Prevention of surgical adhesions with gelatine sealing sheet in a canine adhesion model.

OBJECTIVES: Although reoperation has been increasingly performed in cardiovascular surgery in recent years, preventing surgical adhesions remains an unsolved complication. Therefore, this study aimed to investigate whether gelatine sealing sheets are more effective than fibrin sealing sheets in preventing surgical adhesions. METHODS: Bilateral femoral arteries of 20 beagle dogs under general anaesthesia were pricked with syringe needles, and gelatine and fibrin sealing sheets were applied on the bleeding points to make canine adhesion models. The femoral artery was harvested after 4 and 12 weeks to evaluate adhesion formations. The adhesive grade was quantified by scoring the area and strength of adhesion tissues. Histological staining was performed to examine the structural features of surgical adhesions. RESULTS: Significantly fewer macroscopic adhesions were observed with gelatine sealing sheets than those with fibrin sealing sheets at 4 and 12 weeks postoperatively. Microscopically, CD3+ T lymphocytes at 4 and 12 weeks postoperatively in gelatine sealing sheets were significantly lower than those in fibrin sealing sheets. Microvessel density determined by CD34 at 4 and 12 weeks postoperatively in gelatine sealing sheets was also significantly lower than those in fibrin sealing sheets. CONCLUSIONS: The gelatine sealing sheets are more effective than the fibrin sealing sheets in preventing surgical adhesions. These findings suggest that the gelatine sealing sheet may help prevent adhesions and thus be a therapeutically effective biomaterial in vascular surgery.

[Effectiveness of Osimertinib for Postoperative Recurrence of Lung Cancer with L861Q Activating EGFR Mutation:Report of a Case].

A 69-year-old woman was referred to our hospital because of an abnormal shadow on a chest roentgenogram at a medical check-up. Chest computed tomography showed a 2.5 cm-diameter tumor in the right pulmonary lower lobe. Fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) could not detect the other lesions. The patient underwent thoracoscopic right lower lobe lobectomy for lung adenocarcinoma. Pathological diagnosis was invasive adenocarcinoma (pT1cN0M0). EGFR status was positive for the L861Q mutation in exon 21. At 31 months after surgery, the recurrence appeared as vertebral and multiple pulmonary lesions, and the treatment with osimertinib showed satisfactory response seven months after starting the treatment.

Implications of Preoperative Transbronchial Lung Biopsy for Non-small Cell Lung Cancer Less than 3-cm.

BACKGROUND/AIM: Transbronchial lung biopsy (TBLB) has been recommended for patients with suspected lung cancer. However, its diagnostic value is limited to small lesions, and some studies have indicated that biopsy might be related to metastasis and/or dissemination. This study aimed to evaluate the outcomes after preoperative TBLB for non-small cell lung cancer (NSCLC) patients. PATIENTS AND METHODS: Data were reviewed from 371 patients with resected pN0 NSCLC less than 3-cm. Patients were divided into two groups: TBLB and Non-TBLB. Recurrence-free survival (RFS) curves were plotted using the Kaplan-Meier method. Cox regression analyses were used to evaluate the hazard ratio (HR) with the endpoint RFS. RESULTS: The 5-year RFS rates were 75.5% in the TBLB group and 91.4% in the Non-TBLB group (p<0.001). Poor RFS was independently associated with TBLB (HR=2.491, 95%CI=1.337-4.640; p=0.004). CONCLUSION: Preoperative TBLB may adversely affect RFS among NSCLC patients with small size tumours.

Surgical treatment for secondary spontaneous pneumothorax: a risk factor analysis.

