Neoadjuvant nivolumab plus chemotherapy in resectable non-small-cell lung cancer in Japanese patients from CheckMate 816.

In the open-label, phase III CheckMate 816 study (NCT02998528), neoadjuvant nivolumab plus chemotherapy demonstrated statistically significant improvements in event-free survival (EFS) and pathological complete response (pCR) versus chemotherapy alone in patients with resectable non-small-cell lung cancer (NSCLC). Here we report efficacy and safety outcomes in the Japanese subpopulation. Patients with stage IB-IIIA, resectable NSCLC were randomized 1:1 to nivolumab plus chemotherapy or chemotherapy alone for three cycles before undergoing definitive surgery within 6 weeks of completing neoadjuvant treatment. The primary end-points (EFS and pCR) and safety were assessed in patients enrolled at 16 centers in Japan. Of the Japanese patients randomized, 93.9% (31/33) in the nivolumab plus chemotherapy arm and 82.9% (29/35) in the chemotherapy arm underwent surgery. At 21.5 months' minimum follow-up, median EFS was 30.6 months (95% confidence interval [CI], 16.8-not reached [NR]) with nivolumab plus chemotherapy versus 19.6 months (95% CI, 8.5-NR) with chemotherapy; hazard ratio, 0.60 (95% CI, 0.30-1.24). The pCR rate was 30.3% (95% CI, 15.6-48.7) versus 5.7% (95% CI, 0.7-19.2), respectively; odds ratio, 7.17 (95% CI, 1.44-35.85). Grade 3/4 treatment-related adverse events were reported in 59.4% versus 42.9% of patients, respectively, with no new safety signals identified. Neoadjuvant nivolumab plus chemotherapy resulted in longer EFS and a higher pCR rate versus chemotherapy alone in Japanese patients, consistent with findings in the global population. These data support nivolumab plus chemotherapy as a neoadjuvant treatment option in Japanese patients with resectable NSCLC.

Endoscopic recannulation of long-segment, grade IV suprastomal tracheal stenosis: An operative technique.

BACKGROUND: Long-segment, grade IV suprastomal tracheal stenosis is rare and difficult to treat (Carpenter et al., 2022 [1]). Patients with grade IV stenosis have significant quality of life impairments since they are tracheostomy dependent and aphonic. Open airway surgery is often needed to improve tracheal patency, restore the patient's voice, and progress towards decannulation (Abouyared et al., 2017 [2]). However, not all patients are candidates for upfront open surgery (Abouyared et al., 2017; Shamji, 2018 [2,3]). Therefore, it is important to develop and refine endoscopic interventions to improve quality of life for these patients. METHODS: We describe a step-by-step endoscopic approach to the recannulation of long-segment, grade IV suprastomal tracheal stenosis. Briefly, our approach utilizes dual (proximal & distal) visualization of the stenosis prior to passing a 25 gauge needle through the stenosis to identify the proper trajectory for recannulation. Then a 16 gauge needle is passed in the same manner, and a wire is placed through the needle and into the distal airway. Once the airway is recannulated, the initial pinpoint opening is gradually widened in Seldinger fashion over the wire with Savary dilators followed by balloon dilation. Finally, a suprastomal L-stent (modified Montgomery T-Tube) is placed to reduce the risk of restenosis (Edwards et al., 2023 [4]). CASE DISCUSSION: A 39-year-old woman with a past medical history significant for poorly controlled type I diabetes mellitus and polysubstance abuse presented with tracheostomy dependence and aphonia. She was diagnosed with a long-segment, grade IV suprastomal tracheal stenosis and initially underwent endoscopic recannulation. This intervention restored her voice and allowed for optimization of her medical conditions before open airway surgery. CONCLUSION: Most patients experience a significant improvement in their quality of life as their voice is typically restored following this procedure. Additionally, individuals who eventually require open airway surgery gain additional time for medical optimization. In our experience, this procedure represents a safe and effective means of extending the utility of traditional endoscopic airway interventions for the management of patients with grade IV stenosis.

