General Thoracic and Cardiovascular Surgery最新文献

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.

Objectives: The presence of pleural adhesions during lung cancer surgery can obstruct the surgical field and inhibit maneuverability, thereby potentially complicating the procedure. The current study examined the potential predictive factors of pleural adhesions using standard preoperative examinations for lung cancer surgery without additional assessments.

Methods: This study included 542 patients with primary lung cancer who underwent chest computed tomography scan and positron emission tomography before undergoing surgery between January 2021 and September 2024. To assess differences in lung expansion between inspiration and natural breathing, the ratio of lung computed tomography scan measurements obtained during maximal inspiration-to-lung positron emission tomography measurements during spontaneous breathing was calculated. The ratios were compared between patients with pleural adhesions and those without.

Results: In total, 56 patients were classified under the adhesion group and 486 under the non-adhesion group. If the ratio of the distance from the lung base to the interlobar fissure, measured on coronal computed tomography scan and positron emission tomography, was ≤ 1.390, and the angle of the lung base, measured on sagittal computed tomography scan, was ≥ 40°, the incidence of pleural adhesions was significantly higher (24.0% vs. 4.7%; p < 0.01).

Conclusion: Standard preoperative examinations could be effective in predicting pleural adhesion.

Objective: This study aimed to evaluate the efficacy of thoracoscopic ligation for secondary spontaneous pneumothorax performed via an extrathoracic looping technique in patients with smoking-induced emphysema.

Methods: We retrospectively analyzed clinical data of 58 patients with secondary spontaneous pneumothorax who had histories of smoking and emphysematous lung changes on chest computed tomography. These patients underwent thoracoscopic surgery at our institute between April 2016 and March 2023. We then compared clinical outcomes of ligation (n = 26) and conventional bullectomy (n = 29).

Results: We found no significant differences in preoperative characteristics of the groups. The operation time (ligation vs bullectomy groups, respectively: median 71 min [interquartile range 52-95] vs 94 min [70-124], p = 0.016); amount of postoperative air leakage (0 mL/min [0-0] vs 50 mL/min [0-70], p < 0.001); duration of postoperative drainage (1 day [1-2] vs 4 days [1-5], p < 0.001); and length of postoperative hospital stay (4 days [3-5] vs 6 days [4-11], p = 0.012) were significantly better for ligation. No patients in the ligation group required postoperative treatment of prolonged air leakage; eight patients (27.6%) in the bullectomy group underwent postoperative treatments including pleurodesis (n = 8), bronchial occlusion (n = 2), or reoperation (n = 2) (p = 0.004). The postoperative complications and recurrence rates were not significantly different between groups.

Conclusions: Because the thoracoscopic ligation technique proposed here allows closing a pulmonary fistula without resecting the visceral pleura, it is a reliable surgical treatment of secondary spontaneous pneumothorax in patients with smoking-induced emphysema.

Objectives: ECPELLA, which uses veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and the Impella percutaneous ventricular assist device, is effective for patients with cardiogenic shock. However, patients with severe right heart dysfunction frequently have difficulty weaning off V-A ECMO. Inhaled nitric oxide (iNO) therapy may induce pulmonary artery pressure while improving right ventricular function. The goal of this study is to determine whether iNO improves right and left ventricular function in patients on ECPELLA.

Methods: This retrospective study, conducted at a single-center, involved 44 ECPELLA-supported patients diagnosed with cardiac shock from January 2019 to August 2024. After applying exclusion criteria, 16 cases who received iNO therapy for right heart failure were analyzed (n = 16). Patients without evidence of right ventricular dysfunction or with incomplete data were excluded. iNO was initiated at 20 ppm when the pulmonary artery pulsatility index (PAPi) was < 1.0 during data collection, the ECMO flow rate was maintained at 2 L/min, and the pulmonary artery catheter measurements were taken before starting iNO and 24 h later.

