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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., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1871/coif). The authors have no conflicts of interest to declare., (2024 AME Publishing Company. All rights reserved.)

Background: Complex segmentectomy for uniportal video-assisted thoracoscopic surgery (VATS) remains controversial due to procedural complexity and the risk of increased complications, unlike multiportal VATS. Demonstrating the perioperative results and proficiency of individual surgeon is believed to influence future dissemination for uniportal VATS. In this study, we aimed to compare the perioperative outcomes and learning curves of complex versus simple segmentectomy for uniportal VATS., Methods: This retrospective cohort study included all patients who had an elective uniportal VATS segmentectomy between July 2018 and June 2023. We documented our initial experience with 100 consecutive segmentectomy cases. A single board-certified experienced surgeon performed all procedures. The perioperative outcomes of the complex (n=45) and simple (n=55) segmentectomy groups were compared using propensity score matching and the cumulative sum technique., Results: Using propensity score matching, 29 patients were chosen from each group. There was no statistically significant difference between the two groups in perioperative outcomes. The initial learning curve for simple segmentectomy was completed after 20 cases, while that for complex segmentectomy was completed after 11 cases., Conclusions: Uniportal VATS complex segmentectomy was safe and comparable to simple segmentectomy in terms of perioperative outcomes and learning curves in an experienced surgeon. Uniportal VATS complex segmentectomy should be considered a viable surgical option., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1028/coif). H.I. serves as an unpaid editorial board member of Journal of Thoracic Disease from August 2024 to July 2026. Takahiro Homma developed the device, CS two-way HandleTM, Unimedic, Japan. The other authors have no conflicts of interest to declare., (2024 AME Publishing Company. All rights reserved.)

Background: Advances in minimally invasive surgery and drainage systems have caused earlier chest-tube-removal. This retrospective study aimed to assess the safety of early chest tube removal using the institution's new criteria 6 hours after thoracic surgery., Methods: Elective thoracic surgery patients from 2017 to 2023 were reviewed for meeting or not meeting the newer institutional requirement for early chest tube removal; (I) no air leak detected under the digital drainage device observation; (II) no fluid drainage of ≥100 mL/h; (III) no ≥3 combined risks [male, chronic obstructive pulmonary disease (COPD), body mass index (BMI) of <18.5 kg/m 2 , severe pleural adhesion, upper lobe lobectomy, or left upper division segmentectomy]. The incidence of adverse events, including chest tube replacement, subcutaneous tube placement, and postoperative thoracentesis, were investigated for 1 month postoperatively. Perioperative outcomes and factors involved in conventional chest tube removal were also assessed., Results: Of the 942 patient charts reviewed, 244 (25.9%) met the criteria for chest tube removal within 6 hours postoperatively. This patient group did not experience adverse events. They also demonstrated shorter postoperative hospital stay (4 vs. 6 days, P<0.001), and lesser postoperative complications (7.4% vs. 25.6%, P<0.001) compared to those for whom early chest tube removal was not done. A correlation with thoracotomy, COPD, and steroid and/or immunosuppressant use was observed for patients in the conventional chest tube removal group., Conclusions: Early chest tube removal after 6 postoperative hours was deemed safe for a selected group of patients who met the criteria for early chest tube removal. This study would support the potential expansion of our early removal criteria., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-23-1905/coif). The authors have no conflicts of interest to declare., (2024 Journal of Thoracic Disease. All rights reserved.)

In Japan, cotton is commonly used in thoracic surgery for the gentle handling of organs as well as obtaining a good surgical field. While uniportal video-assisted thoracoscopic surgery is being recognized as a major surgical approach, use of cotton is not noted in this technique. Uniportal video-assisted thoracoscopic surgery needs curved instruments because they are effective in preventing the interference of instruments. Thus, we developed a novel curved cotton instrument, known as the "CS Two-Way Handle TM ", for uniportal video-assisted thoracoscopic surgery. The CS Two-Way Handle TM can be used not only as a cotton bar but also as a suction aid. Moreover, surgical smoke can be suctioned with the insertion of cotton. This instrument was introduced in our institution in September 2019, along with some other prototypes. When anatomical lung resection using uniportal video-assisted thoracoscopic surgery was first introduced, there were some instances of conversion to conventional multiportal video-assisted thoracoscopic surgery. However, after the CS Two-Way Handle TM introduction, the procedure has become easy to perform and the need for conversion to conventional methods has reduced. The main uses of the CS Two-Way Handle TM are: (I) exposure of the surgical view, (II) lymph node dissection, (III) bleeding control, (IV) suction, and (V) evacuation of surgical smoke. We present our experiences using the CS Two-Way Handle TM in uniportal video-assisted thoracoscopic surgery., Competing Interests: Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-22-1602/coif). The author has no conflicts of interest to declare., (2023 Journal of Thoracic Disease. All rights reserved.)

