Uniportal versus multiportal nonintubated thoracoscopic anatomical resection for lung cancer: A propensity-matched analysis.

BACKGROUND/PURPOSE: No studies have compared between uniportal and multiportal nonintubated thoracoscopic anatomical resection for non-small cell lung cancer (NSCLC). We aimed to compare short- and long-term postoperative outcomes concerning these two methods. METHODS: Our retrospective dataset comprised patients with NSCLC who underwent uniportal or multiportal nonintubated thoracoscopic anatomical resection between January 2011 and December 2019. The primary outcome was recurrence-free survival. Propensity scores were matched according to age, sex, body mass index, pulmonary function, tumor size, cancer stage, and surgical method. RESULTS: In total, 1130 such patients underwent nonintubated video-assisted thoracoscopic surgery (VATS), and 490 consecutive patients with stage I-III NSCLC underwent nonintubated anatomical resection, including lobectomy and segmentectomy (uniportal, n = 158 [32.3%]; multiportal, n = 331 [67.7%]). The uniportal group had fewer dissected lymph nodes and lymph node stations. In paired group analysis, the uniportal group had shorter operation durations (99.8 vs. 138.2 min; P < 0.001), lower intensive care unit (ICU) admission rates and ICU admission intervals (7.0% vs. 27.8%; P < 0.001), and shorter postoperative hospital stays (4.1 days vs. 5.2 days; P < 0.001). The most common postoperative complication was prolonged air leaks. No surgical mortality was observed. The multiportal group had higher complication rates for grades ≥ II NSCLC; however, this difference was not significant (4.4% vs. 1.3%, respectively; P = 0.09). CONCLUSION: Nonintubated uniportal VATS for anatomical resection had better results for some perioperative outcomes than multiportal VATS. Oncological outcomes such as recurrence-free and overall survival remained uncompromised, despite fewer dissected lymph nodes.

Non-Intubated Versus Intubated Video-Assisted Thoracic Surgery in Patients Aged 75 Years and Older: A Propensity Matching Study.

Introduction: In most developed countries, lung cancer is associated with the highest mortality rate among all cancers. The number of elderly patients with lung cancer is increasing, reflecting the global increase in aging population. Patients with impaired lung or cardiac function are at a high risk during intubated general anesthesia, which may preclude them from surgical lung cancer treatment. We evaluated the safety and survival of non-intubated video-assisted thoracoscopic surgery (VATS) versus those of intubated thoracoscopic surgery for surgical resection for lung cancer in older patients. Methods: Patients aged ≥75 years who underwent non-intubated and intubated VATS resection with pathologically confirmed non-small cell lung cancer, using a combination of thoracic epidural anesthesia or intercostal nerve block and intra-thoracic vagal block with target-controlled sedation, from January 2011 to December 2019 were included. Ultimately, 79 non-intubated patients were matched to 158 patients based on age, sex, body mass index, family history, comorbidity index, pulmonary function (forced expiratory volume in one second/ forced vital capacity [%]), and disease stage. The endpoints were overall survival and recurrence progression survival. Results: All patients had malignant lung lesions. Data regarding conversion data and the postoperative result were collected. Both groups had comparable preoperative demographic and cancer staging profiles. The anesthetic duration in the non-intubated group was shorter than that in the intubated group, which showed a significantly higher mean number of lymph nodes harvested (intubated vs non-intubated, 8.3 vs. 6.4) and lymph stations dissected (3.0 vs. 2.6). Intensive care unit (ICU) admission rate and postoperative ICU stay were significantly longer in the intubated group. The complication rate was higher and hospital stay were longer in the intubated group, but these differences were not significant (12% vs. 7.6%; p = .07, respectively). Conclusions: In the elderly, non-intubated thoracoscopic surgery provides similar survival results as the intubated approach, although fewer lymph nodes are harvested. Non-intubated surgery may serve as an alternative to intubated general anesthesia in managing lung cancer in carefully selected elderly patients with a high risk of impaired pulmonary and cardiac function.

Treatment Effectiveness and Tolerability of Long-term Adjuvant First- and Second-Generation Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitor at Different Doses in Patients With Stage IIA-IIIB Epidermal Growth Factor Receptor-Mutated Lung Adenocarcinoma: A Retrospective Study.

