Journal of thoracic disease最新文献

Background: Lung cancer predominantly affects elderly patients, in whom curative thoracic surgery is often complicated by potentially fatal postoperative complications. This study aimed to identify preoperative risk factors and develop a prediction model for major postoperative complications (MPCs) to better select elderly patients for lung cancer surgery.

Methods: We retrospectively reviewed medical records of elderly lung cancer patients treated surgically at Peking University Cancer Hospital from 1995 to 2019. Postoperative MPC occurring within 30 days was rigorously documented and defined according to the Clavien-Dindo grading system. Independent preoperative risk factors of MPC were determined using multivariable logistic regression. Candidate predictors were selected through a two-stage process combining logistic regression with minimization of the Akaike information criterion. Model performance was validated using the area under the receiver operating characteristic curves (AUC), calibration plots, and decision curve analysis (DCA). The model was internally validated using bootstrapping method. A nomogram was also constructed. Additional risk stratification and sensitivity analyses were performed to validate the effectiveness and reliability of the model.

Results: Among 989 patients enrolled, 6.67% experienced MPC. After adjustment in the multivariable logistic regression analysis, thoracotomy emerged as the strongest independent risk factor for MPC [odds ratio (OR) =4.84, 95% confidence interval (CI): 2.53-9.27]. The prediction model incorporating nine preoperative variables achieved an AUC of 0.815 (95% CI: 0.759-0.871). The final model demonstrated robust discrimination after internal validation (bootstrapped AUC =0.779, 95% CI: 0.723-0.836), and DCA confirmed its clinical utility. Risk stratification analysis revealed a 10.5-fold increase in the incidence of MPC among patients classified as high-risk compared with those at low-risk. Finally, an easy-to-use online tool was developed to potentially assist physicians in the clinic.

Conclusions: Thoracotomy significantly increased the risk of MPC. This newly developed model provides valuable support for surgical decision-making and facilitates tailored perioperative care strategies for elderly lung cancer patients.

Background and objective: 3-dimensional (3D) reconstruction techniques, including physical forms such as 3D printing, and virtual forms such as virtual and augmented reality (VR/AR), are gaining popularity. Multiple platforms have received regulatory approval and many more are being developed for use in thoracic surgery. However, uptake of these technologies has been slow, likely owing to poor understanding, unclear guidance on implementation, and associated costs. In this context, we aim to provide a review of the existing literature on 3D reconstruction in thoracic surgery, while also forming a guide for thoracic surgeons.

Methods: We searched PubMed using MeSH term "thoracic surgery" combined individually with "augmented reality", "virtual reality", and "3D reconstruction". We limited the search to the last 15 years [2010-2025] with results totaling 287 publications. We identified the highest impact articles involving each of these technologies. We also searched the Food and Drug Administration (FDA) website and identified 510k-approved VR and AR technologies with the potential for use in thoracic surgery.

Key content and findings: We broke up our findings into four main sections: (I) how these models are created; (II) indications for use in thoracic surgery; (III) models that are currently available; and (IV) surgeons' perceptions and limitations. These models are typically built from traditional imaging, such as computed tomography scans, segmented into individual structures either manually or via artificial intelligence, and then placed into a file compatible with either projection on VR/AR headsets or a 3D printer. These models can then be used in a variety of ways in thoracic surgery, such as training, pre-operative planning, intra-operative guidance, or creation of 3D-printed prostheses. Currently, the primary limitations are varying accuracy of models, available evidence for use, uptake by surgeons, and cost of the technology.

Conclusions: 3D reconstruction and mixed reality platforms are an important development with many uses within thoracic surgery. Further study into their development, use, and safety will be vital in the coming years. Surgeons should understand these uses and limitations prior to implementation into practice.

Background: Trans-sternal thymectomy has been shown to be an effective treatment for select patients with non-thymomatous myasthenia gravis (MG). The purpose of this study was to evaluate whether similar neuromuscular benefits are achieved when utilizing minimally invasive surgical approaches to thymectomy, as compared to a trans-sternal approach, in patients with non-thymomatous MG.

Methods: Pooled data for all patients undergoing thymectomy from 2012 to 2020 for non-thymomatous MG from four institutions were retrospectively reviewed. Patients were stratified by surgical approach, minimally invasive [robotic or video-assisted thoracoscopic (VATS) vs. trans-sternal]. Clinical neurologic follow-up was ascertained from the medical record by a neurologist at 3-month intervals, for 2 years postoperatively.

Results: A total of 54 patients were included with 54% (n=29) undergoing minimally invasive thymectomy (MIT) and 46% (n=25) undergoing a trans-sternal approach. There were no differences in baseline disease severity measured by proportion requiring intravenous immunoglobulin (IVIG), quantitative myasthenia scores, or daily prednisone dose. Similarly, there were no significant differences in major comorbidities. There was one conversion to a sternotomy for innominate vein bleeding. Perioperative complications were uncommon and largely similar between groups. Patients undergoing minimally invasive surgery had decreased length of hospital stay (2.5 vs. 5 days, P<0.01). There were no differences observed in prednisone dose or quantitative myasthenia scores during the 2-year follow-up period.

Conclusions: Our study confirms the results of the landmark MGTX (Randomized Trial of Thymectomy in Myasthenia Gravis) trial in a real-world multicenter experience. Similar outcomes were achieved regardless of surgical approach. These data support thymectomy for MG either by a minimally invasive or trans-sternal approach. This is the first study to compare disease-specific, rather than perioperative, outcomes of thymectomy via sternotomy vs. minimally invasive approach.

Background: Postoperative intensive care plays a crucial role in the perioperative management of coronary artery bypass graft (CABG) surgery. It is well established that patients requiring prolonged mechanical ventilation (PMV) have an increased risk of developing multiple secondary complications such as ventilator-associated pneumonia accounting for the increase of overall morbidity and mortality. The primary focus of our investigation was to identify new risk factors associated with PMV following CABG surgery.

Methods: All patients who underwent isolated coronary artery bypass surgery and were treated in an interdisciplinary surgical intensive care unit (ISICU) of a tertiary University Medical Center in 2023 were included in this retrospective observational study.

Results: A total of 339 patients were included in the study. Among the 280 patients who were successfully extubated within 24 hours after surgery (82.6%), the median ventilation time was 15 hours. In contrast, in the PMV group, the median ventilation time was 48.5 hours. Explorative statistical analysis showed significant differences between the two groups for duration of ventilation, ischemia time, time on cardiopulmonary bypass (CPB), duration of surgery, intensive care unit (ICU) length of stay, hospital length of stay, postoperative drainage loss within 12 and 24 hours after surgery, as well as the European System for Cardiac Operative Risk Evaluation (EuroSCORE). In-hospital mortality was greater in patients with PMV compared to patients without PMV (10.2% vs. 0.0%, P<0.001). Multivariate logistic regression analysis revealed longer time on CPB [odds ratio (OR) =1.01, 95% confidence interval (CI): 1-1.02], a lactate peak within the first 24 hours (OR =1.35, 95% CI: 1.2-1.53), and a higher preoperative EuroSCORE (OR =1.23, 95% CI: 1.05-1.45) as significant independent association for the development of PMV.

Conclusions: Comprehensive understanding of the factors that increase the risk of PMV and a precise characterization of patients prone to PMV are considered essential for the management by the attending intensivist. Early identification of risk factors enables the implementation of targeted interventions, which may optimize intensive care management and ultimately contribute to improved patient outcomes.

[This corrects the article DOI: 10.21037/jtd-24-331.].

Background: Idiopathic pulmonary fibrosis (IPF) is a poor prognostic fibrotic interstitial lung disease (ILD) of unknown etiology. Similarly, the prognosis of patients with ILD and progressive pulmonary fibrosis (PPF) is poor. Nintedanib reduces the decline in forced vital capacity (FVC) and improves the survival of patients with IPF and non-IPF ILDs meeting PPF criteria (hereafter "PPF"). Diarrhea is a significant adverse event associated with nintedanib, and it is sometimes the reason for the discontinuation of the drug. In this study, we aimed to identify clinical predictors of nintedanib-induced diarrhea and to clarify significance of ILD biomarkers to predict their occurrence after the adjustment using the significant clinical predictors.

Methods: Seventy-nine patients with ILDs treated with nintedanib were included in this study. Diarrhea was retrospectively evaluated based on interviews, and medical records were reviewed for other clinical findings. Furthermore, biomarkers including surfactant protein-D (SP-D) serum levels and peripheral blood monocyte counts were examined. Parameters' predictive abilities were examined using univariate and multivariate logistic regression analyses.

Results: Participants comprised 57 males and 22 non-smokers. The underlying ILDs included IPF (n=39) and PPF (n=40). PPF included idiopathic interstitial pneumonia (IIP) other than IPF (n=19), fibrotic hypersensitivity pneumonitis (FHP) (n=8), connective tissue disease-related ILDs (CTD-ILDs) (n=8), and other ILDs (n=5). Fourteen patients underwent corticosteroid therapy at the initiation of nintedanib. Nintedanib-induced diarrhea occurred within 3 months in 47 patients (IPF, n=30; PPF, n=17). IPF, no corticosteroid therapy, nintedanib per body surface area (BSA), and %FVC ≤80% were associated with the occurrence of diarrhea within 3 months after commencing nintedanib treatment by multivariate logistic regression analysis. Additionally, monocyte counts ≤650/µL and serum SP-D >157.5 ng/mL were associated with occurrence of diarrhea after the adjustment of other factors.

Conclusions: Nintedanib-induced diarrhea is significantly associated with various complex factors. IPF, no corticosteroid therapy, a higher nintedanib dose per BSA, and a lower %FVC were associated with the occurrence of diarrhea within 3 months of initiating nintedanib therapy. Lower monocyte counts and higher levels of serum SP-D at the initiation of nintedanib might suggest occurrence of diarrhea. Although large-scale studies are needed to draw definite conclusions regarding our hypothesis, the results of our study and hypothesis of nintedanib-induced diarrhea might suggest future research direction and lead to new management of nintedanib-induced diarrhea.

Background: The treatment of esophageal cancer requires optimized surgical approaches to improve patient outcomes. Minimally invasive esophagectomy (MIE) has demonstrated advantages compared to open procedures, but the difference in efficacy of single-incision versus multi-incision techniques under various reconstruction routes remains unclear. This retrospective propensity-weighted study aimed to evaluate the perioperative outcomes and short-term functional recovery between single-incision laparo-thoracoscopic MIE with retrosternal reconstruction (SIMIE-RS) and multi-incision MIE with posterior mediastinal reconstruction (MIMIE-PM) in patients with esophageal cancer.

Methods: This retrospective study included 339 patients with esophageal cancer who underwent McKeown esophagectomy. The inverse probability of the treatment weighting (IPTW) approach was employed to assess outcome between SIMIE-RS and MIMIE-PM. The primary endpoints included postoperative complications, functional recovery parameters, and perioperative outcomes. Secondary endpoints included oncological adequacy, hospital length of stay, and quality of life indicators.

Results: Pulmonary complications were markedly reduced in the SIMIE-RS group as compared to the MIMIE-PM group, with a lower incidence of pneumonia (0.9% vs. 5.5%; P=0.02). Postoperative pain control was substantially improved in the SIMIE-RS group, who exhibited lower visual analog scale scores at 24 hours (3.1±1.0 vs. 7.5±1.1; P<0.001) and 72 hours (1.6±1.1 vs. 3.3±1.2; P<0.001) as compared to the MIMIE-PM group. SIMIE-RS also provided greater functional recovery, with superior forced expiratory volume in 1 second (FEV1) preservation at 1 month (3.2±0.5 vs. 2.4±0.6; P<0.001) and reduced reflux symptoms (1.2±0.5 vs. 1.8±0.9; P<0.001). Hospital length of stay was significantly shorter in the SIMIE-RS group than in the MIMIE-PM group (7.0±1.6 vs. 9.7±1.5 days; P<0.001). The safety profiles of the SIMIE-RS group and MIMIE-PM group were comparable in terms of surgery-related complications, including anastomotic leakage (2.8% vs. 5.0%; P=0.55), recurrent laryngeal nerve paralysis (0.9% vs. 1.0%; P>0.99), and chylothorax (0.9% vs. 1.5%; P=0.66). Oncological adequacy was maintained, with similar total lymph node yields between the groups (33±11.1 vs. 32.1±12.2; P=0.53).

