Journal of Chest Surgery最新文献

Background: Recurrence after video-assisted thoracoscopic surgery (VATS) bullectomy for primary spontaneous pneumothorax (PSP) remains a major clinical concern. Pleural reinforcement has been proposed to reduce recurrence; however, comparative evidence between fibrin sealant (FS) patches and polyglycolic acid (PGA) sheets is limited.

Methods: We retrospectively reviewed 188 patients with PSP who underwent VATS bullectomy with pleural reinforcement between 2015 and 2025 (FS group, n=42; PGA group, n=146). Perioperative outcomes and recurrence-free survival (RFS) were compared. Baseline imbalances were adjusted using inverse probability of treatment weighting. Survival outcomes were evaluated using Kaplan-Meier analysis and restricted mean survival time (RMST). Predictors of recurrence were assessed with Firth's penalized Cox regression.

Results: The FS group showed significantly shorter operative time (29.6 minutes vs. 39.6 minutes, p<0.001) and a reduced length of hospital stay (3.4 days vs. 4.2 days, p=0.042) compared with the PGA group, whereas chest tube duration was comparable between groups. Overall recurrence was 11.7%. Kaplan-Meier analysis demonstrated no significant difference in RFS (p=0.174), but RMST analysis indicated significantly fewer recurrences with FS (p=0.038). Multivariable Cox regression identified female sex as an independent protective factor against recurrence (hazard ratio, 0.117; p=0.028).

Conclusion: FS patches showed a trend toward lower recurrence, achieving statistical significance in RMST analysis. FS appears to be a safe and effective option for pleural reinforcement following VATS bullectomy in patients with PSP.

Foreign body aspiration is frequently encountered in children but can also occur in adults, where it often remains undiagnosed for years. Forgotten foreign bodies within the bronchial tree may later manifest with either vague symptoms or life-threatening complications, such as massive hemoptysis. Contrast-enhanced computed tomography of the thorax is the preferred initial diagnostic modality and can suggest the presence of a foreign body. We present a case involving an adult who remained undiagnosed until adulthood, when he was ultimately found to have a foreign body embedded in the lung parenchyma.

Background: Pleural drainage is essential for preventing and managing respiratory complications after video-assisted thoracoscopic esophagectomy (VATE). Conventional large-bore drains often cause significant pain. Small-bore drains (e.g., 19F Blake drains) may reduce discomfort; however, evidence regarding their use in VATE is limited. This study compared drainage effectiveness and pain between 19F Blake drains and conventional 28F drains after VATE for esophageal cancer.

Methods: This retrospective study included 77 male patients with middle- or lower-third esophageal cancer who underwent VATE with laparoscopic retrosternal tunneling from November 2018 to November 2022. Fifty-five patients received a 28F conventional drain, and 22 received a 19F Blake drain. Outcomes included drainage duration and volume, pain levels (Visual Analog Scale [VAS]), postoperative pneumonia rates, and pulmonary function (forced vital capacity [FVC], forced expiratory volume in 1 second [FEV1]) on postoperative day 3.

Results: The 19F group reported significantly lower pain scores on postoperative days 1-3 (VAS: 2.95-3.25 vs. 4.07-4.62, p<0.001). Drainage duration and pneumonia rates were similar between groups. The 19F group demonstrated a trend toward higher drainage volume and significantly better preservation of pulmonary function, with smaller declines in FVC (ΔFVC: 0.24±0.20 L vs. 0.63±0.17 L, p<0.001) and FEV1 (ΔFEV1: 0.38±0.25 L vs. 0.58±0.25 L, p=0.02).

Conclusion: 19F Blake drains provide similar drainage effectiveness to that of 28F drains, with reduced postoperative pain and better pulmonary function preservation. These findings support the use of 19F Blake drains to improve patient comfort and recovery following VATE.

Coronary artery bypass grafting (CABG) has been established as the most effective treatment for patients with multi-vessel coronary artery disease. To maximize outcomes by restoring perfusion to the largest possible myocardial territory, complete revascularization (CR) has long been a key objective of CABG. Because the anatomic severity of coronary artery stenosis on coronary angiography has been the main criterion for selecting target vessels for several decades, the definition of CR has traditionally been based on angiographic anatomy. Numerous studies have examined the impact of anatomic CR on outcomes after CABG; however, the results remain controversial. At the same time, there has been increasing interest in ischemia-inducing coronary artery stenosis assessed by functional studies such as dobutamine-stress echocardiography, nuclear imaging tests, fractional flow reserve, and quantitative flow ratio. This has raised the importance of defining CR based on functional ischemia rather than anatomic stenosis. Nevertheless, only a few studies have reported the impact of functional CR on CABG outcomes. Therefore, this narrative review summarizes the various definitions of CR in CABG, highlights its benefits and shortcomings, and introduces the available literature evaluating the effects of anatomic and functional CR on long-term clinical outcomes.