Introduction: For patients with epidermal growth factor receptor (EGFR)-mutated lung cancer who undergo surgery, adjuvant tyrosine kinase inhibitor (TKI) therapy other than osimertinib is an alternative option. We aimed to discuss the long-term safety and efficacy of TKI treatment in real-world data. Methods: From January 2011 to May 2020, patients with stage II-III EGFR-mutated adenocarcinoma who underwent cancer resection surgery at a single center were enrolled. The primary endpoint was disease relapse, and the secondary endpoint was overall survival. In total, 30 patients were included in the study. In our study, all patients underwent complete resection using video-assisted thoracoscopic surgery. The patients were divided into a dose interruption (prolonged interval use) group and non-dose adjustment group. Results: The patients' pathological stages were II-III. The initial EGFR TKIs were mostly gefitinib (n = 25, 83%), and others were erlotinib (n = 3, 10%) and afatinib (n = 2, 6%). The mean disease-free survival (DFS) was 53.3 months. The 2- and 5-year DFS rate was 90.0 and 73.3%, respectively. The median TKI treatment duration in this study was 44.5 months (range, 6-133 months), which was the longest in the literature review. Of these patients, nine had dose interruption. We compared the two groups and found no treatment differences between them. There were no significant side effect potentials between both groups. Conclusion: To our knowledge, this study provides the longest experience of TKI in patients with resected EGFR mutations and also provided a dose reduction strategy (prolonged medication interval) for patients who had intolerable side effects.

Factors Associated with Nodal Upstaging in Clinical T1a-bN0M0 Non-Small Cell Lung Cancers.

Nodal upstaging of lung adenocarcinoma occurs when unexpected pathological lymph node metastasis is found after surgical intervention, and may be associated with a worse prognosis. In this study, we aimed to determine the predictive factors of nodal upstaging in cT1a-bN0M0 primary lung adenocarcinoma. We retrospectively reviewed a prospective database (January 2011 to May 2017) at National Taiwan University Hospital and identified patients with cT1a-bN0M0 (solid part tumor diameter ≤ 2 cm) lung adenocarcinoma who underwent video-assisted thoracoscopic lobectomy. Logistic regression models and survival analysis were used to examine and compare the predictive factors of nodal upstaging. A total of 352 patients were included. Among them, 28 (7.8%) patients had nodal upstaging. Abnormal preoperative serum carcinoembryonic antigen (CEA) levels, solid part tumor diameter ≥ 1.3 cm, and consolidation-tumor (C/T) ratio ≥ 0.50 on chest computed tomography (CT) were significant predictive factors associated with nodal upstaging, and patients with nodal upstaging tended to have worse survival. Standard lobectomy is recommended for patients with these predictive factors. If neither of the predictive factors are positive, a less invasive procedure may be a reasonable alternative. Further studies are needed to verify these data.

Primary Tumor Resection for Stage IV Non-small-cell Lung Cancer Without Progression After First-Line Epidermal Growth Factor Receptor-Tyrosine Kinase Inhibitor Treatment: A Retrospective Case-Control Study.

BACKGROUND: In studies of stage IV epidermal growth factor receptor (EGFR)-mutant nonsmall-cell lung cancer (NSCLC), <10% of patients underwent surgery; thus, the effect of surgery in these patients remains unclear. We investigated whether primary lung tumor resection could improve the survival of patients with stage IV EGFR-mutant NSCLC without progression after first-line EGFR-tyrosine kinase inhibitor (EGFR-TKI) treatment. METHODS: This retrospective case-control study included patients treated with first-line EGFR-TKIs without progression on follow-up imaging. Patients in the surgery group (n = 56) underwent primary tumor resection, followed by TKI maintenance therapy. Patients in the control group (n = 224; matched for age, metastatic status, and Eastern Cooperative Oncology Group performance status) received only TKI maintenance therapy. Local ablative therapy for distant metastasis was allowed in both groups. The primary endpoint was progression-free survival. The secondary endpoints were overall survival, failure patterns, and complications/adverse events. RESULTS: The median time from TKI treatment to surgery was 5.1 months. For the surgery and control groups, the median follow-up periods were 34.0 and 38.5 months, respectively, with a median (95% confidence interval) progression-free survival of 29.6 (18.9-40.3) and 13.0 (11.8-14.2) months, respectively (P < 0.001). Progression occurred in 29/56 (51.8%) and 207/224 (92.4%) patients, respectively. The median overall survival in the surgery group was not reached. The rate of surgical complications of grade ≥2 was 12.5%; complications were treated conservatively. CONCLUSIONS: Primary tumor resection is feasible for patients with EGFR-mutant nonprogressed NSCLC during first-line EGFR-TKI treatment and may improve survival better than maintenance EGFR-TKI therapy alone.

