Unplanned Perioperative Reoperation Following Pulmonary Resection in Lung Cancer Patients: A Report of a Single-Center Experience.

BACKGROUND: Pulmonary resection is an important part of comprehensive treatment of lung cancer. Despite the progress in recent thoracic surgery, reoperation is occasionally inevitable for managing severe perioperative complications. This study aimed to investigate the incidence and causes of perioperative reoperation in lung cancer patients. METHODS: We retrospectively collected patients who underwent reoperation following pulmonary resection from January 2010 to February 2021 in China-Japan Friendship Hospital. RESULTS: Among the 5032 lung cancer patients who received primary pulmonary resection in our institute, 37 patients underwent perioperative reoperation with the rate being 0.74%. Lobectomy was the most frequently executed procedure (56.8%). The mean duration of the primary surgery was 143.6 ± 65.1 min. About half of the cases received secondary surgery within 24 h of the primary surgery, whereas only one case underwent secondary surgery 30 days after the primary surgery (due to chylous leakage). The major causes of the reoperation were bleeding (73.0%), chylous leakage (13.5%), lobar torsion (5.4%), air leakage (2.7%), atelectasis (2.9%), and cardiac herniation (2.7%). CONCLUSION: The most prevalent reasons for unplanned reoperation following pulmonary resection in lung cancer patients include bleeding, chylous leakage, and lobar torsion. The strict control of the surgical indications and standardization of surgical procedures are fundamental to reduce unplanned secondary operations after pulmonary resections. Timely identification of the need to secondary surgery is also important to ensure patients' safety.

Innovation: ice cream in the recovery room rules out chylothorax after thoracic lymphadenectomy and affords same-day chest tube removal.

Objectives: Early removal of chest tubes reduces pain and morbidity. This study aimed to remove chest tubes immediately after robotic pulmonary resection with complete thoracic lymphadenectomy by administering ice cream to rule out chylothorax. Methods: This quality improvement study utilized prospectively gathered data from one thoracic surgeon. Patients were given 3.6 fl oz of ice cream in the recovery room within 1 h after their operation. Chest tubes were removed within 4 h if there was no chylous drainage and air leak on the digital drainage system. Results: From January 2022 to August 2023, 343 patients underwent robotic pulmonary resection with complete thoracic lymphadenectomy. The median time to ingest the ice cream was 1.5 h after skin closure. The incidence of chylothorax was 0.87% (3/343). Two patients were diagnosed with chylothorax after consuming ice cream within 4 h of surgery. One patient, whose chest tube remained in place due to an air leak, had a chylothorax diagnosed on postoperative day 1 (POD1). All three patients were discharged home on POD1 with their chest tubes in place, adhering to a no-fat, medium-chain triglyceride diet. All chylothoraces resolved within 6 days. None of the remaining patients developed chylothorax postoperatively with a minimum follow-up period of 90 days. Conclusions: Providing ice cream to patients after pulmonary resection and complete thoracic lymphadenectomy is an effective and reliable technique to rule out chylothorax early in the postoperative period and facilitates early chest tube removal. Further studies are needed to ensure that this simple, inexpensive test is reproducible.

Predictive factors of early autologous blood pleurodesis for postoperative air leak.

BACKGROUND: The usefulness of autologous blood pleurodesis for air leak after pulmonary resection is well known; however, factors predicting the therapeutic efficacy are poorly understood. Herein, we aimed to examine the predictors of early autologous blood pleurodesis for air leak following pulmonary resection. METHODS: Patients who underwent pulmonary resection and autologous blood pleurodesis with thrombin for postoperative air leak between January 2016 and October 2022 were retrospectively analyzed. Patients received 50-100 mL of autologous blood and 20,000 units of thrombin on postoperative days 1-4. If necessary, the same procedure or pleurodesis with other chemical agents was repeated until the air leak stopped. Patients were divided into single-dose and multiple-dose groups based on the number of times pleurodesis had occurred before the air leak stopped and were statistically analyzed. Logistic regression analysis was performed to identify predictors of treatment efficacy. RESULTS: Of the 922 patients who underwent pulmonary resection, 57 patients (6.2%) were included and divided into single-dose (n = 38) and multiple-dose (n = 19) groups. The amount of air leaks was identified as a significant predictor of multiple dosing, with a cutoff of 60 mL/min, in multivariate logistic regression analyses (odds ratio 1.13, 95% CI 1.03-1.24, p = 0.0065). The multiple-dose group showed a significantly higher recurrence of air leak (p = 0.0417). CONCLUSIONS: The amount of air leaks after pulmonary resection is the only significant factor predicting whether multiple autologous blood pleurodesis is required, and the recurrence rate of pneumothorax is significantly higher in such cases.

