodes were identified in 20.7% (6/29) of TTL patients, being the only site of lymph-node metastases in three of them. TTL was associated with lower upper mediastinal lymph-node recurrence rate (6.5%) compared with STL (21.5%, p = 0.134), although the overall recurrence rate was similar (STL, 44.8% versus TTL, 46.4%). No significant intergroup differences were also evident with regard to 3-year DSS and OS rates. CONCLUSIONS: RLN LND can be safely performed in ESCC patients who had undergone nCRT, ultimately resulting in an improved local control, and should be practiced as part of the surgical routine.

Current port maintenance strategies are insufficient: View based on actual presentations of implanted ports.

Nursing staff play a crucial role in maintaining a functional port. Nursing guidelines recommend standard maintenance with 10 ml irrigation without consideration for variations among patients and individual nursing staff. The aim of this study is to identify the efficacy of the current maintenance strategy and analyze the correlation between complications and actual port presentations, based on disassembled intravenous ports after removal from patients. We attempt to organize the information and propose a definite maintenance strategy.After treatment completion, or due to complications, 434 implanted intravenous ports were removed from patients. All ports were deconstructed to observe their actual presentations and were then analyzed in conjunction with medical records. The correlation between complications and actual presentations was analyzed.From March 2012 to December 2017, 434 implanted intravenous ports were removed from oncology patients after completion of treatment or catheter related complications. From the view of maintenance related presentations, injection chamber blood clot was highly correlated with chemotherapy completion (P < .001) and malfunction (P = .005), while tip blood clot (P = .043) was related with chemotherapy completion and catheter fibrin (P = .015) was related to malfunction. From the view of structure related presentations, broken catheter integrity was correlated to chemotherapy completion (P = .007), fracture (P < .001), and malfunction (P = .008). Compression groove was related to chemotherapy completion (P = .03) and broken catheter at protruding stud was related to fracture (P = .04), while diaphragm rupture was correlated to chemotherapy completion (P = .048) and malfunction. (P < .001).Current port maintenance is insufficient for ideal port maintenance, whereby maintenance-related presentations, including tip clot, catheter fibrin, and injection chamber blood clot were identified. We propose a recommended maintenance strategy based on our findings. Structure-related presentations, including broken catheter integrity, broken catheter at protruding stud and diaphragm rupture were seen in patients with longer implantation period. Removal of the implanted port may be considered after 5 years if no disease relapse is noted.

Superior Vena Cava Port Catheter Tip Confirmation: Quantified Formula for Intravascular Catheter Length versus Anatomic Landmark Reference.

BACKGROUND: Adequate tip location is crucial for intravenous port implantation because it can minimize catheter-related complications. Adequate tip location cannot be observed directly and needs to be confirmed by imaging tools. A quantified intravascular catheter length formula has been proposed and we attempt to compare its clinical effectiveness with anatomic landmark references. METHODS: During the period from March 2012 to February 2013, 503 patients who received port implantation where implanted catheter length depended on carina level as confirmed by intraoperative fluoroscopy were assigned to Group A. From March 2013 to February 2014, 521 patients who received port implantation based on quantified intravascular catheter length formula were assigned to Group B. Clinical outcomes were compared. RESULTS: Catheter tip location of Group A, as revealed by intraoperative fluoroscopy and postoperative chest film, was 1.18 ± 0.51 and 1.1 ± 1.3 cm below carina, respectively. Catheter tip location of Group B, as revealed by intraoperative fluoroscopy and postoperative chest film, was 1.25 ± 1.05 and 1.05 ± 1.32 cm below carina, respectively. Similar catheter tip location was identified in both groups. The functional period of implanted ports, complication rate (3.58% and 2.53%), and incidence (0.049 and 0.0506 episodes/1,000 catheter days) were similar in both groups. CONCLUSIONS: The quantified intravascular catheter length formula can predict an adequate catheter length just as well as carina do and results in good catheter tip location. The formula could replace the clinical use of anatomic landmarks and serve as an easy tool for practitioners.

Correction: Correlation between image characteristics and pathologic findings in non small cell lung cancer patients after anatomic resection.

[This corrects the article DOI: 10.1371/journal.pone.0206386.].

Management of intra-operative major bleeding during single-port video-assisted thoracoscopic anatomic resection: two-center experience.

BACKGROUND: Our objective is to report on two centers' experience of intra-operative management of major vascular injury during single-port video-assisted thoracoscopic (SPVATS) anatomic resections, including bleeding control techniques, incidence, results, and risk factor analysis. METHODS: Consecutive patients (n = 442) who received SPVATS anatomic lung resections in two centers were enrolled. The different clinical parameters studied included age, previous thoracic surgery, obesity (BMI > 30), tumor location, neoadjuvant therapy, and pleural symphysis. In addition, peri-operative outcomes were compared between the groups, with or without vessel injury. RESULTS: There were no intra-operative deaths in our study. Overall major bleeding incidence was 4.5%, whereby 70% of major bleeding episodes could be managed with SPVATS techniques. In order to determine risk factors possibly related to intra-operative bleeding, we used case control matching to homogenize our study population. After case control matching, pleural symphysis was significantly related in the univariate (p = 0.005, Odds ratio 4.415, 95% CI 1.424-13.685) and multivariate analysis (p = 0.006, Odds ratio 4.926, 95% CI 1.577-15.384). Operative time (p < 0.001), blood loss (p < 0.001), and post-operative hospital stay (p = 0.012) were longer in patients with major vascular injury. There were no differences in 30-day mortality and 90-day morbidity. CONCLUSIONS: In summary, major intra-operative bleeding episodes during SPVATS anatomic lung resections are acceptable and most such bleeding episodes can be safely managed with SPVATS techniques.