Durable benefit after treatment of obstructive benign prostatic hyperplasia with a novel drug-device combination product: 2-year outcomes from the EVEREST-I study.

PURPOSE: To evaluate the safety and efficacy of the Optilume BPH Catheter System for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). METHODS: This open-label, single-arm study enrolled eighty subjects with LUTS secondary to BPH who were treated with the Optilume BPH Catheter System. Symptoms were recorded utilizing the International Prostate Symptom Score (IPSS) and Benign Prostatic Hyperplasia Impact Index (BPH-II). Functional improvement was measured utilizing peak urinary flow rate (Qmax) and post-void residual urine volume (PVR). Adverse events were systematically captured and reported at each follow-up visit. RESULTS: Subjects treated with the Optilume BPH Catheter System experienced a significant improvement in LUTS from baseline through 2 years of follow-up, as measured by IPSS (22.3 vs 8.2, p < 0.001) and BPH-II (6.9 vs 2.3, p < 0.001). Functional improvement was also significant, with Qmax improving from an average of 10.9 mL/s at baseline to 17.2 mL/s at the 2-year follow-up and PVR improving from 63.1 to 45.0 mL. Treatment-related adverse events were typically minor, with none occurring between 1- and 2-year post-treatment. CONCLUSIONS: The Optilume BPH Catheter System is a unique minimally invasive surgical therapy that combines mechanical and pharmaceutical aspects for the treatment of BPH. The functional and symptomatic improvements seen after treatment are significant and have been sustained through 2 years in this early feasibility study. REGISTRATION: NCT03423979, registered February 6, 2018.

Efficacy of minimally invasive proximal gastrectomy followed by valvuloplastic esophagogastrostomy using the double flap technique in preventing reflux oesophagitis.

BACKGROUND: Valvuloplastic esophagogastrostomy (VEG) using the double flap technique (DFT) after proximal gastrectomy (PG) represents a promising procedure for the prevention of reflux oesophagitis. We aimed to retrospectively investigate the efficacy of minimally invasive PG followed by VEG-DFT in preventing reflux oesophagitis among patients who require intra-mediastinal anastomosis. METHODS: A total of 80 patients who underwent reconstruction with DFT after LPG from November 2013 to January 2021 were enrolled in the present study. Data were obtained through a review of our prospectively maintained database. At 1 year after surgery, multivariate analyses were performed to identify risk factors for gastroesophageal reflux disease of Los Angeles (LA) classification grade B or higher. RESULTS: The incidence of LA grade B or higher reflux oesophagitis 1 year after surgery was 10%. Multivariate analyses revealed that the longitudinal length of the resected oesophagus of > 20 mm was the only significant risk factor for reflux oesophagitis. Patients with a longitudinal length of the resected oesophagus > 20 mm (group-L, n = 35) had a significantly longer total operative time and a higher rate of complications within 30 days of surgery than those with a length of ≤ 20 mm (group-S, n = 45). LA grade B or higher reflux oesophagitis was significantly higher in group-L than in group-S (20% vs. 2.2%; P = 0.011). CONCLUSIONS: There is a need for surgical procedures with improved efficacy for the prevention of reflux oesophagitis in patients requiring oesophageal resection of > 20-mm.

First human surgery using a surgical assistance robotics device for laparoscopic cholecystectomies.

BACKGROUND: Over the past 20 years, surgeons involved in soft tissue minimally invasive surgery have experienced the pros and cons of both conventional and tele-robotic laparoscopic approaches. The Maestro System, developed by Moon Surgical (Paris, France) aims to overcome the challenges inherent to both approaches thanks to a new concept that augments the surgeon's performance at the bedside during a laparoscopic procedure. METHODS: The current study aims to present the first human experience with laparoscopic cholecystectomy with the Maestro system on 10 patients. RESULTS: All ten procedures were completed successfully. No significant complications related to the use of the Maestro system werenoted. CONCLUSION: Our preliminary observations appear to support the benefits of the Maestro system in non-emergent laparoscopic cholecystectomies. It goes without saying that further research is necessary to demonstrate the safety of this approach in other procedures.