Undiagnosed solitary caseating granulomas: Is lung resection surgery a feasible method for diagnosis and treatment?

BACKGROUND: In many patients, low-dose computed tomography (CT) screening for lung cancer reveals asymptomatic pulmonary nodules. Lung resection surgery may be indicated in these patients; however, distinguishing malignancies from benign lesions preoperatively can be challenging. METHODS: From 2013 to 2018, 4181 patients undergoing surgery for pulmonary nodules were reviewed at National Taiwan University Hospital, and 837 were diagnosed with benign pathologies. Only patients with pathological diagnosis as caseating granulomatous inflammation were included, sixty-nine patients were then analyzed for preoperative clinical and imaging characteristics, surgical methods and complications, pathogens, medical treatment and outcomes. Mycobacterial evidence was obtained from the culture of respiratory or surgical specimen. RESULTS: Overall, 68% of the patients were asymptomatic before surgery. More than half of the nodules were in the upper lobes, and all patients underwent video-assisted thoracoscopic surgery (VATS). Some patients (14.5%) developed grade I complications, and the mean postoperative hospital stay was 4 days. The final pathology reports of 20% benign entities postoperatively, and caseating granulomatous inflammation accounted for a significant part. MTB and NTM were cultured from one-fourth of the patients respectively. All patients with confirmed MTB infection received antimycobacterial treatment, while the medical treatment in NTM-infected patients was decided by the infectious disease specialists. The mean follow-up period was 736 days, and no recurrence was found. CONCLUSION: Lung resection surgery is an aggressive but safe and feasible method for diagnosing MTB- or NTM-associated pulmonary nodules, and, potentially, an effective therapeutic tool for patients with undiagnosed MTB- or NTM-associated pulmonary nodules.

Previous Extrapulmonary Malignancies Impact Outcomes in Patients With Surgically Resected Lung Cancer.

Background: As the overall survival of patients with cancer continues to improve, the incidence of second primary malignancies seems to be increasing. Previous studies have shown controversial results regarding the survival of patients with primary lung cancer with previous extrapulmonary malignancies. This study aimed to determine the clinical picture and outcomes of this particular subgroup of patients. Materials and Methods: We included 2,408 patients who underwent pulmonary resection for primary lung cancer at our institute between January 1, 2011 and December 30, 2017 in this retrospective study. Medical records were extracted and clinicopathological parameters and postoperative prognoses were compared between patients with lung cancer with and without previous extrapulmonary malignancies. Results: There were 200 (8.3%) patients with previous extrapulmonary malignancies. Breast cancer (30.5%), gastrointestinal cancer (17%), and thyroid cancer (9%) were the most common previous extrapulmonary malignancies. Age, sex, a family history of lung cancer, and preoperative carcinoembryonic antigen levels were significantly different between the two groups. Patients with previous breast or thyroid cancer had significantly better overall survival than those without previous malignancies. Conversely, patients with other previous extrapulmonary malignancies had significantly poorer overall survival (p < 0.001). The interval between the two cancer diagnoses did not significantly correlate with clinical outcome. Conclusion: Although overall survival was lower in patients with previous extrapulmonary malignancies, previous breast or thyroid cancer did not increase mortality. Our findings may help surgeons to predict prognosis in this subgroup of patients with primary lung cancer.

Thoracoscopic Wedge Resection Versus Segmentectomy for cT1N0 Lung Adenocarcinoma.