Feasibility of transumbilical anatomic "Lung" segmentectomy in a canine model.

BACKGROUND: Transumbilical approach has been shown to be feasible to perform lung wedge resection and anatomic lobectomy. This study uses a canine model to assess the feasibility of transumbilical segmentectomy. METHODS: Transumbilical segmentectomy was performed in 10 beagle dogs using a 3-cm umbilical incision combined with a 2.5-cm diaphragmatic incision. We evaluated the surgical outcomes, operative complications, physiologic changes, hemodynamic changes, and inflammatory changes of the procedures. RESULTS: Transumbilical segmentectomy was successfully completed in eight of ten animals. There was one mortality complication related to lung injury causing hemodynamic collapse. Another animal required conventional thoracotomy to complete the surgery due to limited working space. There were no notable events in the postoperative period for all eight dogs that completed the segmentectomy via the transumbilical approach. CONCLUSION: This animal study demonstrates that the pulmonary segmentectomy can be performed with current standard endoscopic instruments via a single transumbilical incision.We believe that advancing surgical innovation and good collaboration between multi-disciplinary research teams will further establish clearer roles for transumbilical segmentectomy in thoracic surgery.

Correlation between image characteristics and pathologic findings in non small cell lung cancer patients after anatomic resection.

INTRODUCTION: Tumor characteristics in computed tomography (CT) are correlated to pathologic presentation and survival. However, most studies have been based on thin slice thickness CT while lymph node metastatic pattern has remained unclear. The aim of this study was to analyze the correlation between image characteristics under 5 mm slice thickness and pathology findings in non small lung cancer patients who have received curative resection. MATERIALS AND METHODS: From January 2010 to May 2014, 440 patients who underwent curative resection were included and medical records were reviewed retrospectively. The tumor size and consolidation tumor ratio were simultaneously evaluated and measured by a physician, a thoracic surgeon, and a radiologist. The correlation between image and pathology characteristics and its survival impact was analyzed. RESULTS: Tumor sizes, as measured by CT and by pathologic measurement were highly coincident. (p < 0.001) GGO predominant lesions were correlated to well-differentiated adenocarcinoma, (p< 0.001), and less tumor necrosis (p<0.0001), lymphocyte infiltration (p = 0.0042) and tumor purity (p <0.0001). In addition, less risk of visceral pleura (p < 0.0001) and angiolymphatic invasion, and fewer metastases to N1 lymph node (p = 0.004) involvement were identified. No lymph node metastasis (0/12) was identified in sub-centimeter pure GGO lesion. The consolidation tumor ratio could be used to differentiate patients' survival and excellent 5-year overall survival was identified in pure GGO lesion cases. CONCLUSION: No lymph node metastasis was identified in sub-centimeter pure GGO lesion. The consolidation tumor ratio could be used to differentiate patients' disease status and overall survival, while excellent 5-year overall survival was identified in cases with pure GGO lesion.

Recommended irrigation volume for an intravenous port: Ex vivo simulation study.

BACKGROUND: An intravenous port, which differs from a central venous catheter, has an injection chamber at the end of the catheter. This structural difference causes the irrigation flow pattern to be quite different from that of the central venous catheter. Furthermore, the intraluminal volume differs due to the size of the injection chamber and implanted catheter length. Hence, the ideal recommended irrigation volume varies because of differences in intraluminal volume, however, the recommended irrigation volume is 10 ml and may be a cause for reported port malfunctions. This study investigates the best irrigation volume for an intravenous port by simulating the clinical scenario ex-vivo to access its usefulness. MATERIALS AND METHODS: This study was composed of two tests. The irrigation volume test attempted to quantify the irrigation volume of an implanted port while the irrigation rate test attempted to simulate daily nursing practice in order to clarify the effect of irrigation flow. The human blood needed for the simulation was donated by volunteers and the total volume was 10 ml per test. The irrigation volume test was done by syringe pump with varying pre-set irrigation volume after the port and connected catheter were filled with volunteer blood. After irrigation with pre-set volume, the retained intraluminal solution was collected and quantified by Bradford assay in order to titrate the best irrigation volume. The irrigation rate test tried to simulate daily maintenance practice in different settings with the quantified irrigation volume as identified by the irrigation volume test. The retained intraluminal solution was collected and quantified by Bradford assay in order to confirm the efficacy of the quantified irrigation volume. RESULTS: In both SVC and IVC ports, we identified the twenty times the intravascular volume as sufficient for a complete wash out of the blood component in the irrigation volume test. The minimal irrigation volume for SVC and IVC port were 10 ml and 15.6 ml respectively. In irrigation rate test, the irrigation for SVC and IVC port was 10 and 20 ml, respectively, for the sake of preparation convenience. We not only identified the importance of preparation, i.e. irrigation of the extension line but also confirmed the efficacy of the recommended irrigation volume. CONCLUSION: The irrigation volume should be varied according to the intraluminal volume. Maintenance should be performed after the extension line has been irrigated. The recommended port irrigation volume for SVC and IVC route were 10 and 20 ml, respectively.