Feasibility and safety of uniport robotic-assisted thoracoscopic surgery in initial series of anatomical pulmonary resections under learning curve.

OBJECTIVES: Uniport robotic assisted thoracoscopic surgery (U-RATS) is a recently adopted approach in thoracic surgery and is assumed to require a learning curve for surgeons because of technical difficulties. We aimed to verify the feasibility and safety of solo surgery in U-RATS in an initial series of patients, comparing with initial series of uniport video-assisted thoracoscopic surgery (U-VATS). METHODS: The surgical and post-operative outcomes of 25 U-RATS cases were compared with 25 U-VATS cases. The da Vinci Xi Surgical System was used for U-RATS procedure. In both groups, the skin incisions were 4 cm in length, and a 30-degree camera was placed at the posterior and upper edges of the incision. RESULTS: Between June and December 2023, 25 patients with lung malignancies underwent anatomical pulmonary resection via U-RATS, including 13 lobectomies and 12 segmentectomies. Patient characteristics did not differ between the groups. The short-term outcomes were similar between the U-RATS and U-VATS groups, except for operation time (median: 214 vs. 157 min, p = 0.0035). The pain scores on postoperative days 1 and 3 were significantly lower in patients who underwent U-RATS than in those who underwent U-VATS (median: 0 vs. 2, p = 0.010; median: 0 vs. 0, p = 0.027, respectively). CONCLUSIONS: The short-term outcomes are similar between the U-RATS and U-VATS groups, except for operation time. U-RATS is considered to be feasible and safe in the initial series of anatomical pulmonary resections performed by a surgeon who was under the learning curve.

Prognostic significance of Pleural Fluid triglyceride levels based on a low-Fat Diet Management Strategy in patients with Chylothorax following pulmonary resection.

BACKGROUND: Chylothorax is a postoperative complication in patients with lung cancer. Diet-control approaches have been the mainstay for managing this condition. However, a surgical intervention is needed for the patients if conservative treatment is ineffective. Because of the lack of accurate indicators to assess the prognosis of the postoperative complication at an early stage, the criteria of surgical treatment were not consistent. METHODS: We reviewed 2942 patients who underwent pulmonary resection and lymph node dissection for primary lung cancer at our hospital between March 2021 and December 2022. The prognostic implications of clinical indicators were assessed in patients with postoperative chylothorax who were managed with a low-fat diet. Binary logistic regression was used to explore the predictive value of these indicators for patient prognosis. RESULTS: Postoperative chylothorax occurred in 108 patients and 79 patients were treated with a low-fat diet management while 29 patients were managed with TPN. In contrast to drainage volume, the pleural effusion triglyceride level after 2 days of low-fat diet exhibited enhanced predictive efficacy in predicting patient prognosis. When the pleural fluid triglyceride level of 1.33 mmol/L was used as the diagnostic threshold for prognosis, the sensitivity and specificity reached 100% and 80.6%, respectively. CONCLUSIONS: The pleural effusion triglyceride level after 2 days of low-fat diet can serve as a valuable prognostic indicator in patients undergoing lung surgery and experiencing chylothorax. This predictive approach will help thoracic surgeons to identify patients with poor prognosis in a timely manner and make decision to perform necessary surgical interventions.

Persistent cough after pulmonary resection: Minor issue, major hurdle.

