Accuracy of a 3-Dimensionally Printed Navigational Template for Localizing Small Pulmonary Nodules: A Noninferiority Randomized Clinical Trial.

Importance: Localization of small lung nodules are challenging because of the difficulty of nodule recognition during video-assisted thoracoscopic surgery. Using 3-dimensional (3-D) printing technology, a navigational template was recently created to assist percutaneous lung nodule localization; however, the efficacy and safety of this template have not yet been evaluated. Objective: To assess the noninferiority of the efficacy and safety of a 3-D-printed navigational template guide for localizing small peripheral lung nodules. Design, Setting, and Participants: This noninferiority randomized clinical trial conducted between October 2016 and October 2017 at Shanghai Pulmonary Hospital, Shanghai, China, compared the safety and precision of lung nodule localization using a template-guided approach vs the conventional computed tomography (CT)-guided approach. In total, 213 surgical candidates with small peripheral lung nodules (<2 cm) were recruited to undergo either CT- or template-guided lung nodule localization. An intention-to-treat analysis was conducted. Interventions: Percutaneous lung nodule localization. Main Outcomes and Measures: The primary outcome was the accuracy of lung nodule localization (localizer deviation), and secondary outcomes were procedural duration, radiation dosage, and complication rate. Results: Of the 200 patients randomized at a ratio of 1:1 to the template- and CT-guided groups, most were women (147 vs 53), body mass index ranged from 15.4 to 37.3, the mean (SD) nodule size was 9.7 (2.9) mm, and the mean distance between the outer edge of target nodule and the pleura was 7.8 (range, 0.0-43.9) mm. In total, 190 patients underwent either CT- or template-guided lung nodule localization and subsequent surgery. Among these patients, localizer deviation did not significantly differ between the template- and CT-guided groups (mean [SD], 8.7 [6.9] vs 9.6 [5.8] mm; P = .36). The mean (SD) procedural durations were 7.4 (3.2) minutes for the template-guided group and 9.5 (3.6) minutes for the CT-guided group (P < .001). The mean (SD) radiation dose was 229 (65) mGy × cm in the template-guided group and 313 (84) mGy × cm in CT-guided group (P < .001). Conclusions and Relevance: The use of the 3-D-printed navigational template for localization of small peripheral lung nodules showed efficacy and safety that were not substantially worse than those for the CT-guided approach while significantly simplifying the localization procedure and decreasing patient radiation exposure. Trial Registration: ClinicalTrials.gov identifier: NCT02952261.

Differential diagnosis for hepatic cyst diseases / 中华普通外科杂志

Objective To invastigate how to differentiate the single cystic hepatic hydatidosis from single hepatic cysts.Methods From Apr 2014 to Aug 2018 at the First Affiliated Hospital of Xinjiang Medical University,30 cases of liver single cystic diseases were misdiagnosed · Relevant clinical data were compared including medical history,imaging features,immunological examination etc.Results 18 cases of echinococcosis were misdiagnosed as hepatic cysts before operation,and 12 patients with hepatic cysts were misdiagnosed as hepatic cystic echinococcosis before operation.There were no significant differences between the two groups in eosinophil count (Eo#) (t =1.35,P ＞ 0.05),albumin (t =0.38,P ＞ 0.05),aspartate aminotransferase (t =0.99,P ＞ 0.05),and CT values (t =0.85,P ＞ 0.05).The results suggest that antiEgCF antibody (x2 =4.26,P ＜ 0.05) and EgB antibody (x2 =7.26,P ＜ 0.05) are of significantly differential value in the identification of the two diseases.Conclusion Levels of anti-EgB and anti-EgCF antibodies to hepatic cystic echinococcosis are higher than that to single hepatic cysts.

Modified hook-wire placement technique for localizing multiple pulmonary nodules.

BACKGROUND: The localization of multiple pulmonary nodules is challenging due to a high incidence of pneumothorax after each needle insertion into lung parenchyma. The aim of the current study is to verify the safety and effectiveness of a modified technique utilizing simultaneous Hookwire placement to localize multiple lesions. METHODS: The proposed method comprises a row of metal wires, perpendicular insertion, simultaneous release of Hookwire, and a lateral position to modify a conventional localizing technique. From January 2015 to August 2016, 23 patients were subjected to the modified technique group (Group A), while 53 patients in the conventional group (Group B). Success rates, procedural parameters, and complications were recorded and analyzed. RESULTS: Compared with Group B, Group A had higher success rate of lesion (96.7% vs 83.5%, P = 0.009), lower numbers of CT scans (2.91 vs 5.59, P < 0.001), shorter procedure duration (13.83 minutes vs 22.68 minutes, P < 0.001), and shorter distance between localizers and lesions (4.88 vs 6.29, P = 0.006). The incidence of pneumothorax in Group A was lower (21.8% vs 54.7%, P = 0.008), while lung hemorrhage was not significantly different ( P = 0.735). Lesion number and pneumothorax were risk factors for failure in multiple localizations. CONCLUSIONS: The modified Hookwire placement technique was feasible and successful, which was associated with fewer computed tomography scans, shorter procedure duration, and a lower incidence of pneumothorax.