Results: The median age of the patients was 66 years, with an interquartile range of 59-72, and 11 of the patients (69%) were male. Acute myocardial infarction was the primary diagnosis in eight patients, followed by dilated cardiomyopathy in four, ischemic cardiomyopathy in two, arrhythmogenic right ventricular cardiomyopathy in one, and pulmonary embolism in one. The average duration of iNO therapy was 8 ± 6 days, with 12 patients (75%) successfully weaning off ECPELLA. The 30-day mortality rate was 38% (6/16), with an in-hospital mortality rate of 50% (8/16). Hemodynamic parameters improved significantly after receiving iNO therapy. The PAPi rose from 0.96 ± 0.54 to 1.94 ± 1.7, and the right ventricular fractional area change improved from 24 ± 7.6 to 32 ± 9.5%. In addition, cardiac power output increased from 0.33 ± 0.07 Watt (W) to 0.73 ± 0.21 W, while left ventricular ejection fraction improved from 19 ± 7.6 to 31 ± 16%. Impella flow increased significantly following iNO therapy, and V-A extracorporeal membrane oxygenation-assisted flow decreased. Patients with PAPi levels below 1.0 after iNO therapy had significantly lower ECMO weaning rates and higher 30-day mortality rates.

Conclusions: iNO significantly enhanced both right and left ventricular function in patients undergoing ECPELLA. However, it was also indicated that severe right ventricular dysfunction, which did not respond to iNO, was linked to poor outcomes in patients supported by ECPELLA.

Objective: Studies have reported poor surgical outcomes in patients with lung cancer and interstitial lung disease. Therefore, we retrospectively analyzed the perioperative and long-term outcomes of this patient population.

Methods: Between 2004 and 2021, we enrolled 103 patients with interstitial lung disease and clinical stage I lung cancer (8th edition of the TNM classification) without a history of lung cancer treatment within 5 years before surgery and undergoing complete resection from our institution.

Results: The median patient age was 74 years (range: 60-89 years), and 90 patients were male. The most common surgical procedures were lobectomy (n = 85), followed by partial resection (n = 13), segmentectomy (n = 4), and pneumonectomy (n = 1). The median observation period was 1102 days. Concerning perioperative outcomes, 90-day postoperative mortality was 7 (6.8%) and complications (≥ Grade 3 according to the Clavien-Dindo classification) were observed in 30 patients (29.1%). Regarding long-term outcomes, lung cancer recurrence was observed in 38 patients. Fifty-six patients died during the observation period, but only 20 (35.7%) died of lung cancer recurrence. Pathological upstaging was observed in 51 patients (49.5%). The 5-year overall survival and recurrence-free survival rates were 48.6% and 41.8%, respectively.

Conclusions: A relatively high 90-day mortality rate was observed. Deaths from causes other than lung cancer recurrence were observed more frequently than those from lung cancer recurrence. Hence, when selecting treatment strategies for early lung cancer combined with interstitial lung disease, the risks of acute exacerbation and progression of interstitial lung disease should be considered.

Objective: Frailty is a major risk factor for adverse outcomes following cardiac surgery, yet its routine clinical integration is hindered by the lack of a standardized, convenient assessment method. This study aimed to develop and validate a simplified frailty model using three objective measures: gait speed, serum albumin, and grip strength.

Methods: In this prospective observational study of 261 patients (≥ 65 years) undergoing elective cardiac surgery, frailty was assessed using both the Japanese Cardiovascular Health Study criteria and our simplified model. The model defined frailty as having ≥ 2 of the following: slowness (gait speed < 1.0 m/s), hypoalbuminemia (albumin ≤ 3.5 g/dL), and weakness (grip strength < 28 kg for men, < 18 kg for women).

Results: The simplified model demonstrated high diagnostic accuracy for frailty defined by the Japanese Cardiovascular Health Study criteria (area under the curve = 0.868; sensitivity, 55.8%; specificity, 91.4%). Frailty defined by our model was a strong predictor of worse 3-year survival (hazard ratio, 10.43; 95% confidence interval, 2.82-38.58; p < 0.001) and event-free survival (hazard ratio, 2.52; 95% confidence interval, 1.47-4.34; p < 0.001), with prognostic power comparable to the Japanese Cardiovascular Health Study criteria.

Conclusions: A simplified frailty model incorporating gait speed, serum albumin, and grip strength provides robust diagnostic and prognostic utility. Its objectivity and ease of use may facilitate consistent preoperative risk stratification in patients undergoing cardiac surgery.