Implementation of minimally invasive Ivor Lewis esophagectomy: learning curve of a single high-volume center.

Open esophagectomy is considered to be the main surgical procedure in the world for esophageal cancer treatment. Implementing a new surgical technique is associated with learning curve morbidity. The objective of this study is to determine the learning curve based on anastomotic leakage (AL) after implementing minimally invasive Ivor Lewis esophagectomy (MI-ILE) in January 2015. All 257 patients who underwent MI-ILE in a single high-volume center between January 2015 and December 2020 were retrospectively included in this study. The learning curve was evaluated using the standard CUSUM analysis with an expected AL rate of 11%. Secondary outcome parameters were postoperative complications, textbook outcome, and lymph node yield divided by the year of operation. Hierarchical binary logistic regression analysis was used to check for potential confounding variables. The CUSUM analysis showed a learning curve of 179 cases. The mean AL rate decreased from 33.3% in 2015 to 9.5% in 2020 (P = 0.007). There was an increase in the mean lymph node yield from 21 in 2018 to 28 in 2019 (P < 0.001) and textbook outcome from 37.3% in 2015 to 66.7% in 2020 (P = 0.005). A newly implemented MI-ILE has a learning curve of 179 patients based on a reference AL rate of 11% using the CUSUM method. Whether future generation surgeons will show similar learning curve numbers, implicating continuous development of different introduction programs of new techniques, will have to be the focus of future research.

Fusion and patient-reported outcomes after navigated decortication and direct arthrodesis in minimally invasive sacroiliac joint fusion using cylindrical threaded implants: a case series and literature review.

OBJECTIVE: Sacroiliac joint (SIJ) dysfunction is a significant cause of back pain. Despite recent advances in minimally invasive (MIS) SIJ fusion, the fusion rate remains controversial. This study sought to demonstrate that a navigated decortication and direct arthrodesis technique in MIS SIJ fusion would result in satisfactory fusion rates and patient-reported outcomes (PROs). METHODS: The authors retrospectively reviewed consecutive patients who underwent MIS SIJ fusion from 2018 to 2021. SIJ fusion was performed using cylindrical threaded implants and SIJ decortication employing the O-arm surgical imaging system and StealthStation. The primary outcome was fusion, evaluated using CT at 6, 9, and 12 months postoperatively. Secondary outcomes included revision surgery, time to revision surgery, visual analog scale (VAS) score for back pain, and the Oswestry Disability Index (ODI), measured preoperatively and 6 and 12 months postoperatively. Patient demographics and perioperative data were also collected. PROs over time were analyzed using ANOVA followed by a post hoc analysis. RESULTS: One hundred eighteen patients were included in this study. The mean (± SD) patient age was 58.56 ± 13.12 years, and most patients were female (68.6% vs 31.4% male). There were 19 smokers (16.1%) with an average BMI of 29.92 ± 6.73. One hundred twelve patients (94.9%) underwent successful fusion on CT. The ODI improved significantly from baseline to 6 months (Δ7.73, 95% CI 2.43-13.03, p = 0.002) and from baseline to 12 months (Δ7.54, 95% CI 1.65-13.43, p = 0.008). Similarly, VAS back pain scores improved significantly from baseline to 6 months (Δ2.31, 95% CI 1.07-3.56, p < 0.001) and from baseline to 12 months (Δ1.63, 95% CI 0.25-3.00, p = 0.015). CONCLUSIONS: MIS SIJ fusion with navigated decortication and direct arthrodesis was associated with a high fusion rate and significant improvement in disability and pain scores. Further prospective studies examining this technique are warranted.

Interim safety analysis of the first-in-human clinical trial of the Versius surgical system, a new robot-assisted device for use in minimal access surgery.