Video-assisted thoracic surgery is an optimal alternative to conventional thoracotomy for reoperations for ipsilateral pulmonary lesions.

BACKGROUND: Ipsilateral pulmonary reoperation is empirically considered a contraindication of video-assisted thoracic surgery (VATS) because of intrapleural adhesion and the destruction of anatomical structures caused by previous surgery. The purpose of this study was to present our experience of the use of VATS for ipsilateral reoperations. METHODS: The medical records of patients who underwent VATS reoperation or re-thoracotomy between January 2006 and March 2017 were retrospectively reviewed. Data were compared to assess the feasibility and safety of VATS for ipsilateral reoperations. RESULTS: The study enrolled 64 patients, including 36 patients who underwent attempted ipsilateral VATS reoperations (VATS group) and 28 who underwent conventional re-thoracotomy as a control with clinicopathological characteristics similar to those in the VATS group. Intrapleural severe adhesions were detected in 28 (77.8%) and 22 (78.6%) patients in the VATS and re-thoracotomy groups, respectively (P = 0.906), and their dissection required a longer period in the VATS group (P = 0.014). VATS reoperations were converted to re-thoracotomy or video-assisted mini re-thoracotomy in three patients because of bleeding or difficulty in dissecting hilar structures. There were no significant differences in resection methods, time to reoperation, intraoperative blood loss, or drainage time between the two groups. However, patients in the VATS group had a shorter hospital stay (P < 0.01) and fewer complications (P = 0.042). CONCLUSION: VATS is an optimal alternative to re-thoracotomy for ipsilateral pulmonary lesions, regardless of intrapleural adhesions and the destruction of anatomical structures caused by former operations in selected patients.

Risk Factors of Recurrence in Patients With Clinical Stage IA Adenocarcinoma Presented as Ground-Glass Nodule.

BACKGROUND: In this study we aimed to identify the risk factors of recurrence in patients with clinical stage IA adenocarcinoma presented as ground glass nodule (GGN) on computed tomography scans. PATIENTS AND METHODS: The study included 245 patients with clinical stage IA adenocarcinoma presented as GGN who underwent surgery during 2010 to 2013. All patients were divided into 2 subgroups on the basis of consolidation diameter to tumor diameter (C/T) ratio on lung window: (1) ground-glass opacity (GGO)-dominant subgroup (C/T ≤ 0.5; n = 179); (2) solid-dominant subgroup (C/T > 0.5; n = 66). Recurrence-free survival (RFS) was analyzed to identify independent risk factors of recurrence using the Kaplan-Meier approach and multivariable Cox models. RESULTS: Patients in the GGO-dominant subgroup had a better prognosis than those in the solid-dominant subgroup (5-year RFS: 98% vs. 87%; P < .001). Multivariate analysis confirmed that C/T ratio was an independent risk factor for RFS in patients with clinical stage IA adenocarcinoma presented as GGN (hazard ratio [HR], 9.47; 95% confidence interval [CI], 1.75-51.1; P = .009). In the analysis of the solid-dominant group, multivariate analysis showed that limited resection was an independent risk factor of recurrence in this subgroup (HR, 6.86; 95% CI, 1.50-31.42; P = .013). Regarding the GGO-dominant subgroup, surgical type was not a risk factor of recurrence. CONCLUSION: Patients with clinical stage IA solid-dominant adenocarcinoma (C/T ratio > 0.5) had a higher rate of recurrence after limited resection than lobectomy. Thus, limited resection should be performed cautiously in these patients (C/T ratio > 0.5).

New horizons in surgical treatment of ground-glass nodules of the lung: experience and controversies.

