Journal of thoracic disease最新文献

Background: Cardiopulmonary bypass (CPB) can trigger a systemic inflammatory response during the perioperative period, which may lead to the consumption of the contact system and the production of neutrophil extracellular traps (NETs). This study attempted to determine whether the formation of NETs and contact activation are a vivid occurrence during CPB and whether they are related to post-operative atrial fibrillation (AF) and survival.

Methods: A prospective observational study was conducted in 97 patients who underwent aortic valve and/or aorta replacement surgery with CPB. Circulating markers of NETs [histone-DNA complex, cell-free double stranded DNA (dsDNA), neutrophil elastase] and the contact system [prekallikrein, high molecular weight kininogen (HMWK), activated factor XII (FXIIa)] were measured at four-time points: before surgery (T0), immediately after surgery (T1), 1 day after surgery (T2), and 3 days after surgery (T3).

Results: Elevated levels of circulating NETs markers were observed across post-CPB time. Significantly elevated levels of histone-DNA complex and cell-free dsDNA measured T3 were detected in patients with post-operative AF compared to those without. In logistic regression analysis, levels of histone-DNA complex and cell-free dsDNA measured at T3 were significant markers of risk for occurrence of AF. The levels of cell-free dsDNA measured T2 were significantly higher in non-survivors than in survivors. The level of cell-free dsDNA showed significant prognostic value.

Conclusions: NETs markers may be useful for the assessment of risk for post-operative AF and mortality. Conduct of additional research regarding the role of NETs as clinical markers and as a therapeutic target in CPB is anticipated.

Background: Although robotic surgery has gained popularity, safety concerns remain due to potential delay in addressing intraoperative hemorrhages since the surgeon is not at the bedside. This study aimed to test whether a training program for emergency robotic undocking protocols improved the performance of thoracic operating room (OR) teams.

Methods: An emergency undocking protocol and checklists were created for massive hemorrhage during robotic thoracic surgery. In phase I, two OR teams participated in in-situ simulations of the scenarios in the OR without knowledge of the protocols. In phase II, the protocol and checklists were introduced to four different OR teams by either high-fidelity lab simulation or video-based didactic sessions. The teams' performances were tested with in-situ OR simulations. Performance assessments included the number of missed critical steps, participant-reported feedback, and timeliness of crucial steps.

Results: All teams successfully converted from robot-assisted to open, with the attending at bedside within five minutes from the decision to convert, regardless of phase or education type. Phase I (control) teams had an average of 2.55 critical misses per team while the average was 0.25 for phase II teams (P=0.08). There was no significant difference between phases in time required for the surgeon to be at the bedside (average 132.2 seconds, P=0.64).

Conclusions: Targeted education can lead to improved team performance. This study shows that high-fidelity simulation and didactic sessions can both be used to effectively teach emergency undocking protocols.

Background: The prognosis and first-line treatment response of patients with borderline resectable esophageal squamous cell carcinoma (ESCC) are unsatisfactory. We are conducting the borderline resectable esophageal squamous (BRES-1) study to evaluate the safety and efficacy of camrelizumab combined with chemotherapy in patients with borderline resectable ESCC.

Methods: A total of 30 patients with borderline resectable ESCC will be enrolled in the BRES-1 study. These patients will undergo three stages of treatment: neoadjuvant therapy, surgery, and adjuvant therapy. Preoperative therapies will include camrelizumab, cisplatin, and nab-paclitaxel. Preoperative therapies will include camrelizumab, which will be given every 3 weeks for 6 weeks at a dose of 200 mg (baseline weight <50 kg, 3 mg/kg), nab-paclitaxel (130 mg/m² on days 1 and 8 of one period with 21 days, a total of two cycles), and cisplatin (75 mg/m² on day 1 of one period with 21 days, a total of two cycles). Patients will undergo esophagectomy 3-6 weeks after completing the neoadjuvant treatment. Three weeks after surgery, camrelizumab combined with chemotherapy will continue to be used for two cycles of maintenance therapy. Then, only camrelizumab will be administered for an entire year. The primary endpoint of this study will be pathological complete response (pCR).

Discussion: The BRES-1 trial will evaluate the efficacy and safety of camrelizumab combined with chemotherapy for patients with borderline resectable ESCC. Translational research will explore perioperative complications and drug-related adverse events (AEs).

Trial registration: ChiCTR, ChiCTR2200056728. Registered 11 February 2022. https://www.chictr.org.cn/index.aspx.