Conclusions: SIMIE-RS provides superior perioperative outcomes as compared to MIMIE-PM, with significant reductions in pulmonary complications, enhanced functional recovery, improved pain control, and shortened hospital stays, as well as comparable surgical safety and oncological adequacy. Our findings indicate that SIMIE-RS is a viable innovation in esophageal cancer surgery that concentrates operative trauma while optimizing reconstruction pathways.

Background: Invasive pulmonary adenocarcinoma (IPA) poses a significant threat to global health and patients still experience tumor recurrence and metastasis. This study aimed to construct an optimized prognosis model using machine learning to predict the disease-free survival (DFS) of IPA patients.

Methods: A total of 670 resected IPA patients from 2015 to 2020 were enrolled. Clinicopathological information was collected and the outcomes of patients were followed up. Patients were divided into a training set and a test set at a ratio of 4:1. Four machine learning models were compared to build the DFS models and 5-fold cross validation was performed. The area under the receiver operating characteristic curve (AUC), C-index, calibration curves, and decision curve analysis (DCA) were used to evaluate the model.

Results: Among the four models, the least absolute shrinkage and selection operator (Lasso) model showed the best performance in predicting DFS at 2-year (training set: AUC =0.906, test set: AUC =0.862), at 3-year (training set: AUC =0.894, test set: AUC =0.879), at 4-year (training set: AUC =0.901, test set: AUC =0.902), and at 5-year (training set: AUC =0.927, test set: AUC =0.887). The calibration curves and DCA exhibited a good predictive performance.

Conclusions: Our study successfully constructed a machine-learning based prognostic model to predict DFS, which may provide oncologists with an effective tool for early medical intervention and survival improvement.

Background: Patients with chronic obstructive pulmonary disease (COPD) with eosinophilia exhibit poor lung function. However, the prognostic impact of eosinophilia remains unclear. This study evaluates the relationship between sputum and blood eosinophil variability and the long-term clinical outcomes of COPD.

Methods: Sputum eosinophil proportion ≥3% and blood eosinophil count ≥300 cells/µL were considered high. Based on sputum/blood eosinophil levels at baseline and at the 3-year follow-up, patients with COPD were divided into the persistently low, unstable, and persistently high sputum/blood eosinophils groups. Poisson regression was used to assess acute exacerbation risk, and mixed-effects models were used to evaluate lung function decline.

Results: Compared with the persistently low sputum eosinophils group (n=183), the persistently high sputum eosinophils group (n=68) had more dyspnea and had a higher modified Medical Research Council score, poorer baseline lung function, and experienced more total exacerbations [adjusted relative risk (RR) 1.47, 95% confidence interval (CI): 1.21-1.80, P<0.001] and more moderate-to-severe exacerbations [adjusted RR 1.62, 95% CI: 1.25-2.10, P<0.001]. The unstable sputum eosinophils group (n=122) experienced more total exacerbations (adjusted RR 1.47, 95% CI: 1.24-1.75, P<0.001) and more moderate-to-severe exacerbations (adjusted RR 1.29, 95% CI: 1.02-1.63, P=0.03). Similarly, the persistently high blood eosinophils group experienced more total exacerbations than the persistently low blood eosinophils group (adjusted RR 1.27, 95% CI: 1.05-1.54, P=0.02), the unstable blood eosinophils group experienced more total exacerbations (adjusted RR 1.27, 95% CI: 1.07-1.51, P=0.008) and more moderate-to-severe exacerbations (adjusted RR 1.29, 95% CI: 1.03-1.62, P=0.03). There were no significant differences in lung function decline.

Conclusions: Persistent eosinophil elevation was associated with a higher exacerbation risk.