Ground-glass nodule (GGN) is defined as a nodular shadow with ground-glass opacity that is generally associated with the early-stage lung adenocarcinoma. Nowadays, GGNs of the lung are increasingly detected with thin-section computed tomography scan. GGNs are categorized as pure GGNs and mixed GGNs according to the images from a high-resolution computed tomography. Meanwhile, it is routine to divide GGNs into different categories according to the number, solitary, or multiple, the management of which there is very different. A great number of studies have been conducted to analyze the different characteristics of GGNs in various aspects ranging from radiology, pathology, and surgery to molecular biology. However, plenty of problems still remain unsolved, ranging from the preoperative localization to intraoperative surgical resection procedure, the lymphadenectomy, and sampling of lymph nodes, as well as the accuracy of frozen sections. There has been a large volume of updated published information summarizing recently emerging and rapidly progressing aspects of surgical treatment of solitary and multiple GGNs with the unsolved problems mentioned above. However, there have been few specific reviews of surgical treatment of GGNs so far. This review presents a timely outline of advances in relevant experience and controversies of GGNs for a better understanding of this kind of lesion.

[Application of Digital Drainage System in Postoperative Refractory Prolonged Air Leaks after Pulmonary Surgery].

BACKGROUND: Postoperative prolonged air leaks is one of the most common complications secondary to pulmonary resections. Digital drainage system (DDS) is considered as an accurate and objective device which has been found to be comfortable and well tolerated by patients, economical as well. The aim of this study is to explore the application of DDS in patients with postoperative refractory prolonged air leaks after pulmonary surgery. METHODS: Prolonged air leak (PAL) is defined as air leaks lasting for more than 5 d after video-assisted surgery or more than 7 d after thoracotomy. Postoperative refractory prolonged air leak is defined as a kind of air leak lasting for twice than PAL with grade 2 or 3 air leak, or air leak with severe complications such as subcutaneous or mediastinal emphysema in our study. A total of 8 patients who had postoperative refractory prolonged air leaks after pulmonary resection were treated with digital drainage system combined with pleurodesis from January to December in 2016 in Department of Thoracic Surgery, Shanghai Pulmonary Hospital. All the relevant clinical data of patients were collected for analysis. RESULTS: In our study, 6 patients accepted lobectomy, the other 2 patients underwent segmentectomy. The average air leak and chest tube duration of the patients with postoperative refractory prolonged air leaks after pulmonary resection was (17.3±5.1) d. The average postoperative DDS duration was (5.6±3.7) d. The mean drainage volume of the patients was (2,615.6±1,741.2) mL and (935.0±242.7) mL before and after the application of DDS. The average length of hospital stay was (18.1±5.0) d. CONCLUSIONS: It is safe and feasible to apply digital drainage system to patients with postoperative refractory prolonged air leaks after pulmonary resection. Compared with the conventional drainage system, digital drainage system is more accurate and objective which can offer a larger suction pressure and promote lung recruitment maneuver for pleurodesis, shortening the drainage time and length of hospital stay.

Three-dimensional printing of navigational template in localization of pulmonary nodule: A pilot study.

BACKGROUND: Small pulmonary nodules are a common problem, especially with the wide implementation of lung cancer-screening program. This poses a great challenge to thoracic surgeons because of the difficulty of nodule localization. We recently built an efficient, customized navigational template using 3-dimensional (3D) printing technology to facilitate the procedure of lung nodule localization. This study aims to investigate its feasibility in clinical application. METHODS: Patients with peripheral lung nodules (<2 cm) were enrolled. Preadmission computed tomography images were downloaded and reconstructed into a 3D model. A digital model of the navigational template was designed via computer-aided design software and then exported into 3D printer to produce physical template. The precision of the template-guided nodule localization and associated complications were evaluated. RESULTS: A total of 16 patients were enrolled, and 18 nodules were localized through template-guided localization. The success rate of lung nodule localization was 100%, and the median time of localization was 13 minutes (range 10-16 minutes). In our series, no significant complication occurred, except for 2 asymptomatic pneumothoraxes. The median deviation between the localizer and the center of the nodule was 10.0 mm, ranging from 5 to 20 mm. CONCLUSIONS: This novel navigational template created by 3D printing technology is feasible, and it has acceptable accuracy for the application in lung nodule localization. The use of this navigational template could facilitate the procedure of lung nodule localization and may potentially break the dependence of percutaneous localization on computed tomography scanning.

Relationship of Lymph Node Micrometastasis and Micropapillary Component and Their Joint Influence on Prognosis of Patients With Stage I Lung Adenocarcinoma.

