Journal of thoracic disease最新文献

Background: Aortic coarctation (COA) in adults combined with poststenotic aneurysm (PA) or poststenotic dissection (PD) is rare and challenging to manage. The existence of multiple factors such as kinking, comorbidities, previous surgical history, and descending aortic lesions increases the difficulty of treatment, and there are currently few clinical reports. The purpose of this study was to present our surgical experience in dealing with such patients.

Methods: A retrospective study was conducted on 20 consecutive patients with COA combined with PA or PD who were treated in our center from December 2015 to April 2019. The basic principles, methods, and short- and mid-term prognosis of surgery are present carefully. This paper introduces the individualized treatment scheme as well as its advantages and disadvantages in detail.

Results: The condition of the included patients was complicated, including 12 cases of PA and 8 of PD. Although different surgical schemes were adopted, procedural success rate was 100%. There were no other surgical complications except 2 cases of anastomotic bleeding and 1 case of spinal cord injury. The results of computed tomography angiography (CTA) demonstrated that 9 cases achieved anatomical correction, 10 cases of PA or PD were eliminated or thrombosed to varying degrees, and only 1 case of PA had no obvious change. Up to the follow-up period, except for 1 patient who had a slight cerebrovascular accident and 1 who had no change in PA underwent cheatham platinum (CP) stent surgery, no other cardiovascular adverse events occurred and all patients recovered well.

Conclusions: The optimal surgical strategy developed collaboratively by cardiac surgeons and endovascular specialists has achieved satisfactory short- and mid-term results for COA patients combined with PA or PD. Further research is still necessary, due to the limited number of cases.

Background: Minimally invasive concepts are increasingly influential in modern cardiac surgery. This study aimed to evaluate the effect of completeness of revascularization on clinical outcomes and overall survival in minimally invasive, thoracoscopic coronary artery bypass grafting (CABG) surgery.

Methods: We retrospectively evaluated a consecutive series of 1,149 patients who underwent minimally invasive off-pump CABG with single, double, or triple-vessel revascularization between 2007 and 2018. Of these patients, 185 (16.1%) had incomplete revascularization (IR) (group I), and 964 (83.9%) had complete revascularization (CR) (group C). We used gradient boosted propensity score estimation to account for possible confounding variables.

Results: Median age was 69 years, interquartile range (IQR) 60-76 years, and median EuroSCORE II was 4, IQR 2-7. Of the 1,149 patients, 495 patients suffered from two vessel disease (VD) and 353 presented with three VD. Long-term median follow-up 5.58 (3.27-8.48) years was available for 1,089 patients (94.8%). The incidence of recurrent or persisting angina, myocardial infarction, redo-bypass surgery, and stroke during follow-up did not differ significantly between groups. During follow-up, there were 47 deaths in group I and 172 deaths in group C. The 1-, 3-, 5-, 8-, and 10-year unadjusted survival rates were 94%, 84%, 75%, 62%, and 51% for group I, and 97%, 94%, 88%, 77%, and 72% for group C, respectively (long-rank test P<0.001), favouring CR. Following risk adjustment the long-rank test P value for survival was 0.23.

Conclusions: In minimally invasive coronary surgery, IR resulted in decreased long-term survival, but did not achieve statistical significance after risk adjustment. However, IR should only be used in carefully selected cases.

Background: Anastomotic leakage (AL) has always been one of the most serious complications of esophagectomy with gastric conduit reconstruction. There are many strong risk factors for AL in clinical practice. Notably, the tension at the esophagogastric anastomosis and the blood supply to the gastric conduit directly affect the integrity of the anastomosis. However, there has been a lack of quantitative research on the tension and blood supply of the gastric conduit. Changes in extracellular matrix collagen reflect tension and blood supply, which affect the quality of the anastomosis. This study aimed to establish a quantitative collagen score to describe changes in the collagen structure in the extracellular matrix and to identify patients at high risk of postoperative AL.

Methods: A retrospective study of 213 patients was conducted. Clinical and pathological data were collected at baseline. Optical imaging of the "donut" specimen at the anastomotic gastric end and collagen feature extraction were performed. Least absolute shrinkage and selection operator (LASSO) regression models were used to select the significant collagen features, compute collagen scores, and validate the predictive efficacy of the collagen scores for ALs.

Results: LASSO regression analysis revealed three collagen-related parameters in the gastric donuts: histogram mean, histogram variance, and histogram energy. Based on this analysis, we established a formula to calculate the collagen score. The results of the univariate analysis revealed significant differences in the preoperative low albumin values (P=0.002) and collagen scores between the AL and non-AL groups (P=0.001), while the results of the multivariate analysis revealed significant differences in the collagen scores between the AL and non-AL groups (P=0.002). The areas under the curve (AUCs) of the experimental and validation cohorts were 0.978 [95% confidence interval (CI): 0.931-0.996] and 0.900 (95% CI: 0.824-0.951), respectively.