BACKGROUND: The choice between wedge resection and segmentectomy as a sublobar resection method for patients with cT1N0 lung cancer remains debatable. This study aimed to evaluate the clinical outcomes after wedge resection and segmentectomy for patients with cT1N0 lung adenocarcinoma. METHODS: The study enrolled 1002 consecutive patients with cT1N0 lung adenocarcinoma who underwent sublobar resection at the authors' institution between 2011 and 2017. A propensity score-matching analysis was used to compared the clinical outcomes between the wedge resection and segmentectomy groups. RESULTS: Wedge resection was performed for 810 patients (80.8%), and segmentectomy was performed for 192 patients (19.2%). Wedge resection resulted in better perioperative outcomes than segmentectomy. The multivariate analysis showed that the significant risk factors for poor disease-free survival (DFS) were elevated preoperative serum carcinoembryonic antigen levels, total tumor diameter greater than 2 cm, and a consolidation-to-tumor (C/T) ratio higher than 50%. After propensity-matching, no differences in overall survival or DFS were noted between the two matched groups. However, subgroup analysis showed that segmentectomy was associated with better DFS than wedge resection (p = 0.039) for the patients with a tumor diameter greater than 2 cm and a C/T ratio higher than 50%. CONCLUSION: Segmentectomy is the appropriate surgical method for sublobar resection in cT1N0 lung adenocarcinoma patients with a tumor diameter greater than 2 cm and a C/T ratio higher than 50%. Wedge resection may be a safe and feasible sublobar resection method for patients with a tumor diameter of 2 cm or smaller or a C/T ratio of 50% or lower.

Nonintubated Versus Intubated Uniportal Thoracoscopic Segmentectomy for Lung Tumors.

BACKGROUND: Although the use of the uniportal thoracoscopic technique has spread exponentially recently, a comparison of nonintubated and intubated uniportal thoracoscopic segmentectomies for lung tumors has not been reported. We aimed to compare the feasibility, safety, and short-term postoperative outcomes between the 2 methods. METHODS: From January 2014 to June 2019 we retrospectively reviewed 185 consecutive patients with lung tumors who underwent uniportal thoracoscopic segmentectomy at our institute. A body mass index of ≥25 kg/m2 was considered a contraindication for the nonintubated anesthetic approach. For the remaining cases the anesthetic approach was made at the discretion of each individual anesthesiologist. A propensity-matched analysis incorporating sex and body mass index was used to compare the clinical outcomes of the nonintubated and intubated groups. RESULTS: Fifty patients (27.0%) underwent the procedure with the nonintubated anesthetic approach. The nonintubated group was more likely to be female (P < .001) and with a lower body mass index (P < .001). Other clinical features showed no significant difference. There was no significant difference between the 2 groups in the type of segmentectomy according to the difficulty classification system. After propensity matching 43 matched patients in each group were included. Anesthetic induction duration (12.0 vs 15.3 minutes, P = .014) was shorter in the nonintubated group. No other significant differences in perioperative, postoperative, and anesthetic results were noted between the 2 matched groups. CONCLUSIONS: The nonintubated anesthetic approach can be a safe and feasible alternative to intubated uniportal thoracoscopic segmentectomy.

Clinical outcome of subcentimeter non-small cell lung cancer after VATS resection: Single institute experience with 424 patients.

BACKGROUND/PURPOSE: Non-small cell lung cancer (NSCLC) presenting as subcentimeter lung tumor was increasing due to the popularity of low dose CT in recent years. However, the ideal surgical management is still controversial. We utilized our lung cancer surgery database to study the important issue, aiming to find the optimal treatment with VATS. METHODS: From January 2010 to December 2015, we retrospectively reviewed the clinical characteristics, staging, operation methods, and outcomes of 424 patients with subcentimeter lung cancer. Three groups distinguished by surgical methods were compared. RESULTS: There are 273, 57, and 94 undergoing VATS wedge resection, segmentectomy, and lobectomy, respectively. Of the nine recurrence or metastasis events, seven and two occurred within the wedge resection and lobectomy groups, respectively. The average follow-up time is 779 days (2.16 years). Furthermore, 97.4%, 100%, and 97.9% of patients in the wedge resection, segmentectomy, and lobectomy groups, respectively remained tumor-free during follow-up. The complication rate of approximately 1.5% did not differ significantly between the three groups. An obvious difference in disease-free survival between the three groups (p-value = 0.027; -2 log likelihood score and chi-square test). No cases of recurrence or metastasis were observed in the segmentectomy group. CONCLUSION: Lung cancer with subcentimeter size will be more and more encountered. VATS plays an important role in the management with good post-operative outcome, whether with wedge resection, segmentectomy and lobectomy. However, VATS segmentectomy can deliver 100% overall survival and progression-free survival in our series. Further randomized controlled trial should be conducted to prove the concept.

Propensity-Matched Analysis Comparing Survival After Sublobar Resection and Lobectomy for cT1N0 Lung Adenocarcinoma.