This study aimed to investigate the relationship between lymph node micrometastasis and histologic patterns of adenocarcinoma, with a particular focus on their joint effect on prognosis. We retrospectively reviewed 235 patients with stage I adenocarcinoma from January 2009 to December 2009. Lymph node micrometastasis was evaluated by immunohistochemical staining for cytokeratin (AE1/AE3) and thyroid transcription factor-1. A logistic regression model was applied to confirm the predictive factors of micrometastasis. Survival analysis was performed to evaluate the effect of micrometastasis on prognosis. Lymph node micrometastasis was observed in 35 patients (15%). Patients with micrometastasis had significantly worse recurrence-free survival (P<0.001) and overall survival (P<0.001) compared with those without micrometastasis. Micropapillary component was confirmed as an independent predictor of increased frequency of micrometastasis (P<0.001). Among 62 patients with adenocarcinoma with a micropapillary component, 23 (37%) had lymph node micrometastasis. Micropapillary-positive/micrometastasis-positive patients had significantly worse survival compared with micropapillary-positive/micrometastasis-negative patients (RFS, P=0.039; OS, P=0.002) and micropapillary-negative patients (recurrence-free survival, P<0.001; overall survival, P<0.001). Moreover, the presence of micrometastasis correlated with a higher risk of locoregional recurrence (P=0.031) rather than distant recurrence (P=0.456) in micropapillary-positive patients. In summary, lymph node micrometastasis was more frequently observed in adenocarcinoma with a micropapillary component. Moreover, lymph node micrometastasis could provide helpful prognostic information in patients with resected stage I lung adenocarcinoma with a micropapillary component; thus, immunohistochemical detection of micrometastatic tumor cells in lymph nodes should be recommended.

Remedial localization after dislodgement of primary mechanical localization in lung surgery.

BACKGROUND: Unhooking or displacement of hookwire or microcoil due to technical failures is rather common. We aim to establish a new technique for remedial localization in the case of displacement or unhooking of primary mechanical localization during lung surgery. METHODS: From February 2014 to September 2015, 18 consecutive cases of intraoperative dislodgement during video-assisted thoracoscopic surgery (VATS) were enrolled. Nodule's projection on body surface was located by analyzing computed tomography (CT) images, and a needle was inserted into thoracic cavity through this point. The lung was then inflated, and a small burn was made where the needle tip touched the visceral plural. Wedge resections were subsequently performed for these impalpable small lesions. RESULTS: Eighteen solitary pulmonary nodules (SPNs) from 18 patients were scheduled for VATS wedge resections in this series, including 6 (33.3%) hookwire localization and 12 (66.7%) microcoil localization. Fifteen (83.3%) of 18 nodules were pure ground glass opacity (pGGO) and 3 (16.7%) mixed ground glass opacity (mGGO). The mean diameter of SPNs was 7.7±3.6 mm. The mean distance from SPN to pleura was 12.2±10.9 mm. During remedial localization, 17 (94.4%) nodules were removed successfully by wedge resection, and segmentectomy was performed only in one case with failed outcome. Paraffin pathology showed 2 (11.1%) atypical adenomatous hyperplasia (AAH), 11 (61.1%) adenocarcinoma in situ (AIS), 4 (22.2%) minimally invasive adenocarcinoma (MIA), and 1 (5.6%) inflammatory disease. CONCLUSIONS: This remedial localization technique is practical and reliable. It is a good backup plan in the case of dislodgement, and it can help prevent extended lung resection.

Tumor Spread through Air Spaces Affects the Recurrence and Overall Survival in Patients with Lung Adenocarcinoma >2 to 3 cm.

OBJECTIVES: Tumor spread through air spaces (STAS) is a novel invasive pattern in lung adenocarcinoma (ADC). The effects of the combination of STAS and tumor size on survival have not been well studied. METHODS: A total of 383 patients with ADC 3 cm or smaller (stage IA) and 161 patients with stage IB ADC were identified from 2009 to 2010. Recurrence-free survival (RFS) and overall survival (OS) were compared between patients as stratified by STAS and tumor size. A validation cohort was included in this study. RESULTS: STAS was observed in 116 ADCs 3 cm or smaller (30.3%). In cases involving ADCs 3 cm or smaller, patients with STAS had worse RFS (p = 0.006) and OS rates (p < 0.001) than those without STAS. Furthermore, comparable RFS (p = 0.091) and OS (p = 0.443) rates were observed in patients with ADCs 3 cm or smaller with STAS present and those with stage IB ADC. Multivariate analysis revealed STAS to be an independent prognostic factor in ADCs 3 cm or smaller (RFS, p = 0.043; OS, p = 0.009). Among patients with ADCs larger than 2 to 3 cm, STAS still stratified the prognosis. Moreover, the unfavorable prognosis of patients with ADCs larger than 2 to 3 cm with STAS present was similar to that of patients with stage IB ADC. Among patients with ADCs 2 cm or smaller, STAS failed to stratify the prognosis significantly. Similar results were obtained in the validation cohort. CONCLUSIONS: These results provide preliminary evidence that STAS could be considered as a factor in a staging system to predict prognosis more precisely, especially in ADCs larger than 2 to 3 cm.

