Journal of thoracic disease最新文献

Background: Serum pro-gastrin releasing peptide (proGRP) is a well-recognized diagnostic marker for small cell lung cancer (SCLC). Pleural effusion is common in patients with advanced SCLC. The diagnostic accuracy of pleural proGRP for malignant pleural effusion (MPE) has not yet been established. This study aimed to evaluate the diagnostic accuracy of pleural proGRP for MPE.

Methods: We prospectively recruited patients with undiagnosed pleural effusions from two centers (Hohhot and Changshu). An electrochemiluminescence immunoassay was used to detect pleural fluid proGRP. The diagnostic accuracy of proGRP for MPE was evaluated using a receiver operating characteristic (ROC) curve.

Results: In both the Hohhot (n=153) and Changshu (n=58) cohorts, pleural proGRP in MPE patients did not significantly differ from that in patients with benign pleural effusions (BPEs) (Hohhot, P=0.91; Changshu, P=0.12). In the Hohhot and Changshu cohorts, the areas under the curves (AUCs) of proGRP were 0.51 [95% confidence interval (CI): 0.41-0.60] and 0.62 (95% CI: 0.47-0.77), respectively. However, patients with SCLC-induced MPE had significantly higher proGRP levels than those with BPE and other types of MPE (P=0.001 for both). In the pooled cohort, the AUC of proGRP for SCLC-induced MPE was 0.90 (95% CI: 0.78-1.00, P=0.001). At a threshold of 40 pg/mL, proGRP had a sensitivity of 1.00 (95% CI: 0.61-1.00) and specificity of 0.59 (95% CI: 0.52-0.66). The positive likelihood ratio was 2.61 (95% CI: 1.99-3.41), and the negative likelihood ratio was 0.

Conclusions: Pleural proGRP has no diagnostic value for MPE, but has high diagnostic accuracy for SCLC-induced MPE. In patients with proGRP levels <40 pg/mL, MPE secondary to SCLC can be excluded.

Background: Polymyositis/dermatomyositis (PM/DM) patients often develop interstitial lung disease (ILD), which can lead to relapse despite anti-inflammatory treatments. This study aims to elucidate the clinical characteristics of relapses in PM/DM-associated ILD patients.

Methods: We gathered clinical data, including laboratory results, pulmonary function tests, chest high-resolution computed tomography findings from patients treated at Okinawa Chubu Hospital between January 1, 2010 and December 31, 2018.

Results: We identified a total of 74 patients, comprising 21 men and 53 women. Among them, 38 patients remained relapse-free with maintenance therapy, while 36 experienced relapses despite immunosuppressive management. We followed these patients until June 30, 2023, and 13 patients died. The median survival period was 51.4 months (range, 0.3-214 months). When comparing clinical variables, relapsed patients tended to be younger (49.9 vs. 64.1 years), reported myalgia and rash more frequently (63.9% vs. 28.9% and 61.15% vs. 21.1%, respectively). In terms of laboratory findings, lactate dehydrogenase (LDH) levels were higher in relapsed patients (613±464 vs. 381±203 U/L). Radiological findings showed that ground glass opacity (GGO) was more prevalent in relapsed patients (58.3% vs. 16.7%). A Cox-proportional hazards model for relapse demonstrated that serum LDH [hazard ratio (HR) 1.005, 95% confidence interval (CI): 1.000-1.009, P=0.02] and GGO (HR 1.863, 95% CI: 1.103-3.147, P=0.02) were valuable predictors of relapse. Receiver operating characteristic curve analysis of serum LDH indicated that a threshold of 450 correctly classified relapse in PM/DM-associated ILD patients.

Conclusions: Serum LDH and GGO may serve as predictors of relapse in PM/DM-associated ILD patients.

Background: Enhanced recovery after surgery (ERAS) is a perioperative care protocol, which was introduced several years ago and has gained increasing importance in thoracic surgery. The aim of this study was to provide guidance through clinical implementation and to identify factors for better compliance.

Methods: This prospective cohort study collected data between July 2021 and June 2022 at the Department of Thoracic Surgery (University Hospital Regensburg, Germany). A modified enhanced recovery after thoracic surgery (ERATS) protocol with recommendations covering the pre-, intra- and postoperative phases was established and followed. The primary objective was to evaluate the implementation of the ERATS protocol. Secondary, specific and clinically relevant recommendations were analyzed regarding their compliance.

