General Thoracic and Cardiovascular Surgery最新文献

Background: Pulmonary sequestration (PS) is a rare congenital lung malformation often requiring surgical resection due to recurrent infections or hemoptysis. Traditionally treated via open thoracotomy, recent advancements have made minimal-invasive approaches like robotic-assisted thoracoscopic surgery (RATS) increasingly viable. This study compares outcomes between RATS and open resection for PS in a high-volume center.

Methods: In this retrospective cohort study, 23 adult patients who underwent surgical resection of PS between 2010 and 2023 were analyzed. Fifteen patients were treated via open thoracotomy (THKT), while eight underwent RATS using the DaVinci-X system. We compared preoperative findings, intraoperative variables, and postoperative outcomes.

Results: The patients in the RATS group were younger (median age: 36 vs 47 years) and had a shorter median hospital stay (5 vs 10 days, p < 0.001) compared to the THKT group. The RATS group also experienced earlier chest drainage removal (3 vs. 4 days, p = 0.016). However, the median duration of surgery was longer for RATS (118 vs. 75 min, p = 0.018). A trend towards less postoperative complications was observed in the RATS group (33% vs. 0%).

Conclusions: RATS provides a safe and effective alternative to open surgery for PS resection, with benefits including reduced hospital stay and earlier chest tube removal. Despite longer operative times, the minimally invasive approach may offer enhanced recovery and fewer complications. Continued accumulation of experience with RATS is likely to improve operative efficiency, making it a valuable option in the surgical management of pulmonary malformations.

Objective: Ascending aortic length (AAL) has recently garnered attention as an additional parameter of surgical indication. This study aimed to verify that AAL is extended in ascending aortic aneurysm patients when compared with the normal aorta.

Methods: The study included 132 patients who were diagnosed with true ascending aortic aneurysms from January 2002 to December 2021. The AAL was measured as the distance from the aortic annulus to the origin of the innominate artery. The data of 295 patients who underwent transcatheter aortic valve replacement during same period were compiled as the control group. In order to index AAL, it was divided by the patient's height (Length height index, LHI).

Results: The mean ascending aortic diameter (AAD) and AAL in the 132 patients were 5.3 ± 0.6 cm and 11.7 ± 1.6 cm, respectively. Propensity score matching revealed a significantly longer AAL in the aortic aneurysm group than in the control group (11.7 vs. 8.8 cm, P < 0.05). The LHI in the aortic aneurysm group was significantly greater than in the control group (7.4 vs. 5.7 cm/m, P < 0.05). The relationship between AAD and LHI was analyzed using linear regression analysis. The regression coefficient was 0.59, and the intercept was 4.22. As a tool to predict LHI, the formula: LHI = 0.59 × AAD + 4.22 was obtained.

Conclusions: AAL and LHI were significantly increased in patients with ascending aortic aneurysms. Consequently, LHI may serve as an accurate indicator of surgical intervention.

This letter critically examines the recent article by Takei et al., which proposed the velocity ratio (VR) as the most reliable intraoperative echocardiographic indicator for bilateral pulmonary artery banding (BPAB). While this study represents a valuable step toward standardization, its heavy reliance on VR risks overlooking crucial hemodynamic variables. Drawing upon previous literature, this commentary highlights methodological limitations, clinical implications, and the necessity of integrating multiple echocardiographic and hemodynamic parameters. We advocate for a more comprehensive approach that ensures both systemic and pulmonary circulatory stability in congenital heart disease patients.

Background: Minimally invasive techniques have mostly replaced open thoracotomy for lung resection, yet their comparative benefits remain unclear. We performed a systematic review and meta-analysis to evaluate clinical outcomes associated with robot-assisted (RATS) and video-assisted thoracic surgery (VATS).

Methods: We searched PubMed, Embase, and Cochrane Central for randomized controlled trials (RCTs) comparing RATS to VATS in patients undergoing lung resection. Primary outcomes were conversion to thoracotomy and overall complications. Risk ratios (RR) and mean differences (MD) were used for categorical and continuous outcomes, respectively, considering as significant p-values < 0.05. Trial sequential analysis was also conducted.