PURPOSE: While surgery is an effective treatment for secondary spontaneous pneumothorax (SSP), it can be difficult, because affected patients are usually in a poor general condition. The present study investigated the risk factors of postoperative complications after surgery for SSP. METHODS: Eighty-eight patients with SSP who underwent surgery from January 2006 to March 2018 were investigated. Clinical data were reviewed, and a multivariate analysis was performed. RESULTS: Eighty-four patients (95%) were males, and the median patient age was 72 years. Underlying lung diseases were chronic obstructive pulmonary disease in 58 patients (65.9%), interstitial pneumonia in 26 (29.5%), and others in 4 (4.5%). Postoperative complications developed in 21 patients (24%). Hospital mortality/prolonged length of stay occurred in 6 patients (7%). A multivariate analysis showed that the preoperative performance status (performance status 0-2 vs. 3, hazard ratio: 6.570, 95% confidence interval: 1.980-21.800) was an independent predictor of postoperative complications. CONCLUSION: Surgery for SSP contributed to early chest tube removal and favorable outcomes. However, rare fatal events occurred, and the patient performance status was a risk factor for postoperative complications. A careful evaluation of each patient's performance status is needed to determine the need for surgical intervention for SSP.

Status of pleural lavage cytology in cases of pulmonary metastasis: a single-institution retrospective study.

OBJECTIVE: In primary lung cancer surgery, intraoperative pleural lavage cytology (PLC) has been identified as a prognostic marker. However, there have been no reports on PLC for pulmonary metastasectomies. Therefore, the impact of PLC status for patients undergoing pulmonary metastasectomy remains unknown. We aimed to know the incidence and prognostic impact of positive PLC findings in pulmonary metastasectomies. METHODS: We retrospectively reviewed patients undergoing pulmonary metastasectomies between January 2013 and December 2018. One hundred and eighty-nine PLC procedures in 159 patients undergoing pulmonary metastasectomy were analyzed. Follow-up information was available in 107 patients who underwent 132 procedure, and they were investigated for pleural recurrence-free probability (PRFP) and overall survival (OS) after pulmonary metastasectomy. RESULTS: The type of primary lesion was colorectal cancer (101/189, 53%), urothelial/kidney cancer (17/189, 9%), skeletal/soft tissue tumor (18/189, 10%), hepatobiliary/pancreatic cancer (19/189, 10%), uterine/ovarian cancer (14/189, 7%), otorhinolaryngological cancer (11/189, 6%), and other minor lesions (9/189, 5%). Nine PLC-positive metastasectomies were revealed (9/189, 4.8%). They consisted of six metastasectomies from pancreatic cancer, two from osteosarcoma, and one from tongue cancer. Significant predictors for PLC status was type of primary tumor (P < 0.001). PRFP and OS rate of PLC-positive group were significantly lower than PLC-negative (P < 0.001, respectively). CONCLUSION: PLC-positive results were rarely seen in pulmonary metastasectomies. PLC status was associated with the incidence of ipsilateral pleural recurrence and survival after metastasectomy. Cytologic examination of PLC should be considered in patients undergoing pulmonary metastasectomy.

Clustered Circulating Tumor Cells in Lung Adenocarcinoma: Implications of Test Results of Continuous Variables.

BACKGROUND/AIM: We investigated the relationship between solid component size (SS), carcinoembryonic antigen (CEA), and standardized uptake value (SUVmax) as continuous variables and postoperative clustered circulating tumor cell (C-CTC) detection in patients with pulmonary adenocarcinoma who underwent surgery. PATIENTS AND METHODS: C-CTC detection was the main evaluation item, which was analyzed using the receiver operating characteristic curve to calculate areas under the curves (AUCs) for the variables. Additionally, the two-year recurrence-free survival rates (2Y-RFSRs) were analyzed. RESULTS: Among the 84 patients examined, SS, CEA, and SUVmax had AUCs>0.7, and were independent. Their thresholds were 2.1 cm, 7.5 ng/ml, and 2.9, respectively. The 2Y-RFSR were significantly better in the non-C-CTC group (n=58) and in the group of patients without high levels of these predictors (n=32). CONCLUSION: SS, CEA level, and SUVmax predicted postoperative CTC detection in pulmonary adenocarcinoma patients.

Copeptin concentration following cardiac surgery as a prognostic marker of postoperative acute kidney injury: a prospective cohort study.