Analysis of risk factors for femoral head necrosis after internal fixation of femoral neck fractures with dynamic hip screw and anti-rotation screw / 中华创伤杂志

Objective To explore the influence factors for femoral head necrosis after treatment of femoral neck fractures with dynamic hip screw (DHS) and anti-rotation screw.Methods A retrospective case series analysis was made on the clinical data of 106 cases of femoral neck fractures who had undergone fixation with DHS and anti-rotation screw between May 2010 and May 2015.There were 59 males and 47 females,with an average age of 57.0 years (range,27-76 years).By Garden classification,there were 27 cases of type Ⅱ,51 cases of type Ⅲ and 28 cases of type Ⅳ.All cases were divided into femoral head necrosis group (18 cases) and none-necrosis group (88 cases) according to the radiographs of the fractured hip at the follow-up.Univariate analyses and a multivariate logistic regression analysis were made to test whether the following factors were significantly associated with femoral neck necrosis:sex,age,Garden classification,Pauwels classification,Singh index,injury-to-surgery time interval,reduction methods,reduction quality,complete weight-bearing time,implant removal and the time cost of implant removal surgery.Results All the 106 patients obtained a mean follow-up of 49 months (range,26-76 months).Femoral head necrosis occurred in 18 cases (17.0％).In univariate analyses,Garden classification,reduction quality,implant removal and long time of the implant removal surgery were significantly associated with femoral head necrosis (P ＜ 0.01).In multivariate logistic regression analysis,high level of Garden classification(95％ CI 0.008,0.998,P ＜ 0.05),implant removal and long time of the implant removal surgery (95％ CI 0.000,0.143,P ＜ 0.01) were found to have a significant effect on femoral head necrosis development.Conclusions Fracture displacement,removal of internal fixation and broadening the screw canal,which cand hinder the blood supply of femoral head,will enhance the rate of femoral head necrosis.As a result,it needs prudent consideration to remove internal fixation after internal fixation with DHS combined with anti-rotation screw for femoral neck fractures.When it is difficult to remove the anti-rotation screw,it is better to give up,rather than to force a removal.

Analysis of risk factors for femoral head necrosis after internal fixation of femoral neck fractures with dynamic hip screw and anti-rotation screw / 中华创伤杂志

Objective To explore the influence factors for femoral head necrosis after treatment of femoral neck fractures with dynamic hip screw (DHS) and anti-rotation screw.Methods A retrospective case series analysis was made on the clinical data of 106 cases of femoral neck fractures who had undergone fixation with DHS and anti-rotation screw between May 2010 and May 2015.There were 59 males and 47 females,with an average age of 57.0 years (range,27-76 years).By Garden classification,there were 27 cases of type Ⅱ,51 cases of type Ⅲ and 28 cases of type Ⅳ.All cases were divided into femoral head necrosis group (18 cases) and none-necrosis group (88 cases) according to the radiographs of the fractured hip at the follow-up.Univariate analyses and a multivariate logistic regression analysis were made to test whether the following factors were significantly associated with femoral neck necrosis:sex,age,Garden classification,Pauwels classification,Singh index,injury-to-surgery time interval,reduction methods,reduction quality,complete weight-bearing time,implant removal and the time cost of implant removal surgery.Results All the 106 patients obtained a mean follow-up of 49 months (range,26-76 months).Femoral head necrosis occurred in 18 cases (17.0％).In univariate analyses,Garden classification,reduction quality,implant removal and long time of the implant removal surgery were significantly associated with femoral head necrosis (P ＜ 0.01).In multivariate logistic regression analysis,high level of Garden classification(95％ CI 0.008,0.998,P ＜ 0.05),implant removal and long time of the implant removal surgery (95％ CI 0.000,0.143,P ＜ 0.01) were found to have a significant effect on femoral head necrosis development.Conclusions Fracture displacement,removal of internal fixation and broadening the screw canal,which cand hinder the blood supply of femoral head,will enhance the rate of femoral head necrosis.As a result,it needs prudent consideration to remove internal fixation after internal fixation with DHS combined with anti-rotation screw for femoral neck fractures.When it is difficult to remove the anti-rotation screw,it is better to give up,rather than to force a removal.