Background: Persistent cough is one of the most common complications following pulmonary resection, that impairs patients' quality of life and prolongs recovery time. However, a comprehensive review of persistent cough after pulmonary resection (CAP) has not been performed. Methods: A literature search of PubMed/MEDLINE, Web of Science, and Embase database was conducted for persistent-CAP up to June 2023. Subsequent qualitative systematic review focused on definition, risk factors, prevention, and treatment of persistent-CAP. Results: Persistent-CAP stands as a prevalent postoperative complication subsequent to pulmonary resection procedures. with an incidence of 24.4-55.0 %. Although persistent-CAP has a minor impact on survival, this condition is of critical importance because it presents a major hurdle in recovery after surgery. In this review, we proposed a systemic definition for persistent-CAP based on available evidence and our own data. Several assessment tools used to assess severity of persistent-CAP are also introduced. Risk factors associated with persistent-CAP are explored, including surgical approaches, resection extent, surgical site, lymph node dissection, postoperative gastroesophageal acid reflux, tracheal intubation anesthesia, preoperative comorbidity, and sex among others. Surgical and anesthesia preventions targeting risk factors to prevent persistent-CAP are elaborated. A number of studies have shown that a multidisciplinary approach can effectively relieve persistent-CAP. Conclusions: Although the mechanisms underlying persistent-CAP are still unclear, existing studies demonstrated that persistent-CAP is related to surgical and anesthesia factors. Therefore, in the future, prevention and treatment should be developed based on risk factors to overcome the hurdle of persistent-CAP.

Clinical and Pathologic Differences between Small-Cell Carcinoma and Large-Cell Neuroendocrine Carcinoma of the Lung.

BACKGROUND: Both small-cell carcinoma (SCLC) and large-cell neuroendocrine carcinoma (LCNEC) of the lung are often clinically dealt with as being in the same category as neuroendocrine carcinoma, and their clinical differences have not been adequately assessed. METHODS: The postoperative prognosis was retrospectively analyzed using the data of 196 patients who underwent resection for SCLC or LCNEC. RESULTS: Of the patients included, 99 (50.5%) had SCLC and 97 (49.5%) had LCNEC. The median duration of follow-up was 39 months (interquartile range [IQR] 21-76) and 56 months (IQR 21-87) for SCLC and LCNEC, respectively. The estimated 5-year overall survival (OS) probabilities were 53.7% and 62.7% (p = 0.133) for patients with SCLC and LCNEC, respectively. In the SCLC group, a multivariate analysis showed that adjuvant chemotherapy (hazard ratio 0.54, 95% confidence interval 0.30-0.99, p = 0.04) was the only factor that was significantly associated with OS. In the LCNEC group, univariate analyses demonstrated that pathologic stage I (p = 0.01) was the only factor that was associated with better OS after surgery. CONCLUSIONS: We found different clinical features in SCLC and LCNEC; in patients with SCLC, because OS could be expected to significantly improve with postoperative adjuvant chemotherapy, patients with resected SCLC of any pathologic stage should receive adjuvant chemotherapy. For patients with LCNEC, because pathologic stage I LCNEC is related to better prognosis than any other stages, a thorough clinical staging, including invasive staging, according to present guidelines should be performed to identify clinical stage I LCNEC with the highest certainty.

Adjuvant surgical resection for nontuberculous mycobacterial pulmonary disease: Effectiveness and complications.

BACKGROUND: Standard antibiotic treatment for nontuberculous mycobacteria pulmonary disease (NTMPD) has unsatisfactory success rates. Pulmonary resection is considered adjunctive therapy for patients with refractory disease or severe complications, but surgical indications and extent of resection remain unclear. We present surgical treatment outcomes for NTMPD and analyzes risk factors for unfavorable outcomes. METHODS: We conducted a retrospective investigation of medical records for patients diagnosed with NTMPD who underwent surgical treatment at Asan Medical Center between 2007 and 2021. We analyzed clinical data including microbiological and surgical outcomes. RESULTS: A total of 71 NTMPD patients underwent thoracic surgery. Negative conversion of acid-fast bacillus (AFB) culture following pulmonary resection was observed in 51 (73.9%) patients. In terms of long-term outcomes, negative conversion was sustained in 38 cases (55.1%). Mortality occurred in 7 patients who underwent pulmonary resections for NTMPD. Statistically significant associations with factors for recurrence or non-negative conversion of AFB culture were found in older age (odds ratio [OR] =1.093, 95% confidence interval [CI]: 1.029-1.161, P = 0.004), male sex (OR = 0.251, 95% CI: 0.071-0.892, P = 0.033), and extensive NTMPD lesions involving three lobes or more (OR = 5.362, 95% CI: 1.315-21.857, P = 0.019). Interstitial lung disease (OR = 13.111, 95% CI: 1.554-110.585, P = 0.018) and pneumonectomy (OR = 19.667, 95% CI: 2.017-191.797, P = 0.018) were statistically significant risk factors for postoperative mortality. CONCLUSION: Pulmonary resection can be an effective adjuvant treatment option for NTMPD patients, with post-operative antibiotic treatment as the primary treatment. Careful patient selection is crucial, considering the associated risk factors and resectability due to complications and recurrence.