Results: We included five RCTs comprising 712 patients, of whom 338 (47.5%) underwent RATS, and 374 (52.5%) underwent VATS. No differences were found between groups in conversion to thoracotomy (RR 0.65; 95% CI 0.36-1.20; p = 0.17) and overall complications (RR 0.91; 95% CI 0.69-1.21; p = 0.49). RATS presented a higher number of lymph node stations resected (p < 0.00001) and a shorter length of hospital stay after performing sensitivity analysis (p < 0.00001). There were no differences between RATS and VATS in any of the other secondary outcomes.

Conclusion: Our study results reassure the safety and potential benefits associated with RATS lung resections, demonstrating a significantly higher number of lymph node stations resected and a possible trend toward shorter hospital stays, with similar rates of complications and conversion in comparison to VATS.

Purpose: We sought to understand how centers transplanting liver only (L0), centers transplanting heart and liver (LH), and centers transplanting liver, heart, and lung (LHL) differ regarding volume, waitlist and post-transplant outcomes.

Methods: Data were collected from the Scientific Registry of Transplant Recipients (SRTR) in July 2023. SRTR star ratings were categorized into five tiers, with one being the lowest tier and five the highest tier.

Results: Median liver transplant volumes were 35 [IQR: 14-51] for L0 centers, 45 [10-75] for LH centers, and 101 [69-131] for LHL centers (p < 0.001). Liver waitlist survival (p = 0.13), waitlist duration (p = 0.31) and 1-year survival ratings (p = 0.32) were comparable across all 3 categories. Annual transplant volume was associated with a higher SRTR waitlist duration rating (p < 0.001) but not with 1-year post-transplant survival (p = 0.51).

Conclusion: The presence of a heart transplant and lung transplant programs in liver transplant centers is associated with higher liver transplant volumes, translating to higher waitlist duration tier ratings for liver recipients, but not to improved 1-year post-transplant survival.

Background: The effect of erector spinae plane block and systemic lidocaine infusion for major thoracotomy is still unclear. Therefore, we aimed to compare ESPB, systemic lidocaine and standard analgesia in patients who undergoing major thoracotomy.

Methods: Patients with ASA I-III, aged between 18 and 65 years scheduled for major thoracotomy were enrolled. Patients were randomly assigned to receive an intravenous (IV) infusion of placebo combined with ESP block using placebo (group P), ESP block with 0.25% bupivacaine combined with IV placebo (group ESPB), or IV-lidocaine combined with ESP-block using placebo (group L). The primary outcome was postoperative (24 h) total opioid consumption. The secondary outcomes were VAS scores, rescue analgesia, and intraoperative remifentanil consumption.

Results: Resting VAS scores were significantly lower in both groups ESPB and L compared to group P during the first four postoperative hours. Similarly, dynamic VAS scores were lower in group ESPB and group L compared to group P during the first two postoperative hours (p < 0.05). ESP block was not found to be superior to systemic lidocaine in reducing morphine requirements during the first 24 h (30.25 ± 5.1 vs. 28.7 ± 3.1 respectively, p = 0.567). Additionally, the difference in morphine consumption between group P and either ESP-block or systemic lidocaine groups was minimal, amounting to only 3-4.5 mg. However, the requirement for rescue analgesia was significantly lower in both groups ESPB and L compared to group P (p < 0.05). There was no difference between groups ESPB and L in terms of rescue analgesia requirement.

Conclusion: ESP block did not demonstrate superior postoperative analgesic efficacy compared to systemic lidocaine in patients undergoing major thoracotomy.

Objective: This study aimed to elucidate the relationship between smoking extent and prognosis, imaging characteristics, and clinicopathological factors in patients with clinical stage I lung adenocarcinoma (c-stage I LDA).

Methods: We evaluated 2,285 patients who underwent surgical resection for c-stage I LDA between 2010 and 2018. Patients were classified into three groups based on the Brinkman Index (BI): never smokers (BI = 0), light smokers (0 < BI ≤ 600), and heavy smokers (BI > 600). Clinicopathological features and prognosis were analyzed according to smoking extent.

Results: Significant differences in overall survival (OS) were observed across the smoking groups. Heavy smokers exhibited more invasive imaging characteristics, including a larger solid proportion and a higher maximum standardized uptake value (SUVmax), compared to never and light smokers. In multivariable analyses, heavy smoking was significantly associated with poorer OS (hazard ratio [HR] 2.071, p < 0.001). In addition, older age (HR 1.111, p < 0 .001) and the presence of vascular invasion (HR 2.312, p < 0.001) were also associated with worse OS among heavy smokers.