Conclusions: The collagen score established herein was shown to be related to AL and can be used to predict AL in patients who underwent esophagectomy.

Background and objective: Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, fibrotic interstitial pneumonia, which is the commonest type of idiopathic interstitial pneumonia in the clinic. For most patients, the course of the disease is slow and prolonged, but a percentage of them develop an acute respiratory worsening during the disease, known as an acute exacerbation of IPF (AE-IPF). The updated guidelines define AE-IPF as an acute worsening of dyspnea in an IPF patient within 1 month and exclude other conditions such as left heart failure and pulmonary embolism. However, the prevention and treatment of AE-IPF are still unclear. Based on the high mortality rate caused by AE, in this article, we will focus on the latest research advances in AE-IPF treatment strategies and provide a comprehensive review of its pathogenesis, risk factors, clinical features, and diagnosis.

Methods: This study searched for relevant literature published from 2018 to 2023 in the PubMed database. The search terms used were as follows: "Acute exacerbation", "Idiopathic pulmonary fibrosis", "Biomarker", "Pathogenesis", "Treatment", "HRCT", "Antifibrotic", "Infection", "Immunosuppressant", "Autoantibody", "Oxygen therapy", "Hemoperfusion", "Inflammation".

Key content and findings: The review found that corticosteroids are still the primary treatment strategy at present, although there is some controversy regarding the dosing and tapering of corticosteroids. However, corticosteroids combined with intravenous cyclophosphamide have been shown to be detrimental to the prognosis of patients with AE-IPF. Given its deadly high mortality rate, early intervention is crucial. Pirfenidone and nintedanib have been proven to reduce incidence of AE. Meanwhile, in the future, the lung microbiome may also be a break-through.

Conclusions: This study reviewed the pathogenesis and risk factors of AE-IPF and updated the current and potential treatment strategies regarding AE-IPF. The pathogenesis of AE-IPF is not exact, multiple mechanisms may be involved simultaneously. Corticosteroids remain the mainstream treatment modality in the medical treatment of AE-IFP. Many other treatment modalities have been proposed in succession, but no clear conclusions can be drawn about the effectiveness and safety of these interventions.

Background and objective: Primary and secondary chest wall tumors (bone, breast, and soft tissue), congenital defects, and chest wall osteoradionecrosis often require extensive full-thickness local excisions to guarantee safe oncological margins (in cases of tumors) and complex reconstruction to provide stabilization and good biomechanical results avoiding postoperative respiratory failure. Thus, a personalized approach is required when dealing with chest wall defects, and reconstruction is planned. This review summarizes failed chest wall reconstruction procedures, identifies causes of failure, and highlights principles for complex chest wall reconstruction post-failure.

Methods: We performed a narrative review of the literature on PubMed, Scopus, ScienceDirect, and Google Scholar, including all the relevant studies published from 1970.

Key content and findings: The available experiences in literature are only anecdotic and no current guidelines or rules exist on this topic, also given to its rarity. Proper pre-surgical planning and a multidisciplinary team (MDT) discussion are crucial for complex cases such as infections and radiation-induced chest ulcers after previous surgical treatment. Procedures should eventually include thoracic wall debridement, necrotic tissue excision, pulse-jet lavage, prosthesis removal, and vacuum assisted closure (VAC) therapy as a bridge for chest wall re-reconstruction. Sternotomy wounds require wire and prosthesis removal, and the use of meshes or bone allografts. This review aims to summarize experiences and highlight surgical and oncologic principles for complex chest wall reconstruction after failure.

Conclusions: This review summarizes literature experiences to identify common key points for chest wall reconstruction after failure and to give some advice to surgeons managing this rare, challenging surgery.

Background: Limited data are available regarding the current microbiological characteristics of extracorporeal membrane oxygenation (ECMO)-related infections in intensive care units (ICUs) in China. This retrospective study aimed to determine the epidemiology, risk factors and impact on the outcome of ECMO-related infections.

Methods: A retrospective observational study from January 2014 to December 2019 was performed, and adult patients receiving ECMO support for more than 48 hours were included in this study. The primary outcome was the incidence rate of ECMO-related infection. Clinical data were recorded, and risk factors associated with an increased risk of ECMO-related infection were analyzed.