Significance of preoperative exercise oxygen desaturation in lung cancer with interstitial lung disease.

OBJECTIVES: Evaluating the diffusing capacity for carbon monoxide (DLco) is crucial for patients with lung cancer and interstitial lung disease. However, the clinical significance of assessing exercise oxygen desaturation (EOD) remains unclear. METHODS: We retrospectively analysed 186 consecutive patients with interstitial lung disease who underwent lobectomy for non-small-cell lung cancer. EOD was assessed using the two-flight test (TFT), with TFT positivity defined as ≥5% SpO2 reduction. We investigated the impact of EOD and predicted postoperative (ppo)%DLco on postoperative complications and prognosis. RESULTS: A total of 106 (57%) patients were identified as TFT-positive, and 58 (31%) patients had ppo% DLco < 30%. Pulmonary complications were significantly more prevalent in TFT-positive patients than in TFT-negative patients (52% vs 19%, P < 0.001), and multivariable analysis revealed that TFT-positivity was an independent risk factor (odds ratio 3.46, 95% confidence interval 1.70-7.07, P < 0.001), whereas ppo%DLco was not (P = 0.09). In terms of long-term outcomes, both TFT positivity and ppo%DLco < 30% independently predicted overall survival. We divided the patients into 4 groups based on TFT positivity and ppo%DLco status. TFT-positive patients with ppo%DLco < 30% exhibited the significantly lowest 5-year overall survival among the 4 groups: ppo%DLco ≥ 30% and TFT-negative, 54.2%; ppo%DLco < 30% and TFT-negative, 68.8%; ppo%DLco ≥ 30% and TFT-positive, 38.1%; and ppo%DLco < 30% and TFT-positive, 16.7% (P = 0.001). CONCLUSIONS: Incorporating EOD evaluation was useful for predicting postoperative complications and survival outcomes in patients with lung cancer and interstitial lung disease.

Early Clinical Outcomes of Thoracoscopic Major Pulmonary Resection and Thymectomy Using Novel Articulating Endoscopic Forceps.

Background: Video-assisted thoracoscopic surgery (VATS) is recognized as a safe and effective treatment modality for early-stage lung cancer and anterior mediastinal masses. Recently, novel articulating instruments have been developed and introduced to endoscopic surgery. Here, we share our early experiences with VATS major pulmonary resection and thymectomy performed using ArtiSential articulating instruments. Methods: At the Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 500 patients underwent VATS pulmonary resection between July 2020 and April 2023, while 43 patients underwent VATS thymectomy between January 2020 and April 2023. After exclusion, 224 patients were enrolled for VATS major pulmonary resection, and 38 were enrolled for VATS thymectomy. ArtiSential forceps were utilized in 35 of the 224 patients undergoing pulmonary resection and in 12 of the 38 individuals undergoing thymectomy. Early clinical outcomes were retrospectively analyzed. Results: No significant differences were observed in sex, age, surgical approach, operation time, histological diagnosis, or additional procedures between the patients who underwent surgery using novel articulating instruments and the group treated with conventional endoscopic instruments for both VATS major pulmonary resection and thymectomy. However, the use of the novel articulating endoscopic forceps was associated with a significantly larger number of dissected lymph nodes (p=0.028) and lower estimated blood loss (p=0.009) in VATS major pulmonary resection. Conclusion: Major pulmonary resection and thymectomy via VATS using ArtiSential forceps were found to be safe and effective, with early clinical outcomes comparable to established methods. Further research into long-term clinical outcomes and cost-effectiveness is warranted.