BACKGROUND: The optimal surgical method for cT1N0 lung adenocarcinoma remains controversial. OBJECTIVE: The aim of this study was to evaluate the differences in clinical outcomes of sublobar resection and lobectomy for cT1N0 lung adenocarcinoma patients. METHODS: We included 1035 consecutive patients with cT1N0 lung adenocarcinoma who underwent surgery at our institute from January 2011 to December 2016. The surgical approach, either sublobar resection or lobectomy, was determined at the discretion of each surgeon. A propensity-matched analysis incorporating total tumor diameter, solid component diameter, consolidation-to-tumor (C/T) ratio, and performance status was used to compare the clinical outcomes of the sublobar resection and lobectomy groups. RESULTS: Sublobar resection and lobectomy were performed for 604 (58.4%; wedge resection/segmentectomy: 470/134) and 431 (41.6%) patients, respectively. Patients in the sublobar resection group had smaller total tumor diameters, smaller solid component diameters, lower C/T ratios, and better performance status. More lymph nodes were dissected in the lobectomy group. Patients in the sublobar resection group had better perioperative outcomes. A multivariable analysis revealed that the solid component diameter and serum carcinoembryonic antigen level are independent risk factors for tumor recurrence. After propensity matching, 284 paired patients in each group were included. No differences in overall survival (OS; p = 0.424) or disease-free survival (DFS; p = 0.296) were noted between the two matched groups. CONCLUSIONS: Sublobar resection is not inferior to lobectomy regarding both DFS and OS for cT1N0 lung adenocarcinoma patients. Sublobar resection may be a feasible surgical method for cT1N0 lung adenocarcinoma.

Computed tomography-guided dye localization for deeply situated pulmonary nodules in thoracoscopic surgery.

BACKGROUND: Increased lung cancer screening of asymptomatic adults using low-dose computed tomography (CT) with high-resolution imaging modalities has increased the identification of small and deeply situated pulmonary nodules. This study aimed to evaluate the role of preoperative patient blue vital (PBV) dye localization for an undiagnosed nodule deeply situated in the lung parenchyma followed by minimally invasive lung resection. METHODS: From July 2013 to December 2016, 27 consecutive patients (16 women, median age: 62 years) with small undiagnosed pulmonary nodules at a depth of more than 30 mm underwent preoperative CT-guided PBV dye localization followed by thoracoscopic diagnostic resection of the nodule at National Taiwan University Hospital. The clinical characteristics were collected retrospectively to evaluate the efficacy and safety of the procedure. RESULTS: The median size of pulmonary nodule in preoperative CT images was 11 mm with a median depth of 31.6 mm (range, 30.0-48.6 mm). Of the 27 nodules, 8 were pure ground-glass nodules, 3 were pure solid nodules, and 16 were partially solid nodules. The diagnostic yield of CT-guided dye localization following diagnostic wedge resection was 100%. The final pathological diagnoses were: primary adenocarcinoma of the lung (n=20), adenocarcinoma in situ (n=1), and benign nodules (n=6). Only asymptomatic complications were noted after localization, and the median hospital stay was 3 days [interquartile range (IQR), 3-4 days]. All of 21 patients were cancer-free after a median follow-up of 39.0 months (IQR, 29.5-50.0 months). CONCLUSIONS: This study indicated that preoperative, percutaneous CT-guided PBV dye localization for undiagnosed nodules at a depth of more than 30 mm could be a safe and feasible procedure. Furthermore, it was considerably advantageous for preserving the lung parenchyma, especially for benign nodules.

Computed tomography-guided dye localization prior to uniportal thoracoscopic surgery for lung nodules: A propensity score matching analysis.