OBJECTIVE: The aim of this study was to provide an interim safety analysis of the first 30 surgical procedures performed using the Versius Surgical System. BACKGROUND: Robot-assisted laparoscopy has been developed to overcome some of the important limitations of conventional laparoscopy. The new system is currently undergoing a first-in-human prospective clinical trial to confirm the safety and effectiveness of the device when performing minimal access surgery (MAS). METHODS: Procedures were performed using Versius by a lead surgeon supported by an operating room (OR) team. Male or female patients aged between 18 and 65 years old and requiring elective minor or intermediate gynaecological or general surgical procedures were enrolled. The primary endpoint was the rate of unplanned conversion of procedures to other MAS or open surgery. RESULTS: The procedures included nine cholecystectomies, six robot-assisted total laparoscopic hysterectomies, four appendectomies, five diagnostic laparoscopy cases, two oophorectomies, two fallopian tube recanalisation procedures, an ovarian cystectomy and a salpingo-oophorectomy procedure. All procedures were completed successfully without the need for conversion to MAS or open surgery. No patient returned to the OR within 24 h of surgery and readmittance rate at 30 and 90 days post-surgery was 1/30 (3.3%) and 2/30 (6.7%), respectively. CONCLUSIONS: This first-in-human interim safety analysis demonstrates that the Versius Surgical System is safe and can be used to successfully perform minor or intermediate gynaecological and general surgery procedures. The cases presented here provide evidence that the Versius clinical trial can continue to extend recruitment and begin to include major procedures, in alignment with the IDEAL-D Framework Stage 2b: Exploration.

Complete Aortic Endovascular Repair.

Patients unfit for open repair after development a postdissection aortic arch and thoraco-abdominal aneurysm after open ascending aortic replacement for type A dissection would have no other treatment options. We report the case of a 75-year-old man with a type A aortic dissection treated by ascending aortic replacement. The patient presented an enlargement of the downstream aorta and thoraco-abdominal aneurysm 6-months after. This patient underwent a three-stage surgical sessions, open surgery for extraanatomical supra-aortic trunks reconstruction, endovascular branched treatment of ascending, arch and descending aorta and another one to perform an endovascular fenestrated reconstruction of thoraco-abdominal and infrarenal aorta.

Proposal for a revised system for classifying difficulty of laparoscopic partial liver resection.

PURPOSE: The aim of this retrospective study was to evaluate a revised classification system for predicting the difficulty of laparoscopic partial liver resection. METHODS: Patients who had undergone initial laparoscopic partial liver resection for a solitary lesion from January 2012 to February 2021were classified into two groups according to the type of procedure performed, "scooping-out" versus "cutting." The participants were then further divided into "small" and "large" subgroups according to the tumor's depth and diameter. Finally, they were categorized into two groups, namely "standard" and "advanced." Operative outcomes were compared between the two groups and the proposed revised system for classifying difficulty of laparoscopic partial liver resection compared with the existing scoring system. RESULTS: Of the 65 procedures assessed, 40 were categorized as standard and 25 as advanced. Tumor size (P < 0.001), operation time (P < 0.001), volume of intraoperative blood loss (P = 0.001), rate of the Pringle maneuver (P = 0.044), and resected liver weight (P < 0.001) were significantly greater in the advanced than in the standard group. Differences in operation time and intraoperative blood loss were not identified by the existing difficulty scoring system. CONCLUSION: The proposed revised classification is useful for predicting the difficulty of laparoscopic partial liver resection.

Improvement in distal pancreatectomy for tumors in the body and tail of the pancreas.

BACKGROUND: Pancreatic resections are complex and technically challenging surgical procedures. They often come with potential limitations to high-volume centers. Distal pancreatectomy is a relatively simple procedure in most cases. It facilitates the development of up-to-date minimally invasive surgical procedures in pancreatic surgery including laparoscopic distal pancreatectomy and robot-assisted distal pancreatectomy. MAIN BODY: To obtain a desirable long-term prognosis, R0 resection and adequate lymphadenectomy are crucial to the surgical management of pancreatic cancer, and they demand standard procedure and multi-visceral resection if necessary. With respect to combined organ resection, progress has been made in evaluating and determining when and how to preserve the spleen. The postoperative pancreatic fistula, however, remains the most significant complication of distal pancreatectomy, with a rather high incidence. In addition, a safe closure of the pancreatic remnant persists as an area of concern. Therefore, much efforts that focus on the management of the pancreatic stump have been made to mitigate morbidity. CONCLUSION: This review summarized the historical development of the techniques for pancreatic resections in recent years and describes the progress. The review eventually looked into the controversies regarding distal pancreatectomy for tumors in the body and tail of the pancreas.