Results: The study included 139 patients undergoing elective lung resections. Many ERATS recommendations were already part of standard perioperative care, including perioperative antibiotics, venous thromboembolism prophylaxis and intraoperative warming. Other measures such as anemia management, carbohydrate loading or chest drain management were updated or newly established and standardized according to our ERATS protocol. The recommendations emphasizing early postoperative mobilization were found to be crucial. We identified three groups with significantly different compliance rates: (I) patient-dependent measures which require active participation (49.3%); (II) treatment measures requiring interdisciplinary consensus (85.8%); and (III) surgical measures (88%).

Conclusions: The implementation and continuous evaluation of our perioperative ERATS protocol led to a new categorization of targeted measures into three groups with actors of different competencies. The new grouping enables gradual implementation and a step-by-step targeted approach in order to achieve a higher compliance of ERATS in the future as well as long-term sustainability.

Background: Parathyroidectomy remains the only definitive cure for primary hyperparathyroidism (PHPT). In rare cases, ectopic hyperfunctioning glands are located in the mediastinum, necessitating a thoracic surgical approach. The objective of this project was to review a single high-volume institutional experience of this presentation, with specific attention to the use of a robotic-assisted thoracic surgery (RATS) approach.

Methods: This was a single-center, 5-year retrospective cohort study. All patients who underwent RATS mediastinal mass resection (MMR) for PHPT at the University of Colorado Anschutz Medical Campus were targeted for inclusion. Patient cases were reviewed for demographics, history, operative data, laboratory values, and postoperative course.

Results: Eight patients underwent RATS-MMR for PHPT between 2018-2023. Median [interquartile range] operative time was 178 [138-213] minutes, and length of stay was 2.0 [1.5-2.0] days. One patient experienced post-operative chylothorax requiring dietary modification. There were no other 30-day complications or readmissions. Final pathology confirmed intrathymic parathyroid tissue in all patients. All patients achieved cure of PHPT.

Conclusions: The robotic-assisted approach has low morbidity and associated hospital length of stay and can be safely used to cure PHPT. As this is a rare pathology with an infrequently utilized surgical approach, it is important to critically discuss the diagnostic evaluation and operative course, aimed at educating the thoracic surgeon who may encounter and assist in the management of these patients.

Background: Despite widespread application of minimally invasive video-assisted thoracic surgery (VATS), postoperative pain following this procedure is still a constant clinical challenge. Serratus anterior plane (SAP) block is one of the regional analgesic techniques with promising outcomes. However, due to the limited duration of action, optimal analgesia is often not achieved with a single injection. We tested whether in patients who have been subjected to routine SAP block under preoperative anesthesia, the addition of a second SAP block 24 hours after surgery, improves quality of recovery, lowers postoperative opioid consumption, and reduces the prevalence of chronic pain.

Methods: The present study is a single institutional, prospective, randomized, triple-blinded, placebo-controlled study. Ninety patients undergoing VATS from January 2022 to April 2022 were randomized at 1:1 ratio to receive ultrasound-guided second SAP block with 15 mL 0.375% ropivacaine (SAP block group) or 15 mL normal saline (control group) 24 hours after both groups received routine SAP block with 15 mL 0.375% ropivacaine. The primary outcome was quality of patient recovery, measured using 40-item quality of recovery questionnaire (QoR-40) at postoperative day 2 (POD 2). Secondary outcomes included: postoperative pain scores at rest, postoperative opioid consumptions, number of times that patient controlled analgesia (PCA) pump button was pressed, perioperative complications and adverse effects, prevalence of chronic pain at 2^nd and 3^rd month postoperatively, and length of hospital stay (LOS).

Results: A total of 83 patients completed the study: 43 patients in SAP block group and 40 patients in the control group. The global QoR-40 scores on POD 2 and POD 3 were significantly higher among SAP block group patients (180.07±11.34, 182.09±8.20) compared with the control group (172.18±6.15, 177.50±6.94) (P=0.01, P=0.008) respectively. Postoperative pain scores, opioid consumptions and incidence of postoperative nausea and vomiting were significantly lower among patients in SAP block group versus control group. There were no statistically significant differences in perioperative complications and LOS between the two groups. The prevalence of chronic pain at the 2^nd and 3^rd month postoperatively for patients in SAP block group and control group was 16.3%, 14%, and 32.5%, 27.5% respectively.

Conclusions: In patients undergoing VATS, application of ultrasound-guided second SAP block 24 hours after surgery improved postoperative quality of life, reduced opioid consumption and related side effects, and lowered the prevalence of chronic pain.