PURPOSE: Uniportal video-assisted thoracoscopic surgery (VATS) has recently been reported as an alternative to conventional VATS. However, preoperative image-guided localization is usually required for small nodules. The present study evaluated the efficacy of preoperative computed tomography-guided dye localization prior to uniportal VATS for small undetermined pulmonary nodules. METHODS: We retrospectively reviewed 298 consecutive patients who underwent uniportal VATS to treat undetermined pulmonary nodules (diameter ≤ 1.5 cm). Propensity score matching incorporating preoperative parameters was used to reduce the selection bias in a 1:1 manner. Comprehensive data including clinical features and perioperative variables were compared to evaluate the efficacy of preoperative computed tomography (CT)-guided dye localization prior to uniportal VATS. RESULTS: A total of 232 patients received preoperative CT-guided dye localization (localization group) and 66 did not (direct surgery group), and the propensity score matching analysis generated 55 pairs of patients in both groups. The demographics and operative outcomes, including clinical nodule size, depths of the nodule, were comparable for both groups. The complication rates were low in both groups (3.6% and 1.8%, respectively). The uniportal to multi-portal VATS conversion rate was significantly higher in the direct surgery group than in the localization group (12.7% vs 1.8%, P = 0.030). 5 cases were converted due to failure in tumor identification (7.3% vs 1.8%, P = 0.182). CONCLUSION: Uniportal VATS is a feasible, effective, and safe procedure for the treatment of undetermined pulmonary nodules. The use of preoperative computed tomography-guided dye localization may be associated with a lower risk of conversion of uniportal VATS.

Correlation of tumor spread through air spaces and clinicopathological characteristics in surgically resected lung adenocarcinomas.

OBJECTIVES: Tumor spread through air spaces (STAS) has recently been reported as a novel invasive pattern in lung adenocarcinoma, but the correlation between other clinicopathological and genetic profiles has not been well studied. The aim of this study was to investigate these correlations in patients with surgically resected lung adenocarcinoma. MATERIALS AND METHODS: Five hundred consecutive patients with lung adenocarcinoma who underwent curative lung tumor resection and with available STAS profile were reviewed retrospectively from January to December 2016. The correlations of STAS presence and clinicopathological and genetic characteristics were analyzed. RESULTS: One hundred thirty-four patients (26.8%) had positive STAS. The pathological stage of these patients was adenocarcinoma in situ, IA, IB, II, and III in 25 (5%), 343 (68.6%), 63 (12.6%), 29 (5.8%), and 40 (8%), respectively. Multivariate analysis showed that the presence of STAS was significantly correlated to higher T (p = 0.001) and N (p = 0.032) stages, moderate/poor differentiation (p = 0.001), and the presence of lymphovascular invasion (p = 0.001). Although positive epidermal growth factor receptor mutation and non-lepidic histologic subtypes were correlated with the presence of STAS in the univariate analysis, they were not significantly correlated with the presence of STAS in the multivariate analysis (p = 0.676 and 0.286, respectively). CONCLUSIONS: STAS was significantly correlated with several invasive clinicopathological characteristics in surgically resected lung adenocarcinoma. Based on our results and current evidence, the presence of STAS may be considered as a staging profile in future staging system.

Preoperative Dye Localization for Thoracoscopic Lung Surgery: Hybrid Versus Computed Tomography Room.

BACKGROUND: Preoperative computed tomography (CT)-guided dye localization is essential for the surgical treatment of small lung nodules and is mostly performed by radiologists in the CT room. Several studies reported their early experiences of preoperative localization in the hybrid operating room. A comparison between localization in the CT room and hybrid room has not been reported. Therefore, we compared the outcomes of preoperative localization in the hybrid and CT rooms. METHODS: This study included patients who underwent preoperative CT-guided dye localization for thoracoscopic lung tumor surgery in the hybrid operation room (n = 25) and CT room (n = 283) at our institute. Propensity matched analysis, incorporating nodule size, number, and depth, and operation method, was used to compare the short-term outcomes of these two groups. Each patient in the hybrid room group was matched with 2 patients in the CT room group. RESULTS: Localization was successfully performed in 23 patients (92%) and 50 patients (100%) in the hybrid room and CT room groups, respectively. There was no significant difference in demographics between groups. In the hybrid room group, the global time was shorter (192.6 versus 244.1 minutes, p = 0.003), and the localization time was longer (33.1 versus 22.3 minutes, p < 0.001). All lung nodules were successfully resected in both groups, but the hybrid room group had a relatively higher morbidity rate. CONCLUSIONS: The hybrid operating room may be associated with a shorter global time and similar perioperative and postoperative outcomes compared with the CT room. Localization in the hybrid operating room seems an effective alternative method for managing small lung nodules.

The Size of Spontaneous Pneumothorax is a Predictor of Unsuccessful Catheter Drainage.