Single-port robotic subcostal major pulmonary resection using the single-port robotic system.

BACKGROUND: The da Vinci single-port system (SPS) (Intuitive Surgical, Sunnyvale, CA, USA) was designed for single-port (SP) surgery. Although we have reported our clinical outcomes using the SPS for a simple procedure in general thoracic surgery, major pulmonary resection had been performed only in cadaveric experiments to date. This study evaluated the feasibility of SP subcostal robotic major pulmonary resection using the SPS. Here, we present our initial clinical experience of SP subcostal robotic major pulmonary resection at our institution. METHODS: Twenty-five patients with lung cancer underwent SP major subcostal pulmonary resection using the SPS between March and November 2022. Patient characteristics, intraoperative and perioperative outcomes were assessed. Questionnaires were used to evaluate patient satisfaction with the cosmetic results and quality of life through face-to-face or telephone interviews on postoperative day 30. RESULTS: All patients underwent major pulmonary resection with complete radical resection (R0). Nineteen patients underwent lobectomy, whereas six patients underwent segmentectomy. The mean docking time and total operative time were 4.16 ± 1.19 min (range, 2.3-7.8 min) and 197.6 ± 55.33 min (range, 130-313 min), respectively. No patients underwent conversion to open thoracotomy. One patient required an additional assistant port due to severe pleural adhesions. CONCLUSIONS: SP subcostal robotic major pulmonary resection using the SPS is feasible and safe. With the continuous development of robotic technology and surgical techniques, we believe that more complex general thoracic surgeries will be performed in the future using SPS.

Zero-leak prediction during major lung resection aiming for minimal chest drainage duration: a retrospective analysis.

BACKGROUND: Early chest tube removal should be considered to enhance recovery after surgery. The current study aimed to provide a predictive algorithm for air leak episodes (ALE) and to create a knowledge base for early chest tube removal. METHODS: This retrospective study enrolled patients who underwent thoracoscopic anatomical pulmonary resections in our unit. We defined ALE as any airflow ≥ 10 mL/min recorded in the follow-up charts based on the digital thoracic drainage device. Multivariate regression analysis was used to control for preoperative and intraoperative confounding factors. The ALE prediction algorithm was constructed by combining an additive ALE risk-scoring system using the coefficients of the significant predictive factors with the intraoperative water-sealing test. RESULTS: In 485 consecutive thoracoscopic major pulmonary resections, ALE developed in 209 (43%) patients. Statistically significant ALE-associated preoperative factors included male sex, lower body mass index, radiologically evident emphysema, lobectomy, and upper lobe surgery. Significant ALE-associated intraoperative factors were incomplete fissure and pleural adhesion. The ALE risk scoring demonstrated an average area under the receiver operating characteristic curve of 0.72 in the fivefold cross-validation test. The ALE prediction algorithm correctly predicted ALE-absent patients at a negative predictive value of 80%. CONCLUSIONS: The algorithm may promote the optimization of the chest tube-dwelling duration by identifying potential ALE-absent patients for accelerated tube removal.

Anatomical distribution and clinical significance of translobar bronchi, arteries, and veins hidden in the interlobar fissure.