Background: Pulmonary nodules are small, focal lesions often identified via computed tomography (CT) scans. Although the majority are benign, a small percentage of them may be malignant or potentially become malignant, underscoring the importance of early detection and effective management. This study systematically reviews the epidemiology, risk factors, and management strategies for pulmonary nodules, comparing findings across Chinese and non-Chinese populations to better inform the actuarial calculations for predicting the demand of medical services for patients with pulmonary nodules.

Methods: We performed a systematic analysis of the PubMed and China Knowledge Infrastructure (CNKI) databases for studies reporting the detection rate of pulmonary nodules through CT scans. Both cross-sectional studies and the baseline data from longitudinal studies were included. A modified version of the Newcastle-Ottawa Scale was used to assess the risk of bias and random effect models were used to estimate the overall prevalence.

Results: We identified 32 studies and included 24 of them in our meta-analysis. Pooled analysis showed that the overall prevalence of pulmonary nodules was 0.27 (95% confidence interval: 0.25-0.29) after outliers removal. Subgroup analysis showed that there was no significant difference for prevalence between Chinese and non-Chinese populations. Males (0.38) were shown to have slightly higher prevalence compared to females (0.36), but not significant (P=0.88). Age and smoking are the most frequently reported risk factors by studies.

Conclusions: Overall, 27% of participants were positive for pulmonary nodules. Advancing age and smoking were consistently identified as a key risk factor for the incidence of pulmonary nodules. Although the management strategies are different across studies, recent guidelines recommend personalized management strategies, prioritizing nodule size, characteristics, and individual risk factors to optimize outcomes.

Background: Postoperative atrial fibrillation (POAF) is the most common arrhythmia after cardiac surgery. While thyroid dysfunction can predict POAF, the association between preoperative serum free triiodothyronine (FT3) levels and POAF in patients undergoing off-pump coronary artery bypass (OPCAB) grafting remains unclear. This study aimed to investigate the relationship between preoperative FT3 levels and POAF in OPCAB patients.

Methods: This prospective observational study included patients with sinus rhythm and no history of atrial fibrillation or thyroid disease who underwent OPCAB and FT3 testing at the Tianjin Chest Hospital from June 2021 to March 2023. The relationship between FT3 level and POAF was evaluated using restricted cubic spline. Cox proportional hazards regression models were used to analyze the associations between FT3 concentration categories [low T3 syndrome (LT3S) (FT3 below the normal range), low normal FT3 (3.10-4.59 pmol/L), high normal FT3 (4.60-6.80 pmol/L)] and POAF, adjusting for potential confounders. Stratified analyses were performed to assess effect modification by gender and age (<60 vs. ≥60 years old).

Results: Among 875 patients, 259 (29.6%) developed POAF within 2 days after surgery. Restricted cubic spline analysis showed an S-shaped association between FT3 concentration and POAF risk. Compared to the low normal FT3 group, LT3S was associated with an increased risk of POAF [hazard ratio (HR), 1.41; 95% confidence interval (CI): 1.90-2.19], while high normal FT3 was associated with a decreased risk (HR, 0.72; 95% CI: 0.51-0.99). The association between FT3 and increased POAF risk was more pronounced in patients aged ≥60 years (HR, 1.41; 95% CI: 1.89-2.22).

Conclusions: Preoperative FT3 levels most likely could predict POAF risk after OPCAB, especially in patients aged 60 years and older. Measuring FT3 preoperatively may identify high-risk patients benefiting from close monitoring and prophylactic treatment. Further investigation of thyroid hormone replacement therapy for LT3S is warranted.

Background: Long-term (>30 days) esophageal stenting is controversial. Previous studies have documented complications associated with long-term esophageal stent use. This study's objective was to investigate complications associated with long-term esophageal stent use.

Methods: A retrospective review of stenting done by thoracic surgery for any reason between 2010-2020 was completed. Patients were included if they had at least 30 days of follow-up after their initial stent placement. Outcomes included stent dwell time, patient outcomes, procedural and stent-related complications.

Results: Fifty-six patients, with 25 having ≥2 stents placed were included; overall, 90 stents were placed. The median length of initial esophageal stent dwell time was 59 [interquartile range (IQR), 21-119] days. Stent migration was the most common complication and occurred more with benign indications (P=0.12). As the length of dwell time increased, prevalence of any complication decreased. Complication rates between short-term (<30 days) and long-term stents were not significantly different (P=0.39). No instances of esophageal perforation or aortoesophageal fistulas related to stents were identified. There was one instance of post-esophagectomy tracheoesophageal fistula which was managed successfully with prolonged stenting.

