The phase angle as a predictor of postoperative complications in patients undergoing lung cancer surgery.

PURPOSE: The phase angle (PhA), calculated by bioelectrical impedance analysis, is used as a nutritional risk indicator. A low preoperative PhA has been reported as a marker of postoperative complications in patients with cancer; however, the relationship between the PhA and postoperative complications in patients with lung cancer remains unknown. We conducted this study to assess the predictive ability of the preoperative PhA for postoperative complications in patients undergoing surgery for primary lung cancer. METHODS: We reviewed the data on 240 patients who underwent surgery for primary lung cancer at our institution between August, 2019 and August, 2021. RESULTS: The PhA value in this study was 4.7 ± 0.7°. According to the Clavien-Dindo classification, grade ≥ II postoperative complications occurred in 53 patients (22.0%). Based on the multivariate logistic analysis, only the PhA (odds ratio, 0.51, 95% confidence interval, 0.29-0.90, p = 0.018) was an independent predictor of Clavien-Dindo grade ≥ II postoperative complications. CONCLUSIONS: The PhA may be a valuable marker for predicting the risk of postoperative complications following lung cancer surgery.

γH2AX, a DNA Double-Strand Break Marker, Correlates with PD-L1 Expression in Smoking-Related Lung Adenocarcinoma.

In recent years, the choice of immune checkpoint inhibitors (ICIs) as a treatment based on high expression of programmed death-ligand 1 (PD-L1) in lung cancers has been increasing in prevalence. The high expression of PD-L1 could be a predictor of ICI efficacy as well as high tumor mutation burden (TMB), which is determined using next-generation sequencing (NGS). However, a great deal of effort is required to perform NGS to determine TMB. The present study focused on γH2AX, a double-strand DNA break marker, and the suspected positive relation between TMB and γH2AX was investigated. We assessed the possibility of γH2AX being an alternative marker of TMB or PD-L1. One hundred formalin-fixed, paraffin-embedded specimens of lung cancer were examined. All of the patients in the study received thoracic surgery, having been diagnosed with lung adenocarcinoma or squamous cell carcinoma. The expressions of γH2AX and PD-L1 (clone: SP142) were evaluated immunohistochemically. Other immunohistochemical indicators, p53 and Ki-67, were also used to estimate the relationships of γH2AX. Positive relationships between γH2AX and PD-L1 were proven, especially in lung adenocarcinoma. Tobacco consumption was associated with higher expression of γH2AX, PD-L1, Ki-67, and p53. In conclusion, the immunoexpression of γH2AX could be a predictor for the adaptation of ICIs as well of as PD-L1 and TMB.

Honeycomb lung is a major risk factor for preoperative radiological tumor size underestimation in patients with primary lung cancer.

Background: Lung cancer frequently occurs in lungs with background idiopathic interstitial pneumonias (IIPs). Limited resection is often selected to treat lung cancer in patients with IIPs in whom respiratory function is already compromised. However, accurate surgical margins are essential for curative resection; underestimating these margins is a risk for residual lung cancer after surgery. We aimed to investigate the findings of lung fields adjacent to cancer segments affect the estimation of tumor size on computed tomography compared with the pathological specimen. Methods: This analytical observational study retrospectively investigated 896 patients with lung cancer operated on at Fujita Health University from January 2015 to June 2020. The definition of underestimation was a ≥10 mm difference between the radiological and pathological maximum sizes of the tumor. Results: The lung tumors were in 15 honeycomb, 30 reticulated, 207 emphysematous, and 628 normal lungs. The ratio of underestimation in honeycomb lungs was 33.3% compared to 7.4% without honeycombing (P=0.004). Multivariate analysis showed that honeycombing was a significant risk factor for tumor size underestimation. A Bland-Altman plot represented wide 95% limits of agreement, -40.8 to 70.2 mm, between the pathological and radiological maximum tumor sizes in honeycomb lungs.

Tracheobronchial reconstruction by inverted Barclay's method for tracheobronchial injury in an 8-year-old girl: a case report.