Background: The interlobar bronchovascular structures hidden in the incomplete interlobar fissures (IFs) are often inadvertently transected during pulmonary resections, which could inevitably lead to accidental injury and potentially compromise the function of the preserved area. A thorough examination of the anatomical distribution of translobar bronchi, arteries, and veins holds significant clinical importance. Methods: Three-dimensional computed tomography bronchography and angiography (3D-CTBA) data from patients who underwent pulmonary resection between December 2018 and November 2019 were retrospectively analyzed. The translobar bronchi, arteries, and veins were categorized based on their origin and distribution. Surgical results of patients who underwent surgery involving translobar structures were further reviewed. Results: Among the 310 enrolled patients, incomplete IFs (IIFs) were most frequently observed in horizontal fissures (68.7%), followed by right upper oblique fissures (42.3%), left lower oblique fissures (32.6%), left upper oblique fissures (12.9%), and right lower oblique fissures (11.0%). The incidence of bronchovascular structures was significantly higher in IIFs than in complete IFs (CIFs; 85.5% vs. 5.2%, χ2=1,021.1, P<0.001). A total of three subtypes of translobar bronchi, five subtypes of translobar arteries, and 14 subtypes of translobar veins were identified. Primary subtypes of translobar arteries (frequency >5%) included the left A4/5 (18.7%) that branched from A7/8/7+8 and the common trunk of right Asc.A2+A6 (6.1%). Primary subtypes of translobar veins (frequency >5%) included the right V2 draining into inferior pulmonary vein (IPV) (5.8%), the interlobar V3b (58.4%) within horizontal fissures, the right V4/5 draining into V2/3 (26.1%), the left V4/5 draining into IPV (7.4%), the right V6 draining into V2 (38.4%), and the common trunk of left IPV and superior pulmonary vein (SPV; 9.4%). Moreover, 12.0% of translobar arteries and 75.0% of translobar veins were mistransected during anatomical pulmonary resection, resulting in gas-exchanging dysfunction in the preserved territory. Conclusions: Translobar bronchovascular structures exhibited a high incidence and were more commonly present in IIFs. Surgeons should pay increased attention to these structures to prevent accidental injuries during anatomical pulmonary resection.

Safety and efficacy of new staple-line reinforcement in lung resection: a prospective study of 48 patients.

PURPOSE: To evaluate the safety and efficacy of new staple-line reinforcement (SLR) in pulmonary resection through a prospective study and to compare the results of this study with historical control data in an exploratory study. METHODS: The subjects of this study were 48 patients who underwent thoracoscopic lobectomy. The primary endpoint was air leakage from the staple line. The secondary endpoints were the location of air leakage, duration of air leakage, and postoperative pulmonary complications. RESULTS: The incidence of intraoperative air leakage from the staple line was 6.3%. Three patients had prolonged air leakage as a postoperative pulmonary complication. No malfunction was found in patients who underwent SLR with the stapling device. When compared with the historical group, the SLR group had a significantly lower incidence of air leakage from the staple line (6.3% vs. 28.5%, P < 0.001) and significantly shorter indwelling chest drainage time (P = 0.049) and length of hospital stay (P < 0.001). CONCLUSIONS: The use of SLR in pulmonary resection was safe and effective. When compared with conventional products, SLR could control intraoperative air leakage from the staple line and shorten time needed for indwelling chest drainage and the length of hospital stay.

Early chest tube removal regardless of drainage volume after anatomic pulmonary resection: A multicenter, randomized, controlled trial.

OBJECTIVES: This study aimed to evaluate the safety and feasibility of early chest tube removal after anatomic pulmonary resection, regardless of the drainage volume. METHODS: We conducted a multicenter, randomized, controlled, noninferiority trial. Patients with greater than 300 mL drainage volume during postoperative day 1 were randomly assigned to group A (tube removed on postoperative day 2) and group B (tube retained until drainage volume ≤300 mL/24 hours). The primary end point was the frequency of respiratory-related adverse events (grade 2 or higher based on the Clavien-Dindo classification) within 30 days postoperatively. RESULTS: Between April 2019 and October 2021, 175 patients were assigned to group A (N = 88) or group B (N = 87). One patient in group B who experienced chylothorax was excluded from the study. Respiratory-related adverse events were observed in 10 patients (11.4%) in group A and 12 patients (14.0%) in group B (P = .008). The frequencies of thoracentesis or chest tube reinsertion were not significantly different (8.0% and 9.3% in groups A and B, respectively, P = .752). Additionally, the duration of chest tube placement was significantly shorter in group A than in group B (median, 2 vs 3 days; P < .001). No significant difference between groups A and B was found in postoperative hospital stay (median, 6 vs 7 days, P = .231). CONCLUSIONS: Early chest tube removal, regardless of drainage volume, was safe and feasible in patients who underwent anatomic pulmonary resection.

Contralateral Pulmonary Resection after Pneumonectomy.