Conclusions: Over a 10-year period, there were no instances of stent erosion into the aorta or esophageal perforation, and the most frequent stent-related complication was stent migration. Long-term esophageal stenting did not result in increased rates of stent related complications in our cohort. This case series demonstrates that long-term stents may be safely used for many different indications. Randomized controlled studies may be needed to validate these findings.

Background: A variety of nutritional evaluation parameters has been documented as prognostic indicators in some malignancies. However, the prognostic significance of the controlling nutritional status (CONUT) score, as one of these nutritional indices, in patients with esophageal squamous cell carcinoma (ESCC) remains unclear and warrants investigation. Our study sought to elucidate the prognostic value of this nutritional index in ESCC patients who underwent neoadjuvant therapy followed by esophagectomy.

Methods: This retrospective study encompassed 314 patients diagnosed with ESCC who underwent neoadjuvant therapy followed by esophagectomy at West China Hospital of Sichuan University between August 2016 and August 2021. CONUT scores were computed at two specific time points: prior to neoadjuvant therapy initiation and before surgery, utilizing serum albumin, total lymphocyte, and cholesterol levels of ESCC patients. Furthermore, the delta CONUT (ΔCONUT) score was derived by subtracting the preoperative CONUT score from the pretreatment CONUT score. The associations between CONUT scores and various survival outcomes were evaluated using Kaplan-Meier methods and Cox regression analysis.

Results: Patients with a high preoperative CONUT score demonstrated a higher postoperative complication rate [odds ratio (OR) =2.009, 95% confidence interval (CI): 1.150-3.510, P=0.01] compared to those in the low CONUT group. Multivariate analysis revealed that a ΔCONUT score ≥0 served as an independent negative prognostic indicator for increased postoperative complications (OR =3.008, 95% CI: 1.509-5.999, P=0.002) and poorer overall survival [hazard ratio (HR) =2.388, 95% CI: 1.052-5.422, P=0.04] in ESCC patients who underwent neoadjuvant therapy combined with esophagectomy.

Conclusions: A high preoperative CONUT score and a ΔCONUT score ≥0 were indicative of a poor prognostic nutritional status in ESCC patients who had undergone neoadjuvant therapy followed by esophagectomy.

Background: Aortic root involvement during acute type A aortic dissection (ATAAD) may depend on ascending aortic wall degeneration. Surgical decision-making for extended resection of the aortic root is clinically made without histopathology. The aim of the study was to investigate whether the degree of degeneration of the ascending aortic wall found in patients with ATAAD is associated with the aortic root involvement.

Methods: Collectively, 141 consecutive patients undergoing ATAAD surgery at Tampere University Heart Hospital were investigated. The ascending aortic wall resected in surgery was processed for 11 different variables that describe medial and adventitial degeneration. In addition, atherosclerosis and inflammation were separately evaluated. Patients undergoing aortic root replacement were compared with those with supracoronary reconstruction of the ascending aorta with/without aortic valve surgery (root-sparing surgery) during a mean 4.9-year follow-up.

Results: Aortic root replacement together with the ascending aortic replacement was performed in 39% of the patients (n=55). The mean age for all patients was 65 years [standard deviation (SD 13)]. Many patients with aortic root replacement had moderate to severe aortic valve regurgitation (85.5%). Most of the patients with aortic root-sparing surgery included a supracoronary tube prosthesis (89.5%), while nine patients also had aortic valve replacement. The degree of mucoid extracellular matrix accumulation was more prominent in patients with aortic root replacement compared to patients with root-sparing surgery (2.1 SD 0.4 vs. 1.9 SD 0.4, P=0.04, respectively). During follow-up, there were 52 deaths among patients (log rank P=0.79).

Conclusions: Histopathology of the ascending aorta during ATAAD reveals distinctive aortic wall degeneration in patients with aortic root involvement vs. not. The degree of mucoid extracellular matrix accumulation assessed postoperatively is associated with the choice of surgical procedure in many patients.