BACKGROUND: Tracheobronchial injury in children is rare but can be highly fatal in severe cases. Therefore, prompt diagnosis and treatment are required. The appropriate treatment method depends on the extent and severity of the injury. CASE PRESENTATION: An 8-year-old girl fell from the fifth floor and was transported to a local hospital. She had a tracheobronchial injury, went into cardiopulmonary arrest during transportation to our hospital. She was revived with cardiopulmonary resuscitation, and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was commenced. Subsequently, we performed tracheobronchial reconstruction by inverted Barclay's method for tracheobronchial injury. She was switched from VA-ECMO to venovenous (VV)-ECMO 4 days postoperatively, and VV-ECMO was eventually discontinued 27 days after the surgery. The patient was awake and weaned off the ventilator on postoperative day 58. She was discharged 97 days after the surgery. CONCLUSIONS: Tracheobronchial reconstruction by inverted Barclay's method is the preferred surgical technique when other reconstruction techniques are expected to cause excessive tension on the anastomosis of the right main bronchus.

Evaluation of prognosis after thoracoscopic lobectomy for primary lung cancer.

INTRODUCTION: Thoracoscopic lobectomy for primary lung cancer is performed at many institutions. However, few reports are available on postoperative prognosis for progressive stages. In 2004, we adopted lobectomy by video-assisted thoracoscopic surgery (VATS), which would be applicable to the clinical stages up to stage IIIA. This study reports long-term outcomes of surgery for primary lung cancer at several stages, including IIIA. METHODS: We compared the long-term outcomes of 315 VATS cases with those of 159 open thoracotomy cases. RESULTS: The overall 5-year survival rate was 78.1% for the VATS group and 61.9% for the open thoracotomy group. A statistically significant difference between the survival curves of the two groups was observed (P = .001). When analyzing the survival curves for both groups by pathological (p) stage, significant differences were observed for p-stages IB and IIIA, with the VATS group producing better results than the open thoracotomy group. CONCLUSION: The long-term outcomes of patients with primary lung cancer at our institution were more favorable in the group undergoing VATS lobectomy than in the group undergoing open thoracotomy.

Uniportal video-assisted thoracic surgery lowers the incidence of post-thoracotomy pain syndrome.

OBJECTIVE: We compared post-thoracotomy pain syndrome (PTPS) incidence in patients who underwent uniportal or multiportal video-assisted thoracoscopic surgery (VATS). METHODS: We included 223 patients who underwent either uniportal or multiportal VATS between January 2017 and October 2018 (pulmonary lobectomies and pulmonary segmentectomies-uniportal: n=19, multiportal: n=133; wedge lung resections-uniportal: n=16, multiportal: n=55). We retrospectively studied incidences of PTPS in all subgroups. RESULTS: Incidences of PTPS were significantly less for uniportal procedures for both the pulmonary lobectomy/segmentectomy group (P=0.024) and the wedge lung resection group (P=0.0315) than for multiportal procedures. CONCLUSION: Patients who underwent uniportal VATS procedures had lower incidences of PTPS than the multiportal VATS group. The uniportal VATS approach is therefore beneficial for patients.

Early outcomes in 147 consecutive cases of subxiphoid single-port thymectomy and evaluation of learning curves.

OBJECTIVES: The aim of the present study was to examine some initial results and learning curves concerning subxiphoid single-port thymectomy (SSPT), thereby clarifying the safety of this surgical approach and describing the precautions for adopting it. METHODS: From March 2011 to August 2019, a total of 203 patients underwent thymectomy for either anterior mediastinal tumours or myasthenia gravis at Fujita Health University Hospital. Of these 203 patients, 147 patients who had undergone SSPT were selected as participants for the present study. RESULTS: Of the 147 cases, transition to a different approach was required in three (2.0%) cases: two (1.3%) cases transitioned to median sternotomy, whereas one (0.7%) case transitioned to the side chest trans-intercostal approach. The two cases that transitioned to median sternotomy were the second cases for different operators after they began performing this technique. There were six (4.0%) cases with complications and no deaths. The operation time cumulative summation learning curve analysis revealed that the curves descended from the 38th case. In the 83 cases handled by one surgeon, the learning curves descended from the 31st case. CONCLUSIONS: SSPT is a safe modality with few complications and no associated cases of mortality reported. Operators are required to experience 31-38 cases until the operation time for SSPT was stabilized. Special care should be exercised to prevent vascular damage in the vicinity of the innominate veins during the early stages after SSPT introduction.

