Impact of Sarcopenia on Early Postoperative Complications in Early-Stage Non-Small-Cell Lung Cancer.

BACKGROUND: Risk assessment for pulmonary resection in patients with early-stage non-small-cell lung cancer (NSCLC) is important for minimizing postoperative morbidity. Depletion of skeletal muscle mass is closely associated with impaired nutritional status and limited physical ability. We evaluated the relationship between skeletal muscle depletion and early postoperative complications in patients with early-stage NSCLC. METHODS: Patients who underwent curative lung resection between 2016 and 2018 and who were diagnosed with pathological stage I/II NSCLC were included, and their records were retrospectively analyzed. The psoas volume index (PVI, cm3/m3) was calculated based on computed tomography images from routine preoperative positron emission tomography-computed tomography. Early postoperative complications, defined as those occurring within 90 days of surgery, were compared between the lowest sex-specific quartile for PVI and the remaining quartiles. RESULTS: A strong correlation was found between the volume and the cross-sectional area of the psoas muscle (R2=0.816). The overall rate of complications was 57.6% among patients with a low PVI and 32.8% among those with a normal-to-high PVI. The most common complication was prolonged air leak (low PVI, 16.9%; normal-to-high PVI, 9.6%), followed by pneumonia (low PVI, 13.6%; normal-to-high PVI, 7.9%) and recurrent pleural effusion (low PVI, 11.9%; normal-to-high PVI, 6.8%). The predictors of overall complications were low PVI (odds ratio [OR], 2.18; 95% confidence interval [CI], 1.07-4.09; p=0.03), low hemoglobin level (OR, 0.686; 95% CI, 0.54-0.87; p=0.002), and smoking history (OR, 3.93; 95% CI, 2.03-7.58; p<0.001). CONCLUSION: Low PVI was associated with a higher rate of early postoperative complications in patients with early-stage NSCLC.

Nodal Outcomes of Uniportal versus Multiportal Video-Assisted Thoracoscopic Surgery for Clinical Stage I Lung Cancer.

BACKGROUND: Accurate intraoperative assessment of mediastinal lymph nodes is a critical aspect of lung cancer surgery. The efficacy and potential for upstaging implicit in these dissections must therefore be revisited in the current era of uniportal video-assisted thoracoscopic surgery (VATS). METHODS: A retrospective study was conducted in which 544 patients with stage I (T1abc-T2a, N0, M0) primary lung cancer were analyzed. To assess risk factors for nodal upstaging and to limit any imbalance imposed by surgical choices, we constructed an inverse probability of treatment-weighted (IPTW) logistic regression model (in addition to non-weighted logistic models). We also evaluated risk factors for early locoregional recurrence using IPTW logistic regression analysis. RESULTS: In the comparison of uniportal and multiportal VATS, the resected lymph node count (14.03±8.02 vs. 14.41±7.41, respectively; p=0.48) and rate of nodal upstaging (6.5% vs. 8.7%, respectively; p=0.51) appeared similar. Predictors of nodal upstaging included tumor size (odds ratio [OR], 1.74; 95% confidence interval [CI], 1.12-2.70), carcinoembryonic antigen level (OR, 1.11; 95% CI, 1.04-1.18), and histologically confirmed pleural invasion (OR, 3.97; 95% CI, 1.89-8.34). The risk factors for locoregional recurrence within 1 year were found to be number of resected N2 nodes, age, and nodal upstaging. CONCLUSION: Uniportal and multiportal VATS appear similar with regard to accuracy and thoroughness, showing no significant difference in the extent of nodal dissection.

Comparison of Surgical Outcomes and Survival between Octogenarians and Younger Patients after Pulmonary Resection for Stage I Lung Cancer.

BACKGROUND: Treatment strategies for octogenarians with lung cancer remain controversial. The purpose of this study was to compare surgical outcomes and survival between octogenarians and younger patients with stage IA and IB lung cancer. METHODS: We reviewed the medical records of 34 consecutive octogenarians and 457 younger patients (<70 years) with stage I lung cancer who underwent surgical resection from January 2007 to December 2015. We analyzed the survival and surgical outcomes of the 2 groups according to the lung cancer stage (IA and IB). RESULTS: The only significant differences in the clinicopathological features between the groups were the higher proportion of sublobar resection (56.3% vs. 18.9%) and the smaller number of dissected lymph nodes (LNs) in octogenarians. There was no significant difference in hospital stay (11 days vs. 9 days), pneumonia (5.8% vs 1.9%), or operative mortality (0% vs 0.6%) between the 2 groups. Among patients with stage IA lung cancer, 5-year recurrence-free survival was not significantly different between the octogenarians (n=16) and younger patients (n=318) (86.2% vs. 89.1%, p=0.548). However, 5-year overall survival was significantly lower in octogenarians than in younger patients (79.4% vs. 93.4%, p=0.009). Among patients with stage IB lung cancer, there was no significant difference in 5-year recurrence-free survival (62.1% vs. 73.5%, p=0.55) or overall survival (77.0% vs 85.0%, p=0.75) between octogenarians (n=18) and younger patients (n=139). In multivariable analysis, male sex, the number of dissected LNs, and tumor size were factors related to survival (hazard ratio [HR], 5.795; p=0.017; HR, 0.346, p=0.025; and HR, 1.699; p=0.035, respectively). CONCLUSION: Surgical outcomes and survival after pulmonary resection for stage I lung cancer were comparable in octogenarians and younger patients. Continued careful selection of octogenarians for pulmonary resection is important to achieve good results.