Comparative outcomes of robot-assisted minimally invasive versus open esophagectomy in patients with esophageal squamous cell carcinoma: a propensity score-weighted analysis.

Robots are increasingly used in minimally invasive surgery. We evaluated the clinical benefits of robot-assisted minimally invasive esophagectomy (RAMIE) in comparison with the conventional open esophageal surgery. From 2012 to 2016, 371 patients with esophageal squamous cell carcinoma underwent an Ivor Lewis or McKeown procedure at our institution. Of these, 130 patients underwent laparoscopic gastric conduit formation followed by RAMIE, whereas 241 patients underwent conventional esophageal surgery, including laparotomy and open esophagectomy (OE). We compared the short- and long-term clinical outcomes of these patients using the propensity score-based inverse probability of treatment weighting technique (IPTW). Among the early outcomes, the OE group showed a higher incidence of pneumonia (P = 0.035) and a higher requirement for vasopressors (P = 0.001). Regarding the long-term outcomes, all-cause mortality was significantly higher (P = 0.001) and disease-free survival was lower (P = 0.006) in the OE group. Wound-related problems also occurred more frequently in the OE group (P = 0.020) during the long-term follow-up. There was no statistical intergroup difference in the recurrence rates (P = 0.191). The Cox proportional-hazard analysis demonstrated that wound problems (HR 0.16, 95% CI 0.02-0.57; P = 0.017), pneumonia (HR 0.23, 95% CI 0.06-0.68; P = 0.019), and use of vasopressors (HR 0.14, 95% CI 0.08-0.25; P = 0.001) were independent predictors of mortality. RAMIE could be a better surgical option for selected patients with esophageal squamous cell carcinoma.

Transoral endoscopic thyroid surgery using robotic scope holder: Our initial experiences.

BACKGROUND: : Transoral thyroid surgery represented by the da Vinci system is attracted attention and performed by several institutions. However, the current available da Vinci system still has some limitations to be improved for transoral thyroid surgery including high cost of equipment and expendables, larger diameter scope and instruments and no tactile sensation. It triggered us interest in more easily available robotic scope holder. Soloassist II (AktorMed GmbH, Barbing, Germany) is an active endoscope holder system which is controlled by a joystick. It has total six joints: three joints which are controlled by computer, one is controlled by manual and two act as a gimbal joint following the movement of the main body. MATERIALS AND METHODS: We tried transoral endoscopic thyroidectomy using Soloassist II (AktorMed GmbH, Barbing, Germany) in December 2017 in our hospital. RESULTS: We successfully performed four thyroid lobectomies in four patients with Soloassist II. We refined and described surgical procedures in each step using video clips. It provided an excellent vibration-free stable surgical view which enabled fatigue-free work, without shaking or tilting the horizon. The surgeon could perform transoral endoscopic thyroid surgery with only one assistant surgeon. Docking and preparation time for Soloassist was within 10 min in all four patients. The setup and dismantling could be performed parallel to the usual workflow. No complication was reported by any patient. CONCLUSIONS: : The robotic scope holder (Soloassist II) seems to be safe and feasible equipment for performing transoral endoscopic thyroid surgery. Several possible advantages could be expected with this robotic scope holder.

Transoral endoscopic thyroid surgery in a Korean population.