Background: This study aimed to examine the effects of preoperative interventions in lung cancer patients with untreated chronic obstructive pulmonary disease (COPD). We evaluated the efficiency of preoperative interventions using tiotropium (TIO) or umeclidinium/vilanterol (UMEC/VI)., Methods: We conducted a two-center retrospective study. Perioperative forced expiratory volume in 1 second (FEV 1 ) was compared between a preoperative COPD intervention group and an untreated group. COPD therapeutic drugs were started 2 weeks before surgery and were continued until 3 months after surgery. Radical lobectomy was performed in patients with an FEV 1 of ≥1.5 L., Results: A total of 92 patients were enrolled (untreated, 31 patients; intervention, 61 patients). In the intervention group, 45 (73.8%) patients were prescribed the UMEC/VI intervention and 16 (26.2%) received TIO. The intervention group showed a greater increase in FEV 1 than the untreated group (FEV 1 : 120 vs. 0 mL, P=0.014). In the intervention group, the UMEC/VI group showed a greater increase in FEV 1 than the TIO group (FEV 1 : 160 vs. 7 mL, P=0.0005). In 9 of 15 (60.0%) patients with an FEV 1 of <1.5 L before intervention, FEV 1 increased to ≥1.5 L after intervention. Postoperative FEV 1 in the intervention group was similar to that before intervention, unlike in the untreated group (-0.05 vs. -0.25 mL, P=0.0026). Moreover, the FEV 1 in the untreated group was similar to the preoperative predicted value, whereas that in the intervention group was significantly higher than the predicted value (+0.33 vs. +0.04 mL, P<0.0001)., Conclusions: In lung cancer patients with untreated COPD, active preoperative intervention improved respiratory function, expanded treatment options, and maintained respiratory function to a degree that exceeded preoperative predictions., Competing Interests: Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-22-1704/coif). The author has no conflicts of interest to declare., (2023 Journal of Thoracic Disease. All rights reserved.)

Background: We aimed to analyze perioperative complications, postoperative neuropathic pain, and the necessity of epidural anesthesia in uniportal video-assisted thoracoscopic surgery (U-VATS) compared to conventional multiportal VATS (M-VATS) for anatomical lung resection., Methods: This retrospective study included all patients who underwent elective VATS lobectomy and segmentectomy between April 2016 and December 2019. The exclusion criteria were as follows: age ≤19 years, planned thoracotomy, re-operation in thoracic surgery, median sternotomy, robot-assisted thoracic surgery, simultaneous resection of extrathoracic organs, locally invasive lung tumor with bronchoplasty or angioplasty, past or current neuropathic pain, and a large tumor with a minimum diameter ≥5 cm. M-VATS had 4 ports approach. U-VATS port positions were placed by extending the thoracoscope port of M-VATS., Results: U-VATS patients showed significant differences compared to M-VATS patients: smaller intraoperative bleeding (1 vs. 30 mL; P=0.0010), shorter operative time (141 vs. 183 min; P<0.0001), post-hospitalization (5 vs. 8 days; P=0.0002), fewer complications (23.9% vs. 40.9%; P=0.048), less acute pain, less postoperative neuropathic pain (32.4% vs. 52.1%; P=0.027) and shorter duration of neuropathic pain (30 vs. 60 days; P=0.041). For the postoperative neuropathic pain and pain score until postoperative day 5, there were no differences between the groups with and without epidural anesthesia., Conclusions: As a single-center initial experience, U-VATS lobectomy and segmentectomy seemed safe and minimally invasive based on not only postoperative neuropathic pain and complications but also time management. U-VATS would provide better pain control, without epidural anesthesia., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-22-6/coif). The authors have no conflicts of interest to declare., (2022 Journal of Thoracic Disease. All rights reserved.)

Background: Manual aspiration as the initial management of a large pneumothorax in a clinically stable patient has been reported to be safe and effective. However, the effect with smaller needles, the number of aspiration, the indication other than spontaneous pneumothorax and failure factors are unknown. We assessed the effectiveness and failure risk factors of manual aspiration up to three using a 20- or 22-gauge (G) needle in patients with a large, clinically stable pneumothorax., Methods: We included 107 clinically stable patients with large pneumothorax. Patients who were unstable, required a ventilator, underwent chest tube drainage or had an observed small pneumothorax, bilateral pneumothorax, hemopneumothorax, or postoperative pneumothorax were excluded. Up to three aspirations were performed using 20- or 22-G intravenous needles. When the aspiration volume was ≥2,500 mL or lung expansion did not occur, a chest tube was placed., Results: The first aspiration was successful in 57 patients (53.3%), the second in 16 patients (59.3%), and the third in eight patients (80.0%). No patient experienced any obvious complications or required emergent hospitalization or surgery after aspiration. Aspiration failure was correlated with an inter-pleural distance >20 mm at the level of the hilum [odds ratio (OR): 4.93; 95% confidence interval (CI): 1.49-22.71; P=0.0075], spontaneous secondary pneumothorax (OR: 3.11; 95% CI: 1.14-8.76; P=0.027), and ≤24 h from onset to presentation (OR: 2.95; 95% CI: 1.12-8.26; P=0.028). There were no significant differences in intrathoracic pressure after aspiration or plasma factor XIII levels between patients with resolved and persistent pneumothorax., Conclusions: Manual aspiration up to three times using a small needle might be one of a treatment option in clinically stable patients with any large pneumothorax. Aspiration failure was correlated with an inter-pleural distance >20 mm at the level of the hilum, spontaneous secondary pneumothorax, and ≤24 h from onset to presentation., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-21-1587/coif). The authors have no conflicts of interest to declare., (2022 Journal of Thoracic Disease. All rights reserved.)

Background: To assess the potential of the ultrasonographic sliding lung sign to detect severe intrathoracic adhesions before surgery., Methods: This was a prospective, single-center, observational study including all patients aged 20-89 years undergoing elective thoracic surgery. Patients with pneumothorax, pyothorax, hemothorax, chylothorax, and hydrothorax were excluded. We recorded the ultrasound sliding lung sign, surgical characteristics, and follow-up parameters: past medical history, respiratory function, chest X-ray findings, and computed tomography (CT) findings. Severe intrathoracic adhesion was defined as the need for adhesiolysis requiring more than 30 minutes., Results: A total of 168 patients consented to participate. All 15 patients without the sliding lung sign had hard severe adhesions [specificity 100%, sensitivity 88.2%, positive predictive value (PPV) 100%, negative predictive value (NPV) 98.7%, and area under curve (AUC) 0.94]. There were two false-negative results, both of which were soft adhesions. Although blunting of the costophrenic (CP) angle, CT findings, past medical history, and restrictive lung disease were identified as significant risk factors of severe intrathoracic adhesion, all areas under the curve were low (0.71, 0.71, 0.69, 0.61, respectively). Thoracotomy frequency, intraoperative bleeding, operative time, and postoperative hospitalization were significantly greater in these patients than in those with non-severe adhesions., Conclusions: The ultrasound sliding lung sign could be used to predict severe intrathoracic adhesions before surgery. Preoperative confirmation of the ultrasound sliding lung sign is important for planning surgical approaches and implementing appropriate safety management., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jtd-20-886). The authors have no conflicts of interest to declare., (2020 Journal of Thoracic Disease. All rights reserved.)