Background: Distinguishing benign from malignant sub-centimeter solid pulmonary nodules (SSPNs) continues to be challenging in clinical practice. Earlier diagnosis is crucial for improving patient survival and prognosis. This study aimed to investigate the risk factors of malignant SSPNs and establish and validate a prediction model based on computed tomography (CT) characteristics to assist in their early diagnosis.

Methods: A total of 261 consecutive participants with 261 SSPNs were retrospectively recruited between January 2012 and July 2023 from National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (Center 1), including 161 malignant lesions and 100 benign lesions. Patients were randomly assigned to the training set (n=183) and validation set (n=78) according to a 7:3 ratio. Malignant nodules were confirmed by pathology; and benign nodules were confirmed by follow-up or pathology. Clinical data and CT features were collected to estimate the independent predictors of malignancy of SSPN with multivariate logistic analysis. A clinical prediction model was subsequently established by logistic regression. Furthermore, an additional 69 consecutive patients with 69 SSPNs from The Fourth Hospital of Hebei Medical University (Center 2) between January 2022 and December 2022 were retrospectively included as an external cohort to validate the predictive efficacy of the model. The performance of the prediction model was assessed by sensitivity, specificity, and the area under the receiver operating characteristic curve.

Results: There were 113 (61.7%), 48 (61.5%) and 28 (40.6%) malignant SSPNs in the training, internal and external validation sets, respectively. Multivariate logistic analysis revealed four independent predictors of malignant SSPNs: tumor-lung interface (P=0.002), spiculation (P=0.04), air bronchogram (P=0.047), and invisible at the mediastinal window (P=0.003). The area under the curve (AUC) for the prediction model in the training set was 0.875 [95% confidence interval (CI): 0.818, 0.933]; and the sensitivity and specificity were 94.7% and 68.6%, respectively. The AUCs in the internal and external validation set were (0.781; 95% CI: 0.664, 0.897) and (0.873; 95% CI: 0.791, 0.955), respectively; the sensitivity and specificity were 66.7% and 83.3% for the internal validation data, and 100.0% and 61.0% for the external validation data, respectively.

Conclusions: The prediction model based on CT characteristics could be helpful for distinguishing malignant SSPNs from benign ones.

Background: It has been thought a larger bore biopsy needle may yield a better sample for molecular testing, but this could potentially expose the patient to higher pneumothorax rates. This study aims to determine if a larger bore biopsy system results in more complications.

Methods: A total of 193 patients who underwent computed tomography (CT)-guided lung biopsy in a single tertiary center from 2013-2021 were evaluated retrospectively. Patients were divided into two groups, patients who underwent lung biopsy using the 17/18-gauge (18G) biopsy system and the 19/20-gauge (20G) biopsy system. Data recorded included biopsy needle gauge, nodule location and size, plug use, positioning, the length of the intraparenchymal tract, number of biopsy passes, pneumothorax, chest tube insertion, and admission.

Results: The mean age was 64.1±12.4 years. The median diameter of the lung nodules was 1.95 cm, and the median depth of the intraparenchymal needle tract was 2.7 cm. Pneumothorax was identified during the procedure by CT fluoroscopy or on post-procedural chest X-ray (CXR). The overall rate of pneumothorax among all patients was 35.2%, and 10.9% of the study population (i.e., 30.1% of patients with pneumothorax) required chest tube insertion. The rate of pneumothorax or chest tube insertion was not significantly different between patients who underwent lung biopsy using 17/18G or 19/20G biopsy system. Patients who developed pneumothorax were older, with smaller-sized pulmonary nodules and longer length of the intraparenchymal tract. The pathologic sensitivity of the 18G gun was higher than that of the 20G gun (93% sensitivity, 100% specificity vs. 79.5% sensitivity, 100% specificity). In the multivariate logistic regression fitted model, the length of the intraparenchymal tract was the only factor predictive of post-procedural pneumothorax and chest tube insertion. An intraparenchymal needle tract length of greater than 2 cm was identified to have the best threshold to predict pneumothorax [sensitivity: 73.5%; false positive rate: 57.6%; area under the curve: 66.27%].

Conclusions: Findings suggest similar rates of pneumothorax and chest tube insertion using small 19/20G vs. 17/18G biopsy systems. The 18G system was more sensitive compared to the 20G system in determining pathologic results. Increasing length of lung parenchyma needle tract and smaller lung nodules appear to be risk factors for pneumothorax. Physicians should plan on intraparenchymal tracts that are less than 2 cm to decrease the chance of pneumothorax.