BACKGROUND: Transoral endoscopic thyroidectomy vestibular approach is expected to be a safe alternative to open surgery for certain patients and has been used increasingly by several surgeons around the world for the past 2 years. The purpose of this paper is to review our 2-year experience and describe in detail our preoperative considerations, patient selection, operating room settings, anesthetic considerations, surgical technique, postoperative management, and outcomes. METHODS: We reviewed the medical records of 65 consecutive patients who underwent transoral endoscopic thyroidectomy between July 2016 and May 2018 in our hospital. RESULTS: We have performed 65 thyroid surgeries (54 thyroid lobectomies, 1 completion thyroidectomy, and 10 total thyroidectomies) in 64 patients. Postoperative pathology revealed papillary carcinoma in 55 patients (84.6%), follicular carcinoma in two (3.1%), hyalinizing trabecular tumor in one (1.5%), and other benign tumor in seven (10.8%). All surgical margins were negative. Two (3.1%) patients developed transient vocal cord palsy but recovered within 2 months. One (1.5%) patient with vocal cord palsy had not recovered by 3 months after surgery. Five (7.7%) patients who underwent total thyroidectomy developed transient hypocalcemia but recovered within 2 months. CONCLUSION: Although transoral thyroid surgery is a relatively recent technique requiring further validation, it affords several advantages. Transoral thyroid surgery has not yet been universally accepted, but may be the best choice for thyroid surgery in the future.

Gasless transoral endoscopic thyroidectomy vestibular approach (gasless TOETVA).

BACKGROUND: The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been the subject of increasing interest from several institutions around the world over the last 2 years. Recently, we successfully performed TOETVA in live human patients without CO2 gas using our newly designed retractable blade. METHODS: We reviewed the medical records of 15 consecutive patients who underwent gasless TOETVA using a self-retaining retractor. RESULTS: We successfully performed 13 thyroid lobectomies and 2 total thyroidectomies in 15 patients. No patient exhibited serious postoperative complications such as recurrent laryngeal nerve palsy and permanent hypocalcemia. One patient developed transient hypocalcemia but recovered within 2 months. No patient developed a wound infection; furthermore, no visible scar or dimpling was evident on the neck of any patient. CONCLUSION: Gasless TOETVA provides enough working space and good visibility to perform thyroid surgery without any risk of CO2 gas-related complications.

Bilateral tubo-ovarian abscesses presenting with huge pelvic mass after repeated intrauterine inseminations in a woman with severe endometriosis.

A 32-year-old woman consulted for an evaluation of pelvic pain following intrauterine insemination (IUI). Vaginal and abdominal sonography, septic workup were performed and laparoscopic surgery was scheduled after failure to respond to a course of antibiotics. During laparoscopic surgery, bilateral tubo-ovarian abscesses arising on the endometriotic cysts of both ovaries were identified with a vast amount of brownish peritoneal fluid under the adhesion of the greater omentum. Bilateral ovarian cystectomy, right salpingectomy and lysis adhesion were performed. Pathologic organisms were not detected in any of the specimen cultures. Pelvic infection is an uncommon complication following IUI. Endometriosis might be a risk factor predisposing the pelvic organ to be susceptible to such infection. Performing IUI in a patient with endometriosis should be done with great vigilance.

Endoscopic surgery of spontaneous basal ganglionic hemorrhage.

INTRODUCTION: Although there are controversies about the optimal management of spontaneous intracerebral hemorrhage (ICH), benefits of endoscopic procedures in ICH have been reported. This study is aimed to evaluate the result of 270 patients undergoing endoscopic treatment of ICH. METHODS: This was a retrospective study from July 2008 to June 2017. All procedures were done with the endoscopic technique using a tubular retractor. Patients with the hematoma volume between 30 to 80 ml, with the Glasgow Coma Scale (GCS) between 5 to 14, and evidence of severe mass effect, were included in the study. RESULTS: The average stay in the intensive care unit was 6 days (range 1-17 days). The median pre-operative midline shift of 8.3 mm was reduced to 2.7 mm after surgery. The average hematoma removal ratio, the duration of surgery, and the blood loss was 90%, 90 min, and 60 ml, respectively. There was improvement in the average pre-operative GCS from 9.4 to 11.3 at seventh post-operative day. The post-operative mortality rate was 10.7%. A good outcome was observed in 71% patients at 6 months after surgery. Larger the volume of hematoma, more the operative time, more the pre-operative midline shift, and poorer the GCS, significantly higher was the association with mortality. The patients with a better pre-operative GCS were associated with a better Glasgow Outcome Score. The follow-up period ranged from 7 to 115 months. CONCLUSION: Endoscopic surgery with the help of a tubular retractor was effective and safe. It allowed for a good visualization of the hematoma and the surrounding brain, and helped in proper hemostasis. The hematoma may also be removed with the help of the microscope and the tubular retractor, in case any difficulty during the endoscopic technique is encountered.