Comparison of non-intubated versus intubated video-assisted thoracoscopic lobectomy for lung cancer.

BACKGROUND: Non-intubated, or awake, video-assisted thoracoscopic surgery has been implemented for non-anatomical lung resection and the results obtained were encouraging to consider the approach for anatomical pulmonary resection. This study was conducted to evaluate the perioperative outcomes of the non-intubated and intubated video-assisted thoracoscopic lobectomy in lung cancer in regards to feasibility and safety. METHODS: A retrospective analysis of 62 consecutive video-assisted thoracoscopic lobectomies (31 lobectomies as non-intubated, 31 lobectomies as intubated) performed in Seoul St. Mary's Hospital, The Catholic University of Korea between January and December 2016. RESULTS: Both groups share comparable clinical characteristics including the age, sex, BMI, FEV1, DLCO, smoking history, lung lobes procedure, histological type and pathological staging. There was no difference in the mean of postoperative hospitalization period (6.9 versus 7.6 days, P=0.578) and the total chest tube duration (5.6 versus 5.4 days, P=0.943) between non-intubated and intubated lobectomy respectively. Both groups had a comparable surgical outcome for the anesthesia duration, operative time, blood loss and postoperative complications. The operative time required for lobe-specific surgery was shorter in the non-intubated group except for the LLL (mean 121.7 minutes for non-intubated group versus 118.3 minutes for the intubated group). The only statistically significant surgical outcome was for the number of dissected lymph nodes between both groups (the mean number of nodes for the non-intubated group was 12.6 versus 18.0 nodes for the intubated group, P=0.003). One patient in the non-intubated group required conversion to single lung intubation and mini-thoracotomy because of bleeding with no conversion in the intubated group. No mortality encountered in either group. CONCLUSIONS: The perioperative surgical outcomes for the non-intubated video-assisted thoracoscopic lobectomy are comparable to the intubated technique. Non-intubated video-assisted thoracoscopic lobectomy is safe and is technically feasible. However, further prospective randomized studies are needed for a better comparison between non-intubated and intubated VATS lobectomy.

Segmentectomy versus lobectomy in early non-small cell lung cancer of 2 cm or less in size: A population-based study.

BACKGROUND AND OBJECTIVE: Standard surgical management for early stage lung cancer is lobectomy with mediastinal lymph node dissection. The feasibility of limited resection remains controversial; we retrospectively assessed lung cancer-specific survival (LCSS) and overall survival (OS) in early stage non-small cell lung cancer (NSCLC) to evaluate whether segmentectomy is comparable to standard lobectomy. METHODS: Patients with primary NSCLC of 20 mm or less who were diagnosed from 2000 to 2014 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. To compare the two surgical interventions, a propensity score analysis was performed between lobectomy and segmentectomy. RESULTS: Of the 15 358 patients analysed, there were 14 549 lobectomies and 809 segmentectomies. The 5-year OS was 76% for the lobectomy group and 74.4% for the segmentectomy group. There were no significant differences in OS or LCSS among patients who underwent lobectomy versus segmentectomy, as demonstrated by the propensity-matched hazard ratio (HR) for OS (HR: 1.195, 95% CI: 0.993-1.439) and LCSS (HR: 1.124, 95% CI: 0.860-1.469). The inverse propensity-weighted analysis also supported these results. Segmentectomy was more likely to be performed in elderly patients. In the subset of patients aged ≥75 years, the segmentectomy group demonstrated comparable OS (HR: 1.17, 95% CI: 0.87-1.58, P = 0.31) and LCSS (HR: 0.94, 95% CI: 0.59-1.51, P = 0.81), compared with the lobectomy group. CONCLUSION: Equivalent OS and LCSS were demonstrated in patients with primary NSCLC of 20 mm or less without lymph node or distant metastasis.

Incidence and clinical features of the incidentally found vascular stump thrombus during routine follow up after oncologic lung surgery.