Background: Contralateral pulmonary resection after pneumonectomy presents considerable challenges, and few reports in the literature have described this procedure. Methods: We retrospectively reviewed the medical records of all patients who underwent contralateral lung resection following pneumonectomy for any reason at our institution between November 1994 and December 2020. Results: Thirteen patients (9 men and 4 women) were included in this study. The median age was 57 years (range, 35-77 years), and the median preoperative forced expiratory volume in 1 second was 1.64 L (range, 1.17-2.12 L). Contralateral pulmonary resection was performed at a median interval of 44 months after pneumonectomy (range, 6-564 months). Surgical procedures varied among the patients: 10 underwent single wedge resection, 2 were treated with double wedge resection, and 1 underwent lobectomy. Diagnoses at the time of contralateral lung resection included lung cancer in 7 patients, lung metastasis from other cancers in 3 patients, and tuberculosis in 3 patients. Complications were observed in 4 patients (36%), including acute kidney injury, pneumothorax following chest tube removal, pneumonia, and prolonged air leak. No cases of operative mortality were noted. Conclusion: In carefully selected patients, contralateral pulmonary resection after pneumonectomy can be accomplished with acceptable operative morbidity and mortality.

Surgical outcomes and perioperative risk factors of patients with interstitial lung disease after pulmonary resection.

BACKGROUND: Patients of interstitial lung disease (ILD) combined with pulmonary lesions are increasingly common in clinical practice. Patients with ILD are at significantly higher risk for complications after pulmonary resection (including lobectomy and sublobar resection), especially acute exacerbations of ILD (AE-ILD). The purpose of this study is to summarize the short-term and long-term outcomes after pulmonary resection in ILD patients and to analyze the clinical factors affecting surgical safety. METHODS: From January 2004 to January 2022, a total of 78 patients who were diagnosed with ILD and underwent pulmonary resection at our center were enrolled in this study. Clinical data, pathological findings, surgical procedures, and intraoperative safety of these patients were collected retrospectively. Postoperative 90-day complications and mortality, long-term surgical outcomes from postoperative 90 days to 24 months, and changes in ILD condition were investigated. Logistic regression analysis was used to identify the risk factors associated with postoperative complications. RESULTS: The median age of patients was 66.5 (range 33-86) years, 82.1% (64/78) of patients were male, and 78.2% (61/78) of patients had comorbidities. Idiopathic ILD and secondary ILD accounted for 86% and 14%, thoracotomy and video-assisted thoracoscopic surgery accounted for 12.8% and 87.2%, and lobectomy and sublobar resection accounted for 37.2% and 62.8%, respectively. Postoperative 90-day complications occurred in 25.6% (20/78) of patients, with pulmonary complications and AE-ILD occurring in 15.4% and 9.0% of patients, respectively. The postoperative 90-day mortality rate was 5.1% (4/78), and the cause of death was AE-ILD. Exacerbation of ILD or other complications occurred in 12.8% (10/78) of patients from postoperative 90 days to 24 months. Univariate logistic regression analysis showed that comorbidity, extent of resection, systemic lymph node dissection, operation time, intraoperative blood loss, and pathology of pulmonary lesion were associated with postoperative 90-day complications. In multivariate logistic regression analysis, age-adjusted Charlson Comorbidity Index and intraoperative blood loss were identified as independent risk factors of postoperative 90-day complications. CONCLUSIONS: Patients with ILD have a significantly higher risk of postoperative 90-day complications and mortality after pulmonary resection, especially pulmonary complications and AE-ILD. After postoperative 90 days, the risk of deterioration of pulmonary status remains high, including exacerbation of ILD and complications associated with long-term use of glucocorticoids and immunosuppressant. Age, comorbidity and intraoperative blood loss are high risk factors for postoperative 90-day complications.

Combined anesthesia of acupuncture-pharmacotherapy in pulmonary resection surgery: systematic review and Meta-analysis. / 针药复合麻醉在肺切除手术中应用的系统评价和Meta分析.