Results: A total of 174 adult patients who received ECMO and underwent ECMO for 1,670 days were included in this study. Forty-six patients (26.4%) developed ECMO-related infections, corresponding to 27.5 first episodes/1,000 ECMO days. The most common ECMO-related infection observed was ventilator-associated pneumonia (VAP). Infected patients had longer durations of mechanical ventilation {20.2 [interquartile range (IQR), 12.6, 30.7] vs. 9.0 (IQR, 5.8, 14.7) days, P<0.001}, ECMO support [11.6 (IQR, 8.1, 17.3) vs. 7.6 (IQR, 5.6, 9.7) days, P<0.001] and hospital stays (28.2±20.7 vs. 22.0±15.6 days, P<0.001). The factors independently associated with ECMO-related infection were a dynamic decrease in lymphocyte count [adjusted odds ratio (OR) =3.578, 95% confidence interval (CI): 2.175-4.906, P<0.001] and ECMO duration (adjusted OR =1.207, 95% CI: 1.096-1.330, P<0.001). Compared to patients without infection, infected patients had greater hospital mortality (39.1% vs. 78.3%, P<0.001) and 90-day mortality (40.6% vs. 87.0%, P<0.001). ECMO-related infections were associated with worse outcomes (adjusted Kaplan-Meier curve, log rank test P<0.001).

Conclusions: Patients supported by ECMO had a high risk of developing ECMO-related infection. The most common ECMO-related infection observed was VAP. A dynamic decrease in lymphocyte counts was significantly associated with an increased risk of ECMO-related infection.

Background: Anaplastic lymphoma kinase (ALK)-rearranged pulmonary squamous cell carcinoma (SCC) is a rare subtype of non-small cell lung cancer and the treatment options are limited. We aimed to evaluate the efficacy of ALK tyrosine kinase inhibitors (TKIs) in advanced lung SCC patients with ALK rearrangement.

Methods: We collected 11 primary lung SCC samples at the Zhejiang Cancer Hospital between March 2015 and October 2022. In addition, we conducted a literature search of previous studies, and a pooled analysis of 34 patients was performed. The Kaplan-Meier method was applied to generate progression-free survival (PFS) and overall survival (OS) curves, and a log-rank test was used to compare PFS and OS curves for different subgroups.

Results: A pooled analysis of 36 patients was performed. Nineteen patients (52.8%) achieved partial response and 9 (25.0%) had stable disease. The objective response rate was 52.8%, and the disease control rate was 77.8%. The median PFS was 7.10 months. Further, alectinib was not superior to crizotinib in prolonging PFS (9.00 vs. 6.00 months, P=0.60). The median PFS of patients receiving initial ALK TKIs as the first-line therapy and second- or further-line therapy was 9.00 and 6.00 months (P=0.26), respectively.

Conclusions: Patients with ALK-rearranged lung SCC obtained moderate benefit from ALK-inhibitor therapy. Compared with crizotinib, alectinib did not show superior efficacy in the treatment of ALK-positive lung SCC. Further high-quality trials are warranted.

Background: Postoperative recovery in lung cancer patients is a complex process, where breathing exercises may play a crucial role in enhancing pulmonary function and quality of life (QoL). This study systematically reviews and meta-analyzes the impact of breathing exercises on post-surgical lung function and QoL in lung cancer patients.

Methods: An extensive literature search was conducted across PubMed, Cochrane, Web of Science, and Embase databases using terms like "Lung Neoplasms", "breathing exercises", and "randomized controlled trial", supplemented by Medical Subject Headings (MeSH) and free words. The Cochrane risk of bias tool was used for quality assessment. A systematic review and meta-analysis on the effects of breathing exercises post-lung cancer surgery followed by data extraction and quality evaluation.

Results: From 384 retrieved studies, 10 met the inclusion criteria and were selected for detailed analysis. The main outcomes assessed were postoperative pulmonary function indices and QoL measures. The majority of studies were deemed 'low risk' for random sequence generation and allocation concealment. However, due to the nature of the interventions, blinding was a 'high risk' in most cases. The meta-analysis revealed significant improvements in key pulmonary function indices: forced vital capacity (FVC%) increased by an average of 1.73%, maximal voluntary ventilation (MVV) improved by 7.58 L/min, and maximal inspiratory pressure (MIP) enhanced by 0.95 cmH₂O. Additionally, there was a notable alleviation of postoperative dyspnea and an enhancement in QoL, with anxiety scores decreasing by an average of 3.42 points and complication rates reducing correspondingly. However, the interventions did not significantly affect physical activity levels or performance on the 6-minute walk test (6WMT), with effect sizes for these outcomes being non-significant.

Conclusions: This study indicates that breathing exercises significantly improve postoperative pulmonary function and QoL in lung cancer patients. Future research should delve into the mechanisms behind these exercises and evaluate their long-term rehabilitation effects. Customized programs could further optimize recovery and enhance patient QoL.

Background: Varicella pneumonia is one of the most common and severe complications of chickenpox infection. This study aimed to describe the clinical and radiological features of varicella pneumonia in a cluster of immunocompetent adolescents.

Methods: A retrospective analysis was conducted on a cohort of adolescent patients diagnosed with varicella pneumonia at Wuhan Jinyintan Hospital between February 2023 and May 2023. The clinical and imaging data were collected and analyzed. A total of 116 patients were divided into two groups by the absence (group 1, n=57) or presence (group 2, n=59) of lower respiratory symptoms for data comparison.

Results: Among 116 patients (median age, 16 years; 60 males), rash (100%) was the most prevalent clinical symptom. The most common respiratory symptom and sign were fever (42.2%) and coarse breath sounds (41.4%). Chest computed tomography (CT) performed within five days of symptoms onset revealed multiple (89.7%), peripheral (51.7%), and ill-defined (73.3%) lung nodules in most patients, which gradually improved 6-10 days after symptom onset. Group 2 had higher levels of interleukin-6 (P<0.001), C-reactive protein (P=0.02), serum amyloid-A protein (P=0.002), longer hospital stays (P=0.04), more involved lung lobes (P=0.02), and a higher incidence of multiple nodules (P=0.043) than those of group 1.

Conclusions: In immunocompetent adolescents, clustered varicella pneumonia often presents as mild and more uniform in clinical and radiological presentations than sporadic cases. The most common CT findings were multiple pulmonary nodules. Patients with lower respiratory symptoms exhibited more severe clinical and radiological manifestations. Generally, it is not recommended that patients undergo frequent CT scans in a short period.

Background: Currently, chemotherapy plus immunotherapy followed by maintenance therapy with immune monotherapy is the preferred first-line treatment option for extensive-stage small cell lung cancer (ES-SCLC), but with limited overall survival (OS) and progression-free survival (PFS) benefits. The combination of anti-angiogenic drugs with immunotherapy has shown encouraging anti-tumor activity and tolerability, with some degree of overcoming immune resistance. This study aimed to evaluate the effectiveness and safety of anlotinib plus anti-programmed cell death 1/ligand 1 (anti-PD-1/PD-L1) antibodies as maintenance therapy after first-line chemotherapy combined with immunotherapy in ES-SCLC.

Methods: Between June 2020 and December 2021, 12 patients with newly diagnosed ES-SCLC in the First Affiliated Hospital of Army Medical University were retrospectively analyzed. All patients without disease progression after 4-6 cycles of first-line platinum-containing chemotherapy plus anti-PD-1/PD-L1 antibodies received anlotinib (12 mg oral/day, days 1-14, followed by 1 week off, every 3 weeks per cycle) plus anti-PD-1/PD-L1 antibodies as maintenance therapy. Several patients underwent chest radiotherapy (intensity-modulated radiotherapy using a 6 MV X-ray) without disease progression before maintenance therapy. The effectiveness and safety of anlotinib plus anti-PD-1/PD-L1 antibodies as maintenance therapy after first-line chemotherapy combined with immunotherapy in ES-SCLC were evaluated.

Results: The median follow-up time was 31.1 months. During first-line treatment (including maintenance therapy), one patient achieved a complete response, eight patients achieved a partial response (PR), and three patients had stable disease, with an objective response rate of 75.0% and a disease control rate of 100.0%. During maintenance therapy with anlotinib plus anti-PD-1/PD-L1 antibodies, 50.0% of patients achieved further lesion remission on the basis of the prior initial treatment, of which one patient achieved a PR. The median PFS was 13.6 [95% confidence interval (CI): 11.2-15.6] months, and the median OS was 19.5 (95% CI: 14.5-24.5) months. Treatment-related any grade and grade 3-4 adverse events (AEs) were reported in 100.0% and 58.3% of patients, respectively. No life-threatening AEs were observed. Grade 3-4 AEs included leukocytopenia (58.3%, 7/12), thrombocytopenia (33.3%, 4/12), nausea (33.3%, 4/12), anemia (16.7%, 2/12), and fatigue (8.3%, 1/12). All AEs during maintenance therapy were tolerated and were regarded as grade 1-2, with the majority being fatigue, nausea, rash, and hemoptysis.

Conclusions: The combination of anlotinib with anti-PD-1/PD-L1 antibodies demonstrated encouraging effectiveness and safety in treating patients with ES-SCLC, suggesting that it may be a preferred option for maintenance therapy after first-line chemotherapy combined with immunothera