General Thoracic and Cardiovascular Surgery最新文献

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.

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.

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.

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.