Purpose: Up-to-date national data on minimally invasive cardiac surgery (MICS) are essential for quality control but remain limited. This report summarizes 2022 outcomes of right- or left-minithoracotomy, thoracoscopic/port-assisted, and robotic-assisted MICS in Japan, based on the Japan Cardiovascular Surgery Database (JCVSD).

Methods: Data were collected from patients undergoing mitral valve repair/replacement (MV repair, n = 2525; MVR, n = 279), aortic valve replacement (AVR, n = 1114), coronary artery bypass grafting (CABG, n = 450), atrial septal defect closure (ASD, n = 212), and cardiac tumor resection (n = 113) using MICS approaches. Perioperative data included 30-day and in-hospital mortality, conversion rates, and major morbidities.

Results: For MV repair, the 30-day and in-hospital mortality rates were 0.3% and 0.2% in isolated cases (n = 1461) and 0.4% and 0.6% overall, respectively. Mortality rates for MVR were 2.5% and 4.2% in isolated cases (n = 120) and 2.9% and 4.3% overall, respectively. Mortality rates for AVR were 0.6% and 1.0% in isolated cases (n = 981) and 0.9% and 1.3% overall, respectively. Mortality rates for CABG were 1.6% and 1.8%, respectively. Mortality rates were 0% for both ASD closure and tumor resection. Across the groups, conversion to full sternotomy ranged from 0% to 1.8%.

Conclusion: The 2022 nationwide MICS data demonstrate consistently low mortality and morbidity across all procedure types. As MICS adoption grows, these updated JCVSD findings will serve as vital benchmarks for ongoing quality improvement in Japan.

Objectives: The indications for transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis (AS) are gradually expanding in Japan, with insurance coverage for low-risk patients approved in 2021. Although some reports have compared procedural costs, data addressing low-risk populations remain limited. This study aimed to assess in-hospital costs and outcomes of isolated TAVR versus surgical aortic valve replacement (SAVR) in low-risk patients with AS in real-world practice in Japan.

Methods: We retrospectively analyzed 128 low-risk (Society of Thoracic Surgeons [STS] score < 4%) patients with AS who underwent isolated TAVR (n = 80) or SAVR (n = 48) between August 2021 and December 2024 at The University of Osaka Hospital.

Results: Both groups achieved excellent outcomes, with no in-hospital or 30-day mortality. Patients who underwent TAVR had shorter intensive care unit (ICU) stays (1 [1-1] vs. 3 [2-4] days) and shorter postoperative stays (7 [5-11] vs. 14 [11-18] days). However, total in-hospital and combined operative plus postoperative costs were significantly higher for TAVR (5.62 vs. 5.11 million Japanese Yen (JPY), p < 0.0001), (5.29 million vs. 4.80 million JPY, p = 0.0002).

Conclusions: In this cohort of low-risk patients with AS in Japan, TAVR was associated with significantly higher in-hospital costs than SAVR, despite shorter postoperative stay.

Objective: Prolonged preoperative fasting has been reported to increase patient discomfort, induce insulin resistance, and lead to complications and delayed recovery. We introduced preoperative oral carbohydrate (CHO) loading, and this study aimed to evaluate the influence on the outcomes of esophageal cancer surgery.

Methods: We evaluated 270 patients who underwent minimally invasive esophagectomy for esophageal cancer. Before implementation, patients fasted after the evening meal on the day before surgery and received glucose-electrolyte infusion. After implementation, patients received oral CHO loading up to three hours before surgery instead of infusion. We evaluated its impact on the incidence of perioperative complications, time to first defecation, length of hospital stay, and postoperative glycemic changes using interrupted time series analysis.

Results: There were 136 and 134 patients before and after implementation, respectively. No patient experienced aspiration during anesthesia induction. No significant changes were observed in the incidence of postoperative complications (coefficient 6.51, 95% confidence interval - 20.6 to 33.6) or length of stay (coefficient 1.34, 95% confidence interval - 4.75 to 7.42) after the implementation. Meanwhile, a significant reduction in time to first defecation was observed after implementation (coefficient - 0.73, 95% confidence interval - 1.42 to - 0.05). No significant differences in postoperative blood glucose levels were noted.

Conclusions: Preoperative oral CHO loading for esophageal cancer surgery can be safely implemented without increasing postoperative complications, blood glucose levels, or length of hospital stay, and is associated with reduction in time to first defecation.