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Esophageal duplication cysts are a rare congenital cystic malformation from faulty intrauterine recanalization of the esophagus during the 4-8th weeks of development. They account for 20% of all gastrointestinal duplication cysts and commonly involve the distal esophagus. Presenting symptoms may be related to size and location. Following the PRISMA guidelines, a systematic review was performed by searching published literature in various databases. Data from 97 reported case reports were pooled to present a descriptive and statistical analysis. Patient population was composed of 51(52.5%) males and 46 (47.5%) females, and mean ages was 42.3 years (18–77). Distal cysts were the most prevalent. Seventy-nine (81.4%) patients were symptomatic; common symptoms included dysphagia, chest pain, cough and weight loss. Fifteen (15.5%) patients were treated conservatively and 75 (84.5%) by surgical treatment, among them thoracotomy in 30 (30.9%) patients and VATS in 17 (17.5%) patients. Mean length of hospital stay was 8.6 days (range: 1–26 days). One fatality was registered. Location, unlike size, was not found to influence presenting symptoms or treatment employed. Frequency of conservative treatment was not significantly different between symptomatic and asymptomatic patients. Open approaches were associated with longer stays than their minimally invasive counterparts. Esophageal duplication cysts remain rare in adults and are frequently located in the distal esophagus. Larger cysts are more likely to cause symptoms. Various surgical techniques may successfully be employed in the treatment of this pathology. Minimally invasive procedures have a shorter hospital stay.

The aim of this prospective study was to analyze the impact of abdominal incision type on postoperative pain and quality of life (QOL) in hepatectomy. In patients undergoing hepatectomy by open, hybrid, or pure laparoscopic approaches, we classified abdominal incisions as: pure laparoscopic (LAP), midline (MID), J-shaped (J), and J-shaped incision plus thoracotomy (TRC). Postoperative pain was measured on postoperative day (POD) 3, 7, 30, and 90 using a visual analog scale (VAS). QOL was evaluated using the short-form-36 questionnaire preoperatively and on POD 30 and 90. We categorized 165 patients into LAP (n = 9, 5%), MID (n = 21, 13%), J (n = 95, 58%), and TRC (n = 40, 24%) groups. Median VAS scores on PODs 3/7/30/90 were: LAP, 27.5/7.5/10/10; MID, 30/10/15/5; J, 50/27.5/20/10, and TRC, 50/30/30/19. The J and TRC groups had significantly higher VAS scores vs. MID on PODs 3 and 7; the LAP and MID groups did not differ significantly. No significant positive correlations were observed between incision length and postoperative VAS, when we stratified patients into two groups according to the presence or absence of a transverse incision. Physical QOL summary scores did not return to preoperative levels even on POD 90, in patients with an additional transverse incision. Mental QOL summary scores worsened with postoperative complications rather than with abdominal incision type. Transverse incisions, rather than incision length, led to worse midline incision pain and poorer QOL recovery post-hepatectomy. A hybrid approach may be a considerable option when pure laparoscopic hepatectomy is technically difficult. This study was registered in the UMIN Clinical Trials Registry (registration number: UMIN000017467; http://www.umin.ac.jp/ctr/index.htm )

Bilateral transverse thoracosternotomy, known colloquially as “clamshell thoracotomy,” provides quick and extensive exposure to the thoracic organs. The origins of the radical incision are unclear, and its influence on historical developments in surgery has not been elaborated. Transsternal extension to bilateral thoracotomy likely occurred during World War I and was designated as Tuffier’s method by 1922. Theodore Tuffier had already solidified his reputation as a trailblazing thoracic surgeon in Paris when the French army summoned him to design triage systems for trauma patients during the Great War. Following World War II, cardiