Journal of thoracic disease最新文献

Background: Chylopericardium is a rare disease resulting from lymphatic system dysfunction and characterized by recurrent chylous pericardial effusion and cardiac compression. Traditional treatments like fasting, somatostatin injection and ligation of pericardial lymphatic vessels are less effective, with high recurrence rate. Fenestration is regarded as the last resort for treating chylopericardium. Our team designed a novel minimally invasive pericardial fenestration surgical technique (LONG procedure) for the treatment of chylopericardium. This study assessed its efficacy and technical characteristics, with the aim of providing valuable insights into the surgical treatment and management of chylopericardium.

Methods: The clinical data of 7 patients with chylopericardium treated by the LONG procedure in the lymphatic surgery department from January 2018 to June 2024 were retrospectively analyzed. The data included the patients' medical history, imaging examination, pericardial effusion analysis, operative details, drainage output, length of hospital stay, and follow-up results. The indicators were analyzed to assess the technical characteristics of the LONG procedure.

Results: Seven male patients aged between 7 and 35 years were enrolled in this study. The duration of the disease course ranged from 3 months to 10 years. All patients had previously accepted pericardial drainage, a fat-free diet, and anti-infection treatments. Some patients had also undergone thoracic duct adhesiolysis, embolization, or lymphatic ligation; however, they experienced recurrent pericardial effusion. Upon admission, all patients presented with at least moderate volumes of pericardial effusion. The LONG procedure was successfully performed on all patients, with an operation time of 54 to 95 minutes and minimal intraoperative blood loss (1-5 mL). Chest tubes were removed once the drainage became clear, typically between 15 to 37 days postoperation. Patients were discharged after 1-2 weeks of observation, with no recurrence or complications observed during the follow-up period of up to 5 years.

Conclusions: The LONG procedure seems to be effective for the treatment of chylopericardium with low postoperative recurrence rates, but more research and long-term observation are needed.

Background: Postoperative air leak is the most common complication after pulmonary resection. "Provocative clamping" was first described in 1992 in the context of guiding chest tube removal despite persistent air leak. However, early provocative clamping after pulmonary resection has not been evaluated. This study aimed to evaluate whether provocative clamping leads to severe complications following lung cancer surgery in patients with air leaks, particularly in the context of early chest tube removal.

Methods: This retrospective single-center study included patients who underwent pulmonary resection between September 2022 and October 2023. Air leak on postoperative day 1 or 2 was classified as grade 0-1 (low) or grade 2-4 (high). Low air leak allowed for immediate chest tube removal if there was no apparent pneumothorax or if pleural effusion was <200 mL. Meanwhile, high air leak necessitated chest tube clamping. Radiography was performed 24 hours after (with clamping) if there was no increase in subcutaneous emphysema or symptoms. The chest tube could then be removed if there was no increased pneumothorax.

Results: This study included 74 patients (53 had low leak, and 21 had high leak). The mean chest tube insertion durations were 2.2 days for low leak (range, 1-5 days) and 3.2 days for high leak (range, 2-7 days). The hospital lengths of stay were 3.7 days for low leak (range, 1-6 days) and 4.5 days for high leak (range, 3-8 days). One patient (1.3%) had a prolonged air leak (>5 days). No tension pneumothorax occurred during hospitalization or after discharge. One patient in the high leak group developed hydropneumothorax at 3 weeks after discharge, in whom the chest tube was reinserted.

Conclusions: Use of provocative clamping immediately after pulmonary resection appears to be safe for high-grade air leak patients.

Background: Moderate to severe postoperative pain is common among patients following thoracotomy and serves as a risk factor for developing chronic post-thoracotomy pain (CPTP). This randomized controlled trial evaluated the effects of pre-emptively administered ketamine compared to placebo and standard care on both acute postoperative pain and CPTP.

Methods: Two hundred patients were enrolled in this prospective, randomized trial. The presence and severity of pain were assessed before surgery, first 6 hours after surgery, on postoperative days (PODs) 1-8, 30, and 90. For documentation of neuropathic pain, the Leeds Assessment Score for Neuropathic Symptoms and Signs (LANSS) was used pre- and postoperatively. The incidence and severity of CPTP was assessed by a telephone survey, the self-assessment LANSS (S-LANSS) 30 and 90 days after surgery.

Results: There was significant difference in numeric rating scale (NRS) pain scores when coughing in the first 6 hours after surgery, with less pain in the ketamine group. No difference was seen in NRS pain scores at rest and coughing between the ketamine and placebo group on PODs 1-8. There was no difference in the opioid consumption between the two groups. Thirty-four (18.7%) of the patients had a S-LANSS score ≥12 30 days following surgery, 12 (12.8%) in the ketamine group vs. 22 (25%) in the placebo group (P=0.001). Thirty-three (18.2%) of all patients had a S-LANSS score ≥12 90 days following surgery 8 (8.5%) in the ketamine group vs. 25 (28.4%) in the placebo group (P<0.001).

Conclusions: In summary, pre-emptive ketamine does not reduce opioid consumption and NRS scores after thoracotomy but more importantly it lowers significantly the incidence of chronic postoperative pain, especially neuropathic pain.

Trial registration: The study was registered at ClinicalTrials.gov (NCT03105765).

Background: Controversy continues over the application of wedge resection and segmentectomy for the early stage of non-small cell lung cancer (NSCLC) without affecting long-term survival. This study aimed to investigate the acceptability of wedge resection as an alternative to segmentectomy in patients with T1aN0M0 NSCLC with data from the Surveillance, Epidemiology, and End Results (SEER) database.

Methods: A total of 742 patients with pT1aN0M0 NSCLC from the SEER database were finally involved in this study, including 130 patients in the segmentectomy group and 612 patients in the wedge resection group. Three matching methods, including propensity score matching (PSM), coarsened exact matching (CEM), and inverse probability of treatment weighting using the propensity score (IPTW) were introduced to control and minimize the potential bias. Prognostic analysis was conducted using the Kaplan-Meier method and Cox regression after matching the two groups (P<0.02).

Results: After matching, wedge resection and segmentectomy pairs were well matched without significant differences in all clinical and tumor factors. The prognostic analysis of overall survival (OS) showed no significant difference between wedge resection and segmentectomy in PSM analysis (log-rank test, P=0.08), IPTW analysis (log-rank test, P=0.09), and CEM analysis (log-rank test, P=0.03), respectively. The multivariant Cox analysis revealed that age (P<0.001), sex (P<0.001), histology (P<0.001) and grade (P=0.004) were significant independent prognostic factors for OS.

Conclusions: Wedge resection could be an alternative procedure for patients with pT1aN0M0 NSCLC without affecting survival.

Background: The optimal extent of lymph node resection for early-stage non-small cell lung cancer (NSCLC) remains a topic of debate in the medical community. We aimed to assess the surgical and prognostic outcomes based on the extent of mediastinal lymph node dissection (MLND) for resectable clinical stage IA NSCLC.

Methods: From 2016 to 2018, 1,166 patients with clinical stage IA NSCLC who underwent lobectomy or segmentectomy with complete mediastinal lymph node dissection (C-MLND) or selective mediastinal lymph node dissection (S-MLND) at five hospitals were enrolled. Propensity score matching (PSM) was used to reduce selection bias. Perioperative parameters, postoperative complications, survival and disease control were compared between the groups.

Results: S-MLND and C-MLND were performed on 197 and 969 patients, respectively. After PSM, each group comprised 126 patients and there was no significant difference in 5-year recurrence-free survival (RFS) (C-MLND vs. S-MLND, 87.5% vs. 82.9%; P=0.32) or overall survival (OS) (C-MLND vs. S-MLND, 92.0% vs. 95.9%; P=0.39) between the groups. Similar results were observed for perioperative parameters, pN2 detection (6.3% vs. 4.8%, P=0.11) and recurrence patterns (P=0.28). However, the incidence of postoperative complications was significantly lower in the S-MLND cohort than that in the C-MLND cohort (12.7% vs. 23.0%, P=0.03).

Conclusions: S-MLND demonstrated outcomes that were comparable to those of C-MLND and a reduction in complications, indicating the potential of S-MLND as an alternative approach for selected patients with stage IA NSCLC. Prospective, randomized trials are recommended to confirm these findings and establish clear clinical guidelines.

Background: Cardiac surgery-associated acute kidney injury (CSA-AKI) results in poor prognosis. Several risk factors for CSA-AKI have been reported, including preoperative creatinine level, cardiopulmonary bypass time, and perioperative blood pressure management. Only few studies have reported the effect of vascular stiffness on the incidence of CSA-AKI, and there are is no study reporting on endothelial function and its association with CSA-AKI. The purpose of this study was to evaluate the association between preoperative vascular function, including vascular stiffness and endothelial function, and incidence of CSA-AKI.

Methods: In this prospective observational study, 40 consecutive patients undergoing valve surgery were enrolled. Flow-mediated dilation (FMD) and pulse wave velocity (PWV) were measured before surgery for the evaluation of endothelial function and vascular stiffness. Blood test was also performed for the measurement of serum biomarkers including asymmetric dimethylarginine (ADMA) and vascular cell adhesion molecule-1 (VCAM-1). CSA-AKI was diagnosed by using the Kidney Disease Improving Global Outcomes (KDIGO) criteria.

Results: The mean age of the patients was 72±8.2 years old and 60% were male. All patients underwent valve surgery with two patients undergoing concomitant coronary artery bypass grafting. Preoperative FMD and PWV were 6.3%±2.58% and 1,554±386.6 cm/s respectively. ADMA and VCAM-1 were significantly correlated (r=0.50, P=0.001), and there was a significant correlation between FMD and ADMA (r=-0.42, P=0.007), and FMD and VCAM-1 (r=-0.42, P=0.007). Eleven patients (27.5%) developed CSA-AKI. FMD was lower in patients with CSA-AKI (no AKI: 6.9%±2.57% vs. AKI: 4.6%±1.77%, P=0.009) and PWV was higher in patients with CSA-AKI (no AKI: 1,467±296.4 cm/s vs. AKI: 1,784±506.7 cm/s, P=0.02). Further, VCAM-1 was higher in patients with CSA-AKI (no AKI: 696±247.5 ng/mL vs. AKI: 879±196.2 ng/mL, P=0.03). Multivariable analysis showed that preoperative FMD was an independent risk factor for CSA-AKI (odds ratio: 0.54, P=0.049).

Conclusions: VCAM-1, FMD, and PWV were associated with incidence of CSA-AKI. These measurements may be useful in evaluation of potential risk of CSA-AKI in patients undergoing valve surgery.

Background: The benefits of pulmonary rehabilitation (PR) for patients with idiopathic pulmonary fibrosis (IPF) have been limited to improving dyspnea, exercise capacity, and quality of life (QoL). This study aimed to assess the current status of PR and its effect on prognosis.

Methods: The Nationwide Korean Health Insurance Review and Assessment Service (HIRA) database was used in this study. Annual PR implementation rate since 2016 following its coverage in the health insurance was analyzed. IPF cases were defined using the International Classification of Diseases 10^th Revision (ICD-10) codes and rare intractable diseases (RID) codes. Risk of acute exacerbation (AE) and mortality of IPF patients with or without PR were analyzed.

Results: Of the 4,228 patients with IPF, only 205 (4.85%) received PR. Patients in the PR group were more frequently treated with pirfenidone and systemic steroids than non-PR group. In patients treated with steroids, mortality risk increased regardless of PR application, with hazard ratio (HR) of 1.63 [95% confidence interval (CI): 1.26-2.10, P<0.001] in the PR group and 1.38 (95% CI: 1.21-1.57, P<0.001) in the non-PR group, compared to those not treated with steroids. Additionally, PR did not significant affect mortality risk in patients not receiving steroids (HR, 1.49, 95% CI: 0.87-2.54, P=0.15). Similar patterns were seen for the risk of AE.

Conclusions: PR was applied in only a minority of patients with IPF. It did not succeed in reducing the risk of AE or mortality. A prospective study targeting early-stage patients is needed to evaluate the impact of PR considering the progressive nature of IPF disease itself.

Chest computed tomography (CT) is the most frequently performed imaging examination worldwide. Compared with chest radiography, chest CT greatly improves the detection rate and diagnostic accuracy of chest lesions because of the absence of overlapping structures and is the best imaging technique for the observation of chest lesions. However, there are still frequently missed diagnoses during the interpretation process, especially in certain areas or "blind spots", which may possibly be overlooked by radiologists. Awareness of these blind spots is of great significance to avoid false negative results and potential adverse consequences for patients. In this review, we summarize the common blind spots identified in actual clinical practice, encompassing the central areas within the pulmonary parenchyma (including the perihilar regions, paramediastinal regions, and operative area after surgery), trachea and bronchus, pleura, heart, vascular structure, external mediastinal lymph nodes, thyroid, osseous structures, breast, and upper abdomen. In addition to careful review, clinicians can employ several techniques to mitigate or minimize errors arising from these blind spots in film interpretation and reporting. In this review, we also propose technical methods to reduce missed diagnoses, including advanced imaging post-processing techniques such as multiplanar reconstruction (MPR), maximum intensity projection (MIP), artificial intelligence (AI) and structured reporting which can significantly enhance the detection of lesions and improve diagnostic accuracy.