Prediction of pulmonary function after major lung resection using lung perfusion scintigraphy with single-photon emission computed tomography/computed tomography.

OBJECTIVE: Precise prediction of postoperative pulmonary function is extremely important for accurately evaluating the risk of perioperative morbidity and mortality after major surgery for lung cancer. This study aimed to compare the accuracy of a single-photon emission computed tomography/computed tomography (SPECT/CT) method that we recently developed for predicting postoperative pulmonary function versus the accuracy of both the conventional simplified calculating (SC) method and the method using planar images of lung perfusion scintigraphy. METHODS: The relationship between the postoperative observed % values of the forced expiratory volume in 1 second (FEV1) or diffusing capacity for carbon monoxide (DLCO or DLCO') and the % predicted postoperative (%ppo) values of FEV1, DLCO, or DLCO' calculated by the three methods were analyzed in 30 consecutive patients with lung cancer undergoing lobectomy. RESULTS: The relationship between the postoperative observed % values and %ppo values calculated by the three methods exhibited a strong correlation (Pearson r>0.8, two-tailed p<0.0001). The limits of agreement between the postoperative % values and %ppo values did not differ among the three methods. The absolute values of the differences between the postoperative % values and %ppo values for FEV1 and DLCO' were comparable among the three methods, whereas those for DLCO of SPECT/CT were significantly higher than those of the planar method. Conversely, in patients with preoperative %DLCO' of <80% predicted, the absolute values of the differences between the postoperative %DLCO' and %ppoDLCO' of SPECT/CT tended to be smaller than those of the SC and planar methods. CONCLUSION: The accuracy of SPECT/CT for predicting postoperative pulmonary function is comparable with that of conventional methods in most cases, other than in some patients with diffusion impairment.

Video-assisted thoracoscopic surgery for ectopic mediastinal parathyroid tumor: subxiphoid and lateral thoracic approach.

BACKGROUND: This study aimed to investigate the initial results of an endoscopic surgical approach for the treatment of intramediastinal ectopic parathyroid adenoma and to evaluate the effectiveness of a single-incision resection using the subxiphoid approach. METHODS: Five cases of patients (1.89%) were diagnosed with ectopic mediastinal parathyroid tumor and underwent resection from 2008 to 2017 in Fujita Health University Hospital. They were retrospectively analyzed. RESULTS: Four patients underwent single-port mediastinal tumor resection using the subxiphoid approach and 1 patient underwent multi-port mediastinal tumor resection using the lateral thoracic approach. The operation time was 134±83.52 min, and the amount of blood loss was 81.8±173.41 mL. The rate of conversion to thoracotomy was 0%, and no intraoperative or postoperative complications were observed. The amount of postoperative oral analgesics was 112.83±209.12 tablets, and their administration period was 561.6±1,229.5 days. The length of hospital stay was 4±2.35 days, and the duration of chest tube drainage was 1.33±1.95 days. The patient who underwent multi-port mediastinal tumor resection using the lateral thoracic approach reported postoperative pain. Serum calcium levels decreased from 10.56±1.52 mg/dL preoperatively to 8.96±0.5 mg/dL postoperatively, and serum phosphorous levels increased from 2.84±0.42 mg/dL preoperatively to 3.6±0.51 mg/dL postoperatively. Intact-PTH hormone levels decreased from 221±169.84 pg/dL preoperatively to 70.2±44.28 pg/dL postoperatively. No recurrence of hyperparathyroidism has been observed in any patient. CONCLUSIONS: The single-incision mediastinal tumor resection via the subxiphoid approach, without going through the intercostal space, is considered as a useful endoscopic surgical approach for the treatment of mediastinal ectopic parathyroid adenomas due to the limited occurrence of post-thoracotomy pain syndrome and the superior esthetic outcomes associated with the procedure as compared to thoracotomy and median sternotomy.