Coronary artery bypass grafting (CABG) remains a key revascularization strategy for ischemic heart disease; however, nationwide trends in the Republic of Korea have not been thoroughly investigated. Using data from the Korean National Health Insurance Service, we analyzed adult patients who underwent isolated CABG between 2005 and 2022. We evaluated surgical volume, patient demographics, procedural strategies (off-pump vs. on-pump), and outcomes. International comparisons were conducted using national cardiac surgery registry data. A total of 51,923 CABG cases were identified. Annual surgical volume declined until 2013 but gradually increased thereafter, reaching 3,717 cases in 2022. Despite this recovery, Korea's per capita CABG rate remains among the lowest worldwide. In contrast, more than 60% of procedures were performed off-pump-the highest rate worldwide. Over time, the average patient age and prevalence of diabetes increased, whereas in-hospital mortality showed a modest decline. Compared with other countries, the Republic of Korea demonstrated a uniquely low procedural volume and a strong preference for off-pump CABG. This nationwide analysis highlights Korea's distinctive CABG practice patterns and provides valuable insights for optimizing future clinical and policy decisions in cardiac surgical care.

Salvage surgery is an emerging option for carefully selected patients with advanced epidermal growth factor receptor (EGFR)-mutant non-small cell lung cancer (NSCLC) whose disease remains controlled on tyrosine kinase inhibitor (TKI) therapy. Fourteen retrospective series report median progression-free survival (PFS) of 14-52 months and overall survival (OS) often exceeding 3 years, suggesting better disease control than continued TKI therapy alone. Although PFS generally improves, some cohorts show no OS advantage, probably because effective post-progression treatments dilute survival differences. Non-surgical local consolidative therapies remain essential for oligometastatic disease; nevertheless, resection yields intact specimens for comprehensive pathologic and molecular analysis. Access to tissue permits earlier identification of resistance mechanisms-most commonly the T790M mutation-more accurate prognostication, and more precise systemic-therapy selection. Comprehensive sampling can also identify histologic transformation and compound mutations that precede radiologic progression. Adverse prognostic factors include older age, high preoperative carcinoembryonic antigen levels, advanced pathological T stage, programmed death-ligand 1 ≥1%, and spread through air spaces. Salvage surgery is feasible and effective in carefully selected patients, especially those with oligoresidual disease and favorable tumor biology. Patient selection should integrate performance status, anatomic extent, histopathology, and genomic profile through multidisciplinary discussions. Despite regional differences (e.g., higher EGFR-mutation prevalence and wider adoption of minimally invasive approaches in East Asia) oncologic outcomes are comparable when selection criteria are applied consistently. Prospective trials are warranted to validate these retrospective observations, refine selection algorithms, establish optimal timing, and clarify how surgery can best be integrated with next-generation targeted agents and immunotherapies.

Background: Neoadjuvant chemoradiation therapy (nCRT) has survival benefits for patients with cT1N1 or cT2-3N0-1 esophageal squamous cell carcinoma (ESCC), but heterogeneous disease behavior has been observed in node-negative tumors. This study aimed to investigate the risk of upstaging and the efficacy of upfront esophagectomy compared with nCRT followed by surgery in patients with cT2-3N0 ESCC.

Methods: ESCC patients treated at Taipei Veterans General Hospital, Taiwan, between January 2010 and December 2022 were retrospectively reviewed. Patients who underwent upfront surgery (n=72) and those who received neoadjuvant therapy (n=36) were included in this analysis on an intention-to-treat basis after propensity score matching. Comparisons of TNM (tumor, node, and metastasis) classification shifts between patients who underwent upfront surgery and those who received neoadjuvant therapy, as well as primary outcomes including overall survival (OS) and recurrence-free survival (RFS), were analyzed.

Results: Among patients who underwent upfront surgery, 6 (16.7%) in the cT2 group and 10 (27.8%) in the cT3 group had occult lymph node (LN) metastasis. Most patients (77.4%) who received neoadjuvant therapy experienced downstaging; however, there were no significant differences in OS (5-year OS: 53.8% vs. 51.6%, p=0.666) or RFS (5-year RFS: 48.6% vs. 44.8%, p=0.864) compared with upfront surgery. No significant differences were observed before propensity score matching for either OS (p=0.809) or RFS (p=0.856).

Conclusion: Upfront esophagectomy in patients with cT2-3N0 ESCC provides comparable survival outcomes, despite the higher risk of upstaging and occult LN metastasis.

Background: This study investigated the long-term results of mitral valve replacement (MVR) using mechanical prostheses in children under 3 years of age.

Methods: We retrospectively reviewed 24 patients who underwent MVR with mechanical prostheses before the age of 3 years between 1996 and 2019. Underlying diagnoses included isolated congenital mitral regurgitation (n=4), congenital mitral stenosis (n=4), and various congenital heart defects (n=16). The median follow-up duration was 9.8 years (interquartile range [IQR], 7.3-13.2 years).

Results: The median age and weight at MVR were 16.6 months (IQR, 5.3-24.7 months) and 7.6 kg (IRQ, 4.9-9.5 kg), respectively. The median prosthesis size was 19 mm (range, 16-29 mm). Supra-annular implantation was performed in 12 patients (50%), who were significantly younger and smaller at the time of surgery and received smaller prostheses than those receiving annular implants. Early mortality occurred in 2 patients (8.3%), and 2 late deaths were recorded. The overall survival rate was 83.3% at 15 years. Redo MVR was performed in 9 patients during follow-up. The median increase in valve size was 4 mm. The interval from initial to redo MVR was positively correlated with the increase in valve size (Spearman ρ=0.64, p=0.07). Freedom from redo MVR was 86.3% at 5 years and 75.8% at 10 years.

Conclusion: MVR with mechanical prostheses in children under 3 years of age can yield acceptable long-term survival, although redo MVR is often required. Mechanical MVR remains a viable salvage option in small children when valve repair is not feasible.