Small-bore thoracic catheter drainage is recommended for a first large or symptomatic episode of primary spontaneous pneumothorax (PSP). However, one-third of these patients require a second procedure because of treatment failure. We investigated the factors associated with unsuccessful pigtail catheter drainage in the management of PSP. In this retrospective study, using a prospectively collected database, we enrolled 253 consecutive patients with PSP who underwent pigtail catheter drainage as initial treatment, from December 2006 to June 2011. The chest radiograph was reviewed in each case and pneumothorax size was estimated according to Light's index. Other demographic factors and laboratory data were collected via chart review. Pigtail catheter drainage was successful in 71.9% (182/253) of cases. Treatment failure rates were 42.9%, 25.9%, and 15.5% in patients with pneumothorax sizes of >62.6%, 38-62.6%, and <38%, respectively (tertiles). An alternative cut-off point of 92.5% lung collapse was defined using a classification and regression tree method. According to the multivariate analysis, a large-size pneumothorax (p = 0.009) was the only significant predictor of initial pigtail catheter drainage treatment failure in patients with PSP. Early surgical treatment could be considered for those patients with a large-sized pneumothorax.

Nonintubated uniportal thoracoscopic wedge resection for early lung cancer.

BACKGROUND: Minimal invasive surgery is current choice of treatment for lung cancer. Combined nonintubated anesthesia with uniportal thoracoscopic surgery is not well understood. Here, we report the experience of nonintubated uniportal thoracoscopic surgery in the treatment of primary non-small cell lung cancer (NSCLC). METHODS: From January 2014 to December 2015, we retrospectively reviewed 131 consecutive patients with primary NSCLC who underwent nonintubated uniportal thoracoscopic wedge resection and mediastinal lymph node dissection at a single medical center. RESULTS: Of the 131 patients, 110 (84%) received preoperative computed tomography-guided dye localization. Most of them were diagnosed with early stage invasive adenocarcinoma (N=112, 85.5%; pathological stage IA: 84.7%, N=111), and the mean size of the nodule was small (diameter: 0.85±0.40 cm). All section margins were free of malignancy. In total, 7 of the 131 patients (5.3%) had their treatment converted from uniportal to multi-portal video-assisted thoracoscopic surgery (VATS), and 1 (0.8%) had his treatment converted to endotracheal intubation with general anesthesia. The mean operation time was 91.1±32.6 minutes, and the postoperative complications included pneumonia (0.8%), prolonged air leaks (0.8%), and subcutaneous emphysema (1.5%). CONCLUSIONS: Overall, nonintubated uniportal VATS is a feasible, effective and safe procedure for the treatment of early primary lung cancer.

Chemical pleurodesis for prolonged postoperative air leak in primary spontaneous pneumothorax.

BACKGROUND/PURPOSE: Prolonged air leak is the most common complication after thoracoscopic operation for primary spontaneous pneumothorax (PSP), and the role of chemical pleurodesis in treating air leaks remains unclear. This study evaluated the safety and efficacy of chemical pleurodesis with a comparison between minocycline and OK-432. METHODS: Between 1994 and 2011, 1083 PSP patients were treated by thoracoscopic operation. After the operation, patients with persistent air leak for 3 days or more were managed by minocycline or OK-432 pleurodesis. The demographic and outcome data for these patients were collected by retrospective chart review. RESULTS: Seventy-nine patients (7.3%) with prolonged air leak after thoracoscopy underwent minocycline pleurodesis (60 patients) or OK-432 pleurodesis (19 patients) as the primary treatment. The primary success rate was 63% (38/60) for minocycline pleurodesis and 95% (18/19) for OK-432 pleurodesis (p = 0.009). Postpleurodesis pain was common and comparable between the two groups. No major complications were noted after a total of 121 treatments. Patients undergoing primary OK-432 pleurodesis had shorter durations of postpleurodesis chest drainage (mean 8.5 vs. 2.3 days; p < 0.001) and postoperative hospital stay (mean 11.9 vs. 6.8 days; p < 0.001) than those undergoing primary minocycline pleurodesis. After a median follow-up of 16 months, recurrence was noted in one patient in the OK-432 group and none in the minocycline group. Long-term pulmonary function in the two groups was comparable. CONCLUSION: Chemical pleurodesis using OK-432 or minocycline is safe and convenient for prolonged air leak after thoracoscopic treatment for PSP. Our experience suggested that OK-432 may be more effective than minocycline in reducing air leak.