Conclusion: Smoking extent was independently associated with poorer survival, larger solid tumor size, and higher SUVmax in patients with c-stage I LDA. Age and vascular invasion emerged as strong prognostic factors, particularly among heavy smokers.

Objective: Unilateral upper lung field pulmonary fibrosis (UPF) is a possible complication on the operated side after lung cancer surgery. However, its incidence and associated perioperative factors remain unclear. This study investigated the clinical characteristics of patients with unilateral UPF after primary lung cancer surgery.

Methods: We reviewed the records of all consecutive patients with lung cancer who underwent complete resection at the Institute of Science, Tokyo, between July 2010 and December 2021. We estimated the cumulative incidence and sub-hazard ratios using competing risk regression models.

Results: A total of 979 patients were included in this analysis. The median follow-up period up to the last follow-up was 59.2 months (interquartile range 37.0-84.6 months). With 39 (4.0%) cases of postoperative unilateral UPF, the median follow-up time until the diagnosis of unilateral UPF was 25.5 months (interquartile range 12.9-45.3 months), and the 3-, 5-, and 10-year cumulative incidences of unilateral UPF were 2.7%, 4.0%, and 5.4%, respectively. The 5-year overall survival rate was 87.3%; however, 30 of the 39 patients (76.9%) with unilateral UPF experienced subsequent complications related to unilateral UPF, such as progressive respiratory distress, progressive body weight loss, and pneumonia. Age > 75 years, male sex, low body mass index (< 20 kg/m²), ischemic heart disease, history of pneumonia, emphysema, pulmonary apical cap, and right lower lobe tumors are possible risk factors for unilateral UPF.

Conclusions: Unilateral UPF is an unrecognized late complication of lung cancer surgery that should be carefully monitored in patients with risk factors.

Purpose: We present a new approach for open surgical repair of giant aortoiliac (AI) aneurysms that prioritizes preservation of the hypogastric artery (HA). In cases where the aneurysm extends to the iliac bifurcation and involves both HAs, traditional open repair techniques often require an aortobifemoral bypass with HA exclusion, posing challenges for maintaining pelvic perfusion.

Methods: A retrospective analysis of 10 patients treated between 07/2021 and 07/2023 was conducted. The aneurysms extended to both HA in all cases. Patients were followed up at 30-day and in 6-month intervals thereafter. A total of 10 HA revascularization procedures were performed in 10 patients undergoing open surgical AI aneurysms repair (9 men and 1 woman; median age 68 [65; 70] years). Six-mm polyester grafts were used for aortic tube graft to HA bypass in 10 cases.

Results: Successful open surgical repair of giant AI aneurysms, including those involving the iliac bifurcation, was achieved in all cases. There was one case of perioperative myocardial infarction with pulmonary edema. No instances of gluteal claudication, colon ischemia, or perineal ischemia were observed. Eight patients reported no change in sexual function, while one patient experienced a reduction in erectile function. One patient died in the ICU 2 weeks postoperatively. During a follow-up period of 6-18 months, graft patency was maintained in nine patients.

Conclusion: An additional branch to the HA can reliably maintain pelvic circulation in the short to intermediate term, helping to prevent ischemia in patients requiring extended open surgical repair that involves both HAs.

Background: Neoadjuvant chemotherapy (NAC) is commonly administered to improve long-term survival in patients with locally advanced esophageal squamous cell carcinoma (ESCC). This study investigated the impact of perioperative skeletal muscle index (SMI), assessed by 3D imaging, on survival outcomes.

Methods: We retrospectively reviewed 139 ESCC patients who underwent surgical resection following NAC. SMI was measured pre- and post-NAC using 3D imaging. Patients were stratified into quartiles based on post-NAC SMI, and survival outcomes were evaluated.

Results: Patients in the lowest SMI quartile (Q1) were more likely to develop postoperative pneumonia and had significantly worse 3-year overall survival (OS) and relapse-free survival (RFS) compared with those in Q2-Q4 (P < 0.01). Multivariate analysis identified low SMI as an independent predictor of poor OS (HR: 3.22; 95% CI: 1.86-5.57; P < 0.01).

Conclusions: Low SMI after NAC, as assessed by 3D imaging, is an independent predictor of poor survival in ESCC patients. These findings highlight the importance of muscle preservation and precise 3D evaluation before surgery.