OBJECTIVES: To evaluate the clinical value and safety of combined anesthesia of acupuncture-pharmacotherapy in pulmonary resection surgery. METHODS: The randomized controlled trials (RCTs) related to combined anesthesia of acupuncture-pharmacotherapy in pulmonary resection surgery were searched in PubMed, EMbase, Cochrane Library, Web of Science, SinoMed, CNKI, VIP database, Wanfang database, ClinicalTrials.gov, and the Chinese Clinical Trial Registry (http://www.chictr.org.cn/) from the inception of each database up to July 12, 2022. The methodological quality of the included studies was assessed using the Cochrane risk of bias tool, and Meta-analysis was conducted using RevMan5.4. RESULTS: A total of 33 RCTs were included, involving 2 526 participants. The Meta-analysis results showed that compared to conventional anesthesia, the patients receiving combined anesthesia of acupuncture-pharmacotherapy had more stable vital signs during surgery, reduced intraoperative fentanyl usage [SMD=-3.73, 95%CI(-5.28, -2.18), Z=4.72, P<0.000 01], decreased postoperative sufentanil consumption [MD=-20.85, 95%CI(-24.84, -16.86), Z=10.24, P<0.000 01], reduced total/effective presses of the postoperative patient-controlled analgesia pump [MD=-5.70, 95% CI(-9.04, -2.36), Z=3.35, P=0.000 8], lowered postoperative pain visual analogue scale (VAS) [MD=-1.63, 95%CI(-2.02, -1.23), Z=7.97, P<0.000 01], shorter length of postoperative hospital stay [MD=-1.14, 95%CI(-1.85, -0.43), Z=3.15, P=0.002], and higher levels of CD 4+ T lymphocytes, CD 8+ T lymphocytes, natural killer (NK) cell activity, and superoxide dismutase (SOD). Additionally, tumor necrosis factor-alpha (TNF-α), adrenaline and cortisol levels were decreased (P<0.05). No adverse events related to acupuncture or electrical stimulation were reported, and the incidence of postoperative complications was lower than that of conventional anesthesia [RR=0.47, 95%CI(0.36, 0.62), Z=5.36, P<0.000 01]. CONCLUSIONS: The combined anesthesia of acupuncture-pharmacotherapy in pulmonary resection surgery could improve anesthesia and analgesia effectiveness, reduce anesthesia drug usage, regulate immune responses, suppress stress reactions, and the safety is satisfactory. However, there is substantial heterogeneity among the included studies, and outcome measures vary widely. Further large-sample, high-quality, internationally standardized clinical trials are needed to clarify its clinical value and safety, providing reliable evidence for clinical practice.

Significance of preoperative evaluation of modified advanced lung cancer inflammation index for patients with resectable non-small cell lung cancer.

OBJECTIVES: Body composition and systemic inflammation/nutrition have been identified as important clinical factors in cancer patients. The modified advanced lung cancer inflammation index (mALI), which combines body composition and systemic inflammation/nutrition, is defined as appendicular skeletal muscle index × serum albumin/neutrophil-lymphocyte ratio. This retrospective study aimed to investigate associations between preoperative mALI and surgical outcomes in non-small cell lung cancer (NSCLC) patients. METHODS: We examined 665 patients with resectable stage I-III NSCLC who underwent pulmonary resection. Patients were divided into low-mALI (n = 168) and high-mALI (n = 497) based on the lower quartile. Kaplan-Meier curves and Cox regression analysis were used to assess the prognostic value of mALI. We then performed 1:1 propensity score matching (PSM) for high- and low-mALI to further investigate impacts on survival. RESULTS: Overall survival (OS) and recurrence-free survival (RFS) were both significantly poorer in the low-mALI group than in the high-mALI group (58.2% vs. 79.6%, P < 0.001; 48.8% vs. 66.7%, P < 0.001, respectively). Multivariate analysis revealed low-mALI as an independent predictor of OS (hazard ratio [HR], 2.116; 95% confidence interval (CI) 1.458-3.070; P < 0.001) and RFS (HR, 1.634; 95% CI 1.210-2.207; P = 0.001). After PSM, low-mALI remained as an independent predictor of OS (HR, 2.446; 95% CI 1.263-4.738; P = 0.008) and RFS (HR 1.835; 95% CI 1.074-3.137; P = 0.026). CONCLUSION: Preoperative mALI appears to offer an independent predictor of poor surgical outcomes as a simple, routinely available, and inexpensive biomarker in patients with resectable NSCLC.