General Thoracic and Cardiovascular Surgery最新文献

Objectives

Type A acute aortic dissection (TAAAD) is a life-threatening condition often requiring emergency surgery, with approximately 30% of patients needing reoperation. This study aimed to identify predictors of long-term aortic events from early postoperative computed tomography (CT) examinations.

Methods

A total of 336 cases underwent TAAAD surgery at two institutions between 2002 and 2018. Of these, 302 patients received CT examinations immediately after initial TAAAD surgery. Predictors of aortic events were evaluated from these early postoperative CT exams. Aortic events were defined as any events involving aortic-related death, open surgery, reoperation, endovascular stenting, or thoracic aorta diameter enlargement to ≥ 55 mm.

Results

Excluding 34 in-hospital deaths (10.1%; 34/336), the 1-, 5-, and 10-year actuarial survival rates after primary TAAAD surgery were 98.2%, 88.6%, and 81.7%, respectively. Over a mean follow-up period of 7.4 ± 5.1 years, 67 aortic events (proximal: 19, distal: 45, both: 3) were observed. Freedom from proximal aortic events was 98.6%, 93.9%, and 85.2% at 1, 5, and 10 years, respectively. Proximal anastomosis new entry was identified as a significant risk factor for aortic events, with a 92% vs. 42% incidence at 10 years (p < 0.001). Freedom from distal aortic events was 99.6%, 84.5%, and 67.2% at 1, 5, and 10 years, respectively. A false/true area ratio greater than 1 and distal anastomosis new entry were significant risk factors for aortic events (low-risk group: 83.3% vs. high-risk group: 42.3% at 10 years, p < 0.001).

Conclusions

Detailed analysis of early postoperative CT scans following primary TAAAD surgery may help identify predictors of subsequent aortic events, potentially improving long-term patient management and outcomes.

Background

Patient–prosthesis mismatch (PPM) should be avoided during surgical aortic valve replacement because PPM would worsen the mortality and morbidity. Diagnosis of PPM could be made using various parameters measured by intraoperative transesophageal echocardiography. However, few studies have examined which parameters correlate most accurately between intraoperative and postoperative values.

Methods

This single-center prospective observational study analyzed 46 patients who underwent surgical aortic valve replacement (SAVR). Echocardiography was performed at the following 3-time points: preoperatively, intraoperatively, and 1 month postoperatively. The correlation between intraoperative and postoperative measurement values, including peak velocity (PV), mean pressure gradient (MPG), effective orifice area (EOA), and effective orifice area index (EOAI), were assessed using Pearson’s correlation coefficient. Moreover, to evaluate whether a multivariable linear regression model with intraoperative and postoperative stroke volume added as an explanatory variable improves the correlation, the multiple correlation coefficients were calculated.

Results

PV, MPG, EOA, and EOAI measured intraoperatively and 1 month postoperatively were significantly correlated. The r values of each measurement were 0.35, 0.344, 0.411 and 0.323, respectively. The multivariable linear regression model showed that the multiple correlation coefficients for MG and EOA were 0.491 and 0.663, respectively.

Conclusion

Intraoperative and postoperative PV, MPG, EOA, and EOAI were significantly correlated in patients undergoing SAVR with a bioprosthetic valve. The r value for EOA was 0.441, the largest among the measured values. Adjustment for stroke volume improved the strength of the correlation. Intraoperative evaluation of prosthetic valve function was considered most appropriate using EOA.

Clinical trial number

University Hospital Medical Information Network Clinical Trials Registry, registration number UMIN000046164, https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000052695.

Objective

We retrospectively evaluated whether or not conventional air leak testing is necessary in robotic major pulmonary resections.

Methods

After excluding patients who received 2 or more days of postoperative drainage for chylothorax or excessive pleural effusion, 578 patients who underwent major pulmonary resection using minimally invasive approaches between February 2019 and November 2023 at our institution were included in this study. All patients were divided into two groups including thoracoscopic (n = 471) and robotic (n = 107) approaches. Conventional air leak testing was performed in all patients in the thoracoscopic approach but not in the robotic approach. After propensity score matching of patient backgrounds between the two groups, perioperative outcomes were compared (n = 100 each). The primary endpoint was the rate of drain removal on postoperative day (POD) 2 or later. In addition, factors associated with drain removal on POD 2 or later in the robotic group were identified.