OBJECTIVES: We aimed to evaluate the incidence and clinical features of vascular stump thrombus after oncologic lung surgery. METHODS: A retrospective analysis of records from our institutional database dated between 2009 and 2016 was performed. Data regarding demographics, clinical presentation, medication use, operative findings, pathology, and radiologic findings were retrieved. RESULTS: The study cohort consisted of 648 oncologic surgeries for primary lung cancer. The incidence of thrombus in the entire population was 5.7% (37/648). Most thrombi were incidentally found on follow-up chest computed tomography scans. Univariate Cox proportional hazard analysis showed that age (p = 0.02), adjuvant therapy (p <0.001), neoadjuvant therapy (p = 0.04), left-sided surgery (p = 0.02), complex surgery greater than simple lobectomy or segmentectomy (p <0.001), advanced stages (p <0.001), non-adenocarcinoma (p = 0.003), and thoracotomy approach (p = 0.009) were associated with an increased risk of vascular stump thrombus. There were no embolic events in our cohort, except for a case of pulmonary thromboembolism. During follow-up, 43.2% (16/37) of thrombi had completely resolved, 48.6% (18/37) showed partial regression and stabilization, and 8.1% (3/37) had progressed. CONCLUSIONS: The incidence of vascular stump thrombus in our study was not negligible. The clinical course of stump thrombus appears to be benign in most cases. Anticoagulation may be used with caution based on an individual basis depending on each patient's risk factors.

Endobronchial angiofibroma in the aberrant tracheal bronchus presenting as spontaneous pneumomediastinum.

BACKGROUND: Spontaneous pneumomediastinum is a self-limiting benign disease but abnormal bronchial lesions can be rarely found incidentally, and in selected cases will require surgical resection. MATERIALS AND METHODS: A 38-year-old man presented with a spontaneous pneumomediastinum. Chest computed tomography revealed an incidental linear endobronchial tumour in the aberrant tracheal bronchus. The tumour was removed surgically and diagnosed with a rare benign tumour of endobronchial angiofibroma. CONCLUSIONS: We report a rare case of endobronchial angiofibroma in the aberrant tracheal bronchus which was detected during the evaluation of a spontaneous pneumomediastinum.

The bridge technique for pectus bar fixation: a method to make the bar un-rotatable.

PURPOSE: Pectus bar rotation is a major challenge in pectus repair. However, to date, no satisfactory technique to completely eliminate bar displacement has been introduced. Here, we propose a bar fixation technique using a bridge that makes the bar unmovable. The purpose of this study was to determine the efficacy of this bridge technique. METHODS: A total of 80 patients underwent pectus bar repair of pectus excavatum with the bridge technique from July 2013 to July 2014. The technique involved connecting 2 parallel bars using plate-screws at the ends of the bars. To determine bar position change, the angles between the sternum and pectus bars were measured on postoperative day 5 (POD5) and 4 months (POM4) and compared. RESULTS: The mean patient age was 17.5 years (range, 6-38 years). The mean difference between POD5 and POM4 were 0.23° (P=.602) and 0.35° (P=.338) for the upper and lower bars, respectively. Bar position was virtually unchanged during the follow-up, and there was no bar dislocation or reoperation. CONCLUSIONS: A "bridge technique" designed to connect 2 parallel bars using plates and screws was demonstrated as a method to avoid pectus bar displacement. This approach was easy to implement without using sutures or invasive devices.

Elevation of serum lactate dehydrogenase in patients with pectus excavatum.

INTRODUCTION: Pectus excavatum is the most common congenital chest wall deformity and the depression of the anterior chest wall, which compresses the internal organs. The aim of the present study is to investigate the effects of pectus excavatum on blood laboratory findings. MATERIAL AND METHODS: From March 2011 to December 2011, 71 patients with pectus excavatum who visited Seoul Saint Mary Hospital for Nuss procedure were reviewed and analyzed. The blood samples were routinely taken at the day before surgery and pectus bar removal was usually performed in 2 to 3 years after Nuss procedure. To investigate the effects on blood laboratory findings, preoperative routine blood laboratory data and postoperative changes of abnormal laboratory data were analyzed. RESULTS: Only lactate dehydrogenase (LDH), one of 26 separate routine laboratory tests, was abnormal and significantly elevated than normal value (age <10, p = 0.008; age ≥10, p < 0.001). However, there was no significant correlation between LDH levels and severities of pectus excavatum. The symmetric subgroup had significantly higher LDH level than the asymmetric subgroup (p < 0.001) and there was a significant decrease of LDH level after correction of deformity (p = 0.017). CONCLUSION: In conclusion, only LDH, one of the routine laboratory tests, was significantly elevated than normal value, which was thought to be caused by etiologies of pectus excavatum and the compression of the internal organs. Further studies on LDH including isoenzyme studies in patients with pectus excavatum will be needed, and these studies will provide a deeper and wider comprehension of pectus excavatum.

Single incision thoracoscopic right upper lobectomy with systematic lymph node dissection.

Video-assisted thoracic surgery (VATS) provides less postoperative pain, preservation of the immune response and shorter recovery period, compared with thoracotomy. However, many patients complain of postoperative pain and paresthesia because VATS requires 3 or 4 incisions including a utility incision of 3-5 cm. To overcome this problem, single incision thoracoscopic surgery has emerged; this technique has been adopted for lung cancer surgery since 2010. Complete mediastinal lymph node dissection is the major role of lung cancer surgery. We describe a case of a right upper lobectomy with complete mediastinal lymph node dissection via single incision thoracosopic surgery.