Background: Several tape fixations for chest tube were proposed, although none have a clear scientific basis. We performed a multicenter survey study to investigate the fixation of chest tubes using an available adhesive tape. We evaluated the strength of tape fixation and the effect of the skin coating material used on the fixation strength., Methods: A multi-center questionnaire survey was administered in hospitals with a thoracic surgery division. The net promoter score (NPS) was used to measure the medical staff's satisfaction with an adhesive tape fixation. Fixing strength was calculated as follows: a chest tube was fixed using each taping method to a polyethylene plate and was pulled out in the long axis direction. While pulling out, the maximum resistance force [Newton (N)] and total resistance force [Joule (J)] were measured to calculate the fixing strength., Results: The doctors' NPS showed no significant difference between handmade tape fixation and Quickfix {7 [5-8] vs. 10 [5-10] points, P=0.34}. The nurses' NPS showed no significant difference between handmade tape fixation and Quickfix {5 [5-8] vs. 5 [5-7] points, P=0.72}. The average maximum resistance force was the highest for Quickfix (1.36 J, 65.4 N) and a type of handmade fixation (three sheets stuck with foundation tape plus Y-shape slit plus Ω-shape tape; 1.61 J and 54.0 N). The fixation strength of Quickfix did not decrease with a skin coating agent (from 1.24 to 1.11 J and 63.0 to 66.6 N), although that of a handmade tape fixation decreased (from 1.49 to 0.90 J, 52.6 to 38.1 N)., Conclusions: Quickfix provided secure fixation, regardless of the tube size or skin coating. Quickfix may be the best for standardized fixation because it is not only a stronger agent but is safe, simple, inexpensive, reliable, and can be used successfully by anyone., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare., (2020 Journal of Thoracic Disease. All rights reserved.)

Background: This study analyzed the preventive effect of 50 mg/day pregabalin on postoperative neuropathic pain, and any additional benefits related to sleep and respiratory function., Methods: This prospective randomized controlled study included lung resection patients 20-89 years of age. Patients were randomly assigned to the treatment (pregabalin; initial dose, 50 mg/day) or control (non-steroidal anti-inflammatory drugs) group. Pregabalin patients received non-steroidal anti-inflammatory drugs and pregabalin (25 mg, twice daily) from the second postoperative day. Pain scores, neuropathic pain, analgesic use, respiratory function, and insomnia scale scores for 3 months after surgery were evaluated., Results: This study included 46 patients who received pregabalin and 46 control patients. Pregabalin patients had significantly less postoperative neuropathic pain than control patients (19.6% vs. 41.3%; P=0.0404), and their duration of neuropathic pain was significantly shorter (30 vs . 90 days; P=0.024). The onset of postoperative neuropathic pain, insomnia scale scores, and respiratory function were similar between groups. No pregabalin-related adverse events were reported., Conclusions: Pregabalin (50 mg/day) had a significant preventive effect on postoperative neuropathic pain after thoracic surgery, without side effects. Early postoperative administration of pregabalin would help prevent neuropathic pain and provide better pain control after thoracic surgery., Competing Interests: Conflicts of Interest: This study was presented at an international session of the 114th Annual Congress of the Japan Surgical Society by Takahiro Homma.

Background: This study aimed to clarify the incidence and risk factors of neuropathic pain after thoracic surgery, focusing especially on patients who underwent complete video-assisted thoracoscopic surgery (VATS)., Methods: We retrospectively identified 185 patients who underwent thoracic surgery at our hospital over a 2-year period. Logistic regression analysis was used to analyze the association of various factors with postoperative neuropathic pain., Results: Forty-eight (25.9%) patients developed postoperative neuropathic pain, and 9 (18.8%) of these patients reported persistent pain 1 year postoperatively. The median interval from surgical treatment to the onset of neuropathic pain was 7 days, and the duration was 50 days. Multivariate logistic regression analysis revealed a significant positive correlation between postoperative neuropathic pain and preoperative use of hypnotic medication [odds ratio (OR), 5.45; 95% confidence interval (CI); 2.52-12.17] and duration of surgery ≥2.5 hours (OR, 2.72; 95% CI, 1.27-6.09), and a significant negative association with the complete VATS approach (OR, 0.18; 95% CI, 0.073-0.42)., Conclusions: Preoperative use of hypnotic medication, the thoracotomy approach, and duration of surgery ≥2.5 hours are associated with increased risk of neuropathic pain after thoracic surgery. The complete VATS approach could decrease the incidence of postoperative neuropathic pain, regardless of the duration of surgery., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.