Results

The rate of drain removal at POD 2 or later was not significantly different between the two groups (p = 0.011). Multivariable analysis to identify factors associated with drain removal at POD2 or later in the robotic approach showed that sealant application (p = 0.002) and lobectomy (vs. segmentectomy, p = 0.034) were significantly associated.

Conclusions

In conclusion, even in the absence of air leak testing, a robotic approach for major lung resections can result in a drain removal rate on the day of surgery or POD1 that is comparable to a conventional thoracoscopic approach. However, it may be useful in selected patients requiring sealant placement or undergoing lobectomy.

Objectives: The aim of this study was to investigate the outcomes of lung transplantation for connective tissue disease-related interstitial lung disease (CTD-ILD) conducted at our institution, compared with those for idiopathic interstitial pneumonias (IIPs).

Methods: We retrospectively reviewed patients with CTD-ILD and IIPs who underwent lung transplantation at our hospital from July 2015 to October 2023. We compared patients' backgrounds, early complications within 28 days post-transplant (CTCAE grade 3 or higher), postoperative courses, and prognoses between the two groups.

Results: The CTD-ILD group (n = 19) and the IIPs group (n = 56) were compared. The CTD-ILD group had significantly higher preoperative use of corticosteroids and antifibrotic agents, mean pulmonary arterial pressure, anti-human leukocyte antigen antibody positivity, and donor age (p < 0.05). In addition, the CTD-ILD group had significantly longer operation times (579.0 vs 442.5 min), longer stays in the intensive care unit (17.0 vs 9.0 days) and hospital (58.0 vs 44.0 days); required more tracheostomies (57.9 vs 25.0%); and experienced more respiratory (52.6 vs 25.0%) and gastrointestinal (42.1 vs 8.9%) complications (p < 0.05). However, there were no significant differences in overall survival, nor chronic lung allograft dysfunction (CLAD)-free survival between the two groups.

Conclusion: Perioperative complications, notably respiratory and gastrointestinal complications, were prevalent after lung transplantation among CTD-ILD patients. Despite this, long-term survival rates were comparable to those observed in IIP cases.

Objective: During total arch replacement (TAR) using frozen elephant trunk (FET) technique with Frozenix for true thoracic aortic aneurysm (tTAA), oversized FET tends to be chosen similar to the endovascular devise selection. However, the oversized FET is considered a risk factor for intimal injury. The appropriate size selection of FET remains insufficiently understood.

Methods: Between October 2014 and March 2022, a total of 49 patients underwent TAR using Frozenix for tTAA. Out of 49 patients, four patients planned to staged surgery were excluded, 19 patients were operated on with an undersized Frozenix compared with the descending aorta (undersized FET group) and in 26 patients an equal or oversized Frozenix was used (oversized FET group). Clinical outcomes and postoperative diameter changes were investigated.

Results: In-hospital mortality was 0%. The mean diameter of Frozenix and the descending aorta was 30.7 mm and 28.8 mm, respectively, in the oversized FET group, and 26.7 mm and 30.1 mm in the undersized FET group. Postoperative computed tomography (CT) demonstrated no endoleaks not only in the oversized FET group but also in the undersized FET group. CT also revealed that undersized FET had expanded more than the original diameter in all cases except for two, with an average of 2.47 ± 1.53 mm. Additionally, the descending aorta covered with Frozenix shrank in 10 patients (53%). Postoperative adverse aortic events were not observed.

Conclusions: Undersized Frozenix tightly fit the descending aorta and resulted in complete sealing without endoleaks. Oversized FET is not strictly necessary considering the size-related adverse complications.

Objectives: As the role of segmentectomy expands in managing early-stage lung adenocarcinoma, precise preoperative assessments of tumor invasiveness via computed tomography become crucial. This study aimed to evaluate the effectiveness of solid component analysis of three-dimensional (3D) computed tomography images and establish segmentectomy criteria for early-stage lung adenocarcinomas.