Spontaneous pneumothorax usually presents as a medical emergency and requires prompt attention and treatment. In patients with underlying lung diseases, it is often associated with prolonged hospitalization, persistent air leak and also a high rate of recurrence. It brings considerable clinical burden to patients and therefore advancement of spontaneous pneumothorax management is eagerly anticipated. In recent years, conservative approach with avoidance of invasive treatment has risen to be a main consideration for primary spontaneous pneumothorax (PSP) patients who are clinically stable with minimal symptoms. The body of evidence in secondary spontaneous pneumothorax (SSP) group is less robust compared with that in PSP group. Non-surgical treatment in SSP is becoming more common due to concerns about morbidity and mortality after surgical pleurodesis as patients are usually older with more underlying medical diseases. Until last year, there have been no updates on the international recommendation of pneumothorax management since the British Thoracic Society (BTS) guideline published in 2010. The latest 2023 BTS guideline on pleural diseases provides us a good opportunity to review the latest development and literature of the care for patients with spontaneous pneumothorax. This article will explore the goals of pneumothorax treatment including air evacuation, cessation of persistent air leak and prevention of recurrence.

Background: Andrographolide sulfonate (Andro-S), a traditional Chinese medicine, is commonly used to treat pediatric respiratory tract infections in China. However, its therapeutic effects in infections caused by respiratory syncytial virus (RSV) have not been reported. We thus aimed to investigate the therapeutic effects of Andro-S using a mouse model of RSV infection-induced airway inflammation.

Methods: Immunocompromised (cyclophosphamide-treated) BALB/c mice were intranasally infected with RSV and treated with intranasal or intraperitoneal Andro-S once daily for five consecutive days, starting on the day of infection. Histopathological changes in the lung were evaluated using hematoxylin and eosin staining. Total inflammatory cell counts and macrophage, lymphocyte, neutrophil, and eosinophil counts in the bronchoalveolar lavage fluid (BALF) were microscopically determined. Interferon-γ (IFN-γ) levels in the BALF were detected using enzyme-linked immunosorbent assay (ELISA). The messenger RNA levels of RSV nucleoprotein (N) and Toll-like receptors (TLRs) 1-9 in lung tissues were determined with quantitative real-time polymerase chain reaction (qRT-PCR). The protein levels of RSV N, RSV fusion protein (F), TLR2, TLR3, and TIR domain-containing adapter-inducing interferon-β (TRIF) were detected via Western blot analysis.

Results: RSV infection caused lung inflammation, manifesting as bronchiolitis, alveolitis, and perivascular inflammation; increased the number of inflammatory cells; and elevated IFN-γ levels in the BALF. Lung inflammation was positively correlated with pulmonary RSV N levels in infected mice. Intranasal Andro-S significantly downregulated RSV N, RSV F, TLR3, and TRIF protein expression in the lung and ameliorated lung inflammation in infected animals. However, intraperitoneal Andro-S showed no effects on lung inflammation caused by RSV infection.

Conclusions: Intranasal Andro-S inhibits RSV replication and ameliorates RSV infection-induced lung inflammation by downregulating TLR3 and TRIF. Therefore, intranasal administration may be a suitable drug delivery method for treating RSV infection.

Background: The combination of three-dimensional printing (3DP) technology and near-infrared fluorescence (NIF) technology using indocyanine green (ICG) has demonstrated significant potential in enhancing surgical margin and safety, as well as simplifying segmental resection. However, there is limited literature available on the integrated use of these techniques. The current study assessed the effectiveness and value of integrating 3DP-NIF technologies in the perioperative outcomes of thoracoscopic segmental lung resection.

Methods: This single-center, retrospective study recruited 165 patients with pulmonary nodules who underwent thoracoscopic segmentectomy. Eligible patients were categorized into two groups: the 3DP-NIF group (71 patients) treated with a combination of 3DP-NIF technology, and the three-dimensional computed tomography bronchography and angiography with modified inflation-deflation (3D-CTBA-ID) group (94 patients). Following rigorous propensity-score matching (PSM) analysis (1:1 ratio), perioperative outcomes between these two approaches were compared.

Results: Sixty-six patients were successfully matched in each group. In the 3D-CTBA-ID group, inadequate visualization of segmental planes was noted in 14 cases, compared to only five cases in the 3DP-NIF group (P=0.03). In addition, the 3DP-NIF group demonstrated a shorter time for clear intersegmental boundary line (IBL) presentation {9 [8, 10] vs. 1,860 [1,380, 1,920] s} (P<0.001), and shorter operative time (134.09±34.9 vs. 163.47±49.4 min) (P<0.001), postoperative drainage time (P<0.001), and postoperative hospital stay (P=0.002) compared to the 3D-CTBA-ID group. Furthermore, the incidence of postoperative air leak was higher in the 3D-CTBA-ID group than in the 3DP-NIF group (33.3% vs. 7.6%, P<0.001).

Conclusions: The combination of 3DP-NIF technologies served as a reliable technical safeguard, ensuring the safe and efficient execution of thoracoscopic pulmonary segmentectomy.