BACKGROUND: Copeptin, the C-terminal portion of the arginine vasopressin precursor, is a novel candidate biomarker. This study investigated the prognostic value of copeptin levels following cardiac surgery for the occurrence of postoperative acute kidney injury. METHODS: We studied 23 patients who underwent cardiac surgery between January 2018 and December 2019. The primary endpoint was postoperative acute kidney injury onset. Copeptin levels were measured before, right after, and daily for 7 days. The patients were divided into two groups according to the copeptin levels: low (values <43.7 pmol/L) and high (values ≥43.7 pmol/L). Correlations between copeptin levels and variables, such as central venous pressure, were assessed by bivariate analysis. RESULTS: The high copeptin group exhibited significantly higher levels of arginine vasopressin and cortisol following surgery, compared to those of the low copeptin group. The copeptin concentration following surgery was correlated to central venous pressure (P=0.03) and norepinephrine administered dose (P=0.008). Also, the copeptin levels right after surgery robustly predicted the onset of postoperative acute kidney injury (area under the receiver operating characteristic curve of 0.83, P=0.004). CONCLUSIONS: Elevated copeptin levels in patients following cardiac surgery predicted postoperative acute kidney injury development. Therefore, the copeptin concentration after surgery could represent a promising clinical biomarker of the postoperative cardiac outcome.

Circulating tumor cells detected only after surgery for non-small cell lung cancer: is it a predictor of recurrence?

BACKGROUND: Surgical manipulation of a tumor can lead to shedding of tumor cells that can enter the circulation and lead to metastasis. The present study evaluated the clinical relevance of circulating tumor cells (CTCs) that were identified immediately after non-small cell lung cancer resection in patients without preoperative CTCs, and whether postoperative CTC detection was associated with recurrence. METHODS: Immediate preoperative testing for CTCs was performed for 147 patients with pulmonary nodules. This study included 81 lung cancer patients (55.1%) with negative preoperative results for CTCs and who completed postoperative testing for CTCs. The clinical relevance of postoperative CTC detection was evaluated based on the clinicopathological characteristics and recurrence patterns. RESULTS: Among the eligible patients, the postoperative CTC results were none detected in 58 patients (71.6%, "Group N"), only a single CTC detected in 6 patients (7.4%, "Group S"), and CTC clusters detected in 17 patients (21.0%, "Group C"). The presence of postoperative CTCs was associated with tumor vessel invasion, lymph duct invasion, and pleural invasion. Distant metastasis was very common in cases with postoperatively detected CTC clusters. The 2-year recurrence-free survival rates were 94.6% for Group N, 62.5% for Group S, and 52.9% for Group C (P<0.01). Multivariate analysis revealed that recurrence was independently related to the postoperative detection of single CTCs and CTC clusters. CONCLUSIONS: In cases without preoperative CTCs, we postoperatively detected CTCs and the postoperative CTC results were an independent predictor of recurrence.

A case of a rare non-invasive lung adenocarcinoma.

BACKGROUND: According to the WHO classification, adenocarcinoma in situ (AIS) is a localised small (≤3 cm) adenocarcinoma whose growth is restricted to neoplastic cells along pre-existing alveolar structures, lacking stromal, lymphovascular, or pleural invasion. There is no evidence to define AIS as having a tumour size of ≤3 cm. It is extremely rare for adenocarcinomas with pure lepidic growth lacking invasion to be >3.0 cm. The biological characteristics of these large AISs should be revealed. PRESENTATION OF CASE: The patient was an 82-year-old asymptomatic woman. Chest computed tomography showed a 6-cm-diameter pure ground-glass opacity in the left lower lung. The patient underwent lobectomy. On histologic examination, the tumour was restricted to neoplastic cells along pre-existing alveolar structures, lacking stromal, vascular, alveolar space, and pleural invasion. Papillary patterns were absent. Initially, the histopathological diagnosis was AIS, but the total tumour diameter exceeded 3 cm. The final pathological diagnosis was lepidic adenocarcinoma lacking an invasive component and harbouring an EGFR exon 20 insertion V774_C775insHV mutation using next-generation sequencing (NGS). CONCLUSION: We report a rare case of lepidic adenocarcinoma with a total tumour diameter of 6 cm and without an invasive component. Although EGFR mutations are oncogenic driver mutations, AISs have fewer EGFR mutations than invasive adenocarcinomas do. An adenocarcinoma that progresses to AIS, not stepwise progression, might have uncommon mutations and might be another type of adenocarcinoma. NGS could be useful for detecting uncommon genes that reveal the biological characteristics of AIS, and may contribute to the validation of next TNM classification.