Methods: This retrospective study included 101 cases with adenocarcinoma diagnoses, with patients undergoing segmentectomy for clinical stage 0 or IA between 2012 and 2017. The solid component volume (3D-volume) and solid component ratio (3D-ratio) of tumors were calculated using 3D computed tomography. Additionally, based on two-dimensional (2D) computed tomography, the solid component diameter (2D-diameter) and solid component ratio (2D-ratio) were calculated. The area under the receiver-operating characteristic curve (AUC) was calculated for each method, facilitating predictions of mortality and recurrence within 5 years. The AUC of each measurement was compared with those of invasive component diameter (path-diameter) and invasive component ratio (path-ratio) obtained through pathology analysis.

Results: The predictive performance of 3D-volume did not differ significantly from that of path-diameter, whereas 2D-diameter exhibited less predictive accuracy (AUC: 3D-volume, 2D-diameter, and path-diameter: 0.772, 0.624, and 0.747, respectively; 3D-volume vs. path-diameter: p = 0.697; 2D-diameter vs. path-diameter: p = 0.048). Results were similar for the solid component ratio (AUC: 3D-ratio, 2D-ratio, path-ratio: 0.707, 0.534, and 0.698, respectively; 3D-ratio vs. path-ratio: p = 0.882; 2D-ratio vs. path-ratio: p = 0.038).

Conclusion: Solid component analysis using 3D computed tomography offers advantages in prognostic prediction for early-stage lung adenocarcinomas.

Extended bronchoplasty for the left lower lobe lung tumors with interlobar lymph node involvement is a useful surgical technique for avoiding pneumonectomy. Typically, sleeve bronchoplasty, in which the superior division bronchus and the left main bronchus are separated and anastomosed, is chosen due to the difference in caliber of the anastomosis; herein, we report a wedge extended bronchoplasty in which the superior division bronchus and the left main bronchus were not completely separated. The main point of this technique is to adjust the difference in caliber by suturing the main bronchial membranes.

Background: Malfunctions of robotic instruments during robotic surgery are well known to occur; however, detailed reports on the inherent problems associated with robotic instruments and robotic surgical systems are scarce. The objective of this study was to retrospectively investigate the intraoperative problems associated with robotic surgical systems and robotic instruments.

Materials and methods: This was a single-center retrospective study. Between April 2012 and December 2022, 544 patients with consecutive lung malignancies and/or mediastinal tumors underwent robot-assisted thoracoscopic surgery. Among these, 15 cases had intraoperative problems associated with the robotic surgical system. Human error was defined as a problem caused by the incorrect operation of the robotic surgical system and human factors as problems in which the robotic surgical system stopped owing to damage to the instruments of the robotic surgical system or the self-diagnosis of the robotic surgical system. We retrospectively investigated the causes of intraoperative problems in these cases.

Results: There were 4 cases (0.7%) with problems related to the robotic surgical system, 2 of which were human errors, and 11 (2.0%) with problems related to robotic surgical instruments, 6 of these were related to instruments and 5 were related to robotic staplers. Five of these were related to human factors.

Conclusion: Teams performing robot-assisted thoracoscopic surgery should be familiar with the features of robotic surgical systems and various robotic devices, be aware of reported problems during robot-assisted thoracoscopic surgery, and be prepared for emergencies.

Objectives: Anastomotic leakage in esophageal cancer surgery may be reduced by evaluating the blood flow to the reconstructed organ, but quantitative evaluation of arterial and venous blood flow is difficult. This study aimed to quantitatively assess blood flow using a new technique, as well as determine the relationship between the blood flow in the gastric tube and anastomotic leakage using near-infrared spectroscopy.

Methods: This single-center, observational study included 50 patients aged 51-82 years who underwent radical esophagectomy with gastric tube reconstruction for esophageal cancer between June 2022 and January 2023. Regional tissue oxygen saturation was measured at the antrum (point X), the anastomotic point (point Z), and the midpoint between points X and Z (point Y) before and after gastric tube formation. These three points of oxygen saturation were investigated in relation to anastomotic leakage.

Results: When comparing the presence of leakage to its absence, regional tissue oxygen saturation at points X and Z after gastric tube formation was significantly lower (X: p = 0.03, Z: p = 0.02), with the decreasing rate significantly higher at point Z (p = 0.01). There was no significant difference in the decreasing rate of regional tissue oxygen saturation between points X and Y (X: p = 0.052, Y: p = 0.83).

Conclusion: Regional tissue oxygen saturation levels may be useful for measuring blood flow and could be a predictor of anastomotic leakage.