Robotic surgery for upper gastrointestinal cancer: Current status and future perspectives.

Robotic surgery with the da Vinci Surgical System has been increasingly applied in a wide range of surgical specialties, especially in urology and gynecology. However, in the field of upper gastrointestinal (GI) tract, the da Vinci Surgical System has yet to be standard as a result of a lack of clear benefits in comparison with conventional minimally invasive surgery. We have been carrying out robotic gastrectomy and esophagectomy for operable patients with resectable upper GI malignancies since 2009, and have demonstrated the potential advantages of the use of the robot in possibly reducing postoperative local complications including pancreatic fistula following gastrectomy and recurrent laryngeal nerve palsy after esophagectomy, even though there have been a couple of problems to be solved including longer duration of operation and higher cost. The present review provides updates on robotic surgery for gastric and esophageal cancer based on our experience and review of the literature.

MDT lung cancer care: input from the Surgical Oncologist.

Although there have been many advancements in the multidisciplinary management of non-small cell lung cancer (NSCLC), surgery remains the primary modality of choice for resectable lung cancer when the patient is able to tolerate lung resection physiologically. There have been recent advances in surgical diagnosis and treatment of lung cancer. Increasing use of low-dose computed tomography (CT) screening for lung cancer has resulted in increased detection of small peripheral nodules or semi-solid ground glass opacities. Here, we review different modalities of localization techniques that have been used to aid surgical excisional biopsy when needle biopsy has failed to provide tissue diagnosis. We also report on the current debates regarding the use of sublobar resections for Stage I NSCLC as well as the surgical management of locally advanced NSCLC. Finally, we discuss the complex surgical management of T4 NSCLC lung cancers.

Advantages of laparoscopy in gynecologic surgery in elderly patients.

OBJECTIVE: Geriatric patients requiring gynecological surgery is increasing worldwide. However, older patients are at higher risk of postoperative morbidity and mortality, particularly cardiopulmonary complications. Laparoscopic surgery is widely used as a minimally invasive method for reducing postoperative morbidities. We compared the outcomes of open and laparoscopic gynecologic surgeries in patients older than 55 years. METHODS: We included patients aged >55 years who underwent gynecological surgery at a single tertiary center between 2010 and 2020, excluding vaginal or ovarian cancer surgeries were excluded. Surgical outcomes were compared between the open surgery and laparoscopic groups, with age cutoff was set at 65 years for optimal discriminative power. We performed linear or logistic regression analyses to compare the surgical outcomes according to age and operation type. RESULTS: Among 2,983 patients, 28.6% underwent open surgery and 71.4% underwent laparoscopic surgery. Perioperative outcomes of laparoscopic surgery were better than those of open surgery in all groups. In both the open and laparoscopic surgery groups, the older patients showed worse overall surgical outcomes. However, age-related differences in perioperative outcomes were less severe in the laparoscopic group. In the linear regression analysis, the differences in estimated blood loss, transfusion, and hospital stay between the age groups were smaller in the laparoscopy group. Similar restuls were observed in cancer-only and benign-only cohorts. CONCLUSION: Although the surgical outcomes were worse in the older patients, the difference between age groups was smaller for laparoscopic surgery. Laparoscopic surgery offers more advantages and safety in patients aged >65 years.