Seminars in Thoracic and Cardiovascular Surgery最新文献

Tracheoesophageal fistula (TEF) is a challenging, complex condition with a wide spectrum of underlying causes and clinical manifestations. TEF management requires a deep understanding of anatomical characteristics, underlying conditions, and a multidisciplinary approach to optimize the diagnostic pathways and treatment allocations. The management of benign and malignant TEF has shown progress in its effective treatment; however, surgical techniques remain a challenge and are often complemented by innovative stent deployment strategies. Concurrently, new techniques are being added to the treatment landscape, however, the evidence remains largely limited to case reports. Nevertheless, despite the substantial advancements in the management of TEF, there remains a lack of consensus or established guidelines for this condition in the adult population and treatment approach remains highly individualized. The aim of this article is to summarize the current treatment strategies for this complex disease.

The widespread and ever-expanding use of computed tomography for disease, trauma, cardiac imaging, and lung cancer screening has led to increased incidental detection of indeterminate thymic nodules and masses on CT. Chest MRI provides increased diagnostic specificity and delineation of disease extent and should therefore both reduce unnecessary thymectomy and improve clinical management of thymic masses.

Pulmonary lobectomy via a minimally invasive surgery (MIS) approach represents the current standard of care in early-stage non-small cell lung cancer. However, MIS has mostly relied on intercostal incisions, with the inherent risk of intercostal nerve injury. As a result, several non-intercostal approaches were developed. However, published data on the subject remain scarce. We aim to review existing non-intercostal MIS lobectomy techniques to specifically assess their feasibility and safety. Systematic review from 2010-2025. The outcomes for feasibility and safety were conversion rate and 30-day mortality, respectively. A total of 17 studies were included in the qualitative synthesis. From a combined total of 2376 patients included in the study, 66% (n = 1570) underwent a non-intercostal lobectomy. Among these, 83.5% (n = 1312) were performed via a subxiphoid approach, 15% (n = 236) via subcostal incisions. Among the studies that reported on outcomes, conversion rate and mortality were reported, respectively, as 4.3% (n = 53/1228) and 0.4% (n = 1/259) for subxiphoid approach, 1.4% (n = 2/140) and 0.7% (n = 1/140) for subcostal incisions. There has been growing interest in various non-intercostal approaches to pulmonary lobectomy over the past decade. Notably, recent studies suggest a shift toward higher-quality research and a transition from subxiphoid video-assisted to subcostal robotic-assisted thoracic surgery techniques. Among these, Outside the Cage (OTC) RATS robotic-assisted thoracic surgery emerges as the only fully non-intercostal reproducible robotic approach. Despite encouraging early data, further efforts are required to rigorously evaluate potential benefits. Nonetheless, the evidence to date suggests that it could be both feasible and safe to step "outside the cage."

Thymic epithelial tumors require tailored surgical strategies to optimize outcomes. This review synthesizes current evidence on surgical approaches, emphasizing the critical roles of tumor stage, anatomy, and multidisciplinary planning. For early-stage thymic epithelial tumors (Stage I/II), minimally invasive techniques (video-assisted thoracic surgery, robotic-assisted) demonstrate equivalent oncologic outcomes to open surgery, with reduced morbidity, shorter hospitalization, and faster recovery. Recent propensity-matched studies highlight robotic thymectomy's advantages, including lower blood loss and complication rates, though operative times may be longer. Locally advanced tumors (Stage IIIA-B) demand meticulous R0 resection, often necessitating open approaches for complex resections involving pericardium, phrenic nerves, or great vessels. Induction therapy shows promise in converting borderline resectable tumors and improving R0 rates. For Stage IVA disease, surgery within multimodal regimens may enhance survival, though benefits depend on pleural burden and histology, underscoring the need for individualized management. Emerging debates focus on refining resection extent. Lymphadenectomy gains traction for thymic carcinomas and advanced thymomas due to nodal metastasis risks, while partial thymectomy for early-stage tumors remains controversial, requiring randomized trials to balance oncologic efficacy against long-term immunologic consequences. Thymic surgery continues to evolve, prioritizing R0 resection while integrating minimally invasive advancements and multimodal therapies. Centralized, high-volume centers and international collaboration remain pivotal to addressing these rare malignancies. Future research must clarify lymphadenectomy's role, validate partial thymectomy, and optimize induction strategies through prospective trials.

Endograft infections following thoracic endovascular treatment are rare but associated with high morbidity and mortality. This study describes our experience with the surgical management of infections involving descending thoracic and thoracoabdominal aorta. The study retrospectively reviewed patients who underwent open descending thoracic and thoracoabdominal aortic aneurysm repair between January 1991 and March 2025, including cases of stent graft infections and secondary aortobronchial or aortoenteric fistula. Perioperative characteristics, operative outcomes and overall survival were evaluated. Of 2220 patients who underwent descending thoracic and thoracoabdominal aortic aneurysm repair, 20 patients (0.9%) received surgical treatment for endograft infections: 8 with endograft infection; 7 with aortoesophageal fistula; and 5 with aortobronchial fistula. The extent of repair involved the descending thoracic aneurysm in 18 patients (90%), and thoracoabdominal aortic aneurysm in 2 patients (10%). Endograft explantation and in-situ aortic reconstruction were performed in 19 patients (95%) while flap reconstruction was utilized in 16 patients (80%). Operative mortality was 6 patients (30%). Postoperative stroke occurred in 1 patient (5%) and temporary paraparesis also occurred in 1 patient (5%). Overall survival was 43.5% at 1 year and 36.3% at 5 years. Management of endograft infection involving the descending thoracic and thoracoabdominal aortic aneurysm remains challenging. Surgical repair, including endograft explantation, in-situ reconstruction, and flap installation, yielded acceptable mortality and morbidity rates in this high-risk patient population.

Routine daily chest radiographs (CXR) in intensive care units (ICUs), including cardiovascular (CVICUs) and cardiothoracic (CTICUs), are widely used for early complication detection during the post-operative period. However, evidence suggests that this practice lacks clinical utility, with low diagnostic and therapeutic yields. The evidence consistently demonstrates that an on-demand CXR strategy, performed only for specific clinical indications, offers comparable patient safety, reduced radiation exposure, and substantial cost savings without increasing adverse outcomes, ICU length of stay, or mortality. For post-cardiothoracic surgery patients, complications such as pleural effusions and pneumothoraces are of important concern, yet routine CXRs rarely identify such abnormalities, with very few requiring intervention. Data support an on-demand approach, even after procedures such as chest tube removal, as clinical signs and symptoms are reliable indicators of complications. Transitioning from routine to on-demand CXR practices aligns with evidence-based guidelines, including Choosing Wisely® and the Critical Care Societies Collaborative recommendations. This approach promotes high-value care, minimizes unnecessary imaging, and supports the safe, cost-effective management of ICU patients. Routine CXRs should be reconsidered as standard practice in favor of tailored, patient-specific imaging strategies.