Improvement in Left Cardiac Function Following Mitral Valve Repair: Analyses Based on Cardiac Magnetic Resonance Imaging.

AIM: This study aimed to evaluate the structural and functional changes of left-sided cardiac chambers by cardiac magnetic resonance imaging (CMRI) in patients with chronic mitral regurgitation after mitral valve repair (MVR). PATIENTS AND METHODS: Among 103 patients who underwent MVR, 21 showed normal left ventricular (LV) function; their pre- and postoperative left atrial (LA) and LV functions were examined by CMRI. RESULTS: LV end-diastolic volume, LV end-systolic volume, and LV mass significantly were reduced postoperatively (p<0.01) and postoperative LV ejection fraction tended to decrease. LA volume parameters also significantly decreased postoperatively (p<0.01). The conduit function positively affected the LV filling volume postoperatively (p<0.01); however, no effect on the booster pump function was noted (p=0.01). CONCLUSION: Restoration of LA and LV functions after a successful MVR was not associated with structural improvement in LA and LV.

Protective Effects of Cold Ringer's Solution Perfusion in Abdominal Aortic Surgery Requiring Renal Artery Clamp.

BACKGROUND/AIM: Treating abdominal aortic aneurysms (AAA) of the juxtarenal artery with renal artery clamps burdens the kidneys. We investigated the outcomes of intra-operative renal artery perfusion using the cold Ringer's solution method for renal protection. PATIENTS AND METHODS: We enrolled 290 AAA patients who underwent open aortic repair. Surgical outcomes were investigated based on renal protection. RESULTS: We evaluated 231 patients requiring infrarenal artery clamp (Group I), and 59 patients requiring perfusion in addition to the clamp (Group J). Patient demographics, acute kidney injury (AKI) incidence (Group I: 11.7% and Group J: 20.3%), hospital mortality (Group I: 1.3% and Group J: 1.7%), and 30-day mortality (Group I: 0.4% and Group J: 0%) were not different between the groups. The AKI incidence was low (13%) in cases requiring a renal artery clamp for ≥45 min (n=40). CONCLUSION: Perfusion with cold Ringer's solution offers renal protection and may improve surgical outcomes.

Wedge Resection of Tumor Before Lobectomy for Lung Cancer Could Be a No-touch Isolation Technique.

BACKGROUND/AIM: Circulating tumor cells (CTCs) can be a surrogate biomarker of prospective prognosis. Surgical manipulation can promote the dissemination of CTCs. Prognosis improvement is expected with the no-touch isolation technique (NTIT), preventing surgical manipulation. The Wedge resection of the tumor site before lobectomy could prevent surgical manipulation during lobectomy for non-small cell lung cancer (NSCLC) and reduce the shedding of tumor cells, similar to a NTIT. This study aimed to evaluate the effect of wedge resection technique. PATIENTS AND METHODS: A total of 624 resected NSCLC patients were retrospectively analyzed. Patients were divided in two groups: Wedge and Non-Wedge. Overall survival (OS) curves were plotted using the Kaplan-Meier method. RESULTS: The 5-year OS rates were 89.9% and 84.0% in the Wedge and Non-Wedge groups, respectively (p=0.033). CONCLUSION: The OS in the Wedge group was significantly better than that in the Non-Wedge group. Wedge resection technique for NSCLC may be a NTIT.

Cluster circulating tumor cells in surgical cases of lung cancer.

OBJECTIVES: A cancer lesion sheds tumor cells into the circulating blood as circulating tumor cells (CTCs). Since cluster CTCs have been considered as precursor lesions of metastasis, their clinical implication was investigated in this study according to the preoperative status of cluster CTC detection in surgical cases of clinically early-stage lung cancer. METHODS: Among 104 surgical patients of early-stage lung cancer, CTCs were extracted from the peripheral blood before surgery using a micro-pore size selection method (ScreenCell®) and diagnosed microscopically. Implications of detecting cluster CTC were assessed according to the prognosis and clinicopathological characteristics. RESULTS: The status of CTC detection was not detected in 77 cases (74.0%), single CTC only detection in 7 cases (6.7%), and cluster CTC detected in 20 cases (19.2%). Patients with cluster CTCs exhibited significantly lower recurrence-free survival and overall survival than did patients of other groups. In addition, in hazard ratio analysis, the hazard ratios were independent of other predictors of poor prognosis, and detection of cluster CTCs was associated with predictors of poor prognosis. CONCLUSION: Cluster CTCs were detected in cases where the original lung cancer lesion had clinical predictors of poor prognosis and were independent negative predictors of survival.

A case of atypical thymic carcinoid mimicking a paraganglioma.

BACKGROUND: Thymic atypical carcinoid has high recurrence and metastasis rates due to frequent lymph node metastases. The aim of the study is to report a case of atypical thymic carcinoid mimicking a paraganglioma and to further explain the benefits of using median sternotomy (MS) approach even in thymic epithelial tumours (TETs) sized less than 5 cm. CASE PRESENTATION: The patient was a 59-year-old asymptomatic man. During a medical check-up, positron emission tomography/computed tomography (PET/CT) showed a 4.5 cm-diameter thymus with remarkable uptake. Thoracic surgery was performed to completely remove the tumour with lymph node dissection using MS because of possible malignancy. Although MS is accepted as the standard approach for TETs, minimally invasive thoracotomy (MIT) has emerged over recent decades. Maintaining surgical safety is priority; MIT is generally selected in <5-cm-diameter tumours. Here, we considered that the tumour could be resected using MIT. However, because PET/CT showed marked uptake, we selected the MS approach. Thus, MS can be applied even for small-sized TETs. CONCLUSION: Thymic atypical carcinoid should be considered when PET/CT shows high-uptake tumours in the anterior mediastinum. Clinicians should consider using the MS approach, even if the tumour is <5 cm.

Effectiveness of Intraoperative Pulmonary Wedge Resection of Tumor Site Before Lobectomy for Early Lung Adenocarcinoma.

BACKGROUND/AIM: Circulating tumor cells (CTCs) are tumor cells shed from tumor sites and circulate in the peripheral blood. CTCs can be a surrogate biomarker of recurrence and prognosis. Because surgical manipulation could promote CTCs, it is important to reduce CTCs during surgery. This study aimed to evaluate the effectiveness of intraoperative wedge resection of the tumor site before lobectomy. PATIENTS AND METHODS: A total of 297 resected stage I lung adenocarcinoma patients were retrospectively reviewed. Patients were divided into two groups: Wedge and Non-Wedge. Recurrence-free survival (RFS) curves were plotted using the Kaplan-Meier method. Cox regression analyses were used to evaluate the hazard ratio (HR) with the endpoint RFS. RESULTS: The 5-year RFS rates were 92.9% and 85.5%, in Wedge and Non-Wedge groups, respectively (p=0.006). Wedge resection was an independent factor associated with RFS (HR=0.342, 95%CI=0.141-0.830, p=0.018). CONCLUSION: Wedge resection before lobectomy for lung adenocarcinoma patients can improve RFS rates.

Effect of Cardiac Expansion on Postsurgical Pulmonary Resection Recovery.

BACKGROUND/AIM: In patients undergoing lung resection, even when lung and ventricular function are normal, there may be a prolonged delay in postoperative recovery. The effect of left ventricular extension disorders on recovery after pulmonary resection was investigated. MATERIALS AND METHODS: The postoperative recovery of ninety patients with normal left ventricular ejection fraction and exercise tolerance who underwent anatomical pulmonary resection was evaluated according to the grade of left ventricular expansion (E/e'). RESULTS: Left ventricular extension was normal (≤8) in 53 cases, moderately restricted (8-12) in 36 cases and severely restricted (>12) in 9 cases. No significant difference was found in the postoperative complication rate. However, the severely restricted group had a significantly higher duration of oxygen administration, intensive care unit stay, and postoperative hospital stay, which were found to be independent predictors of ventricular expansion. CONCLUSION: Left ventricular expansion dysfunction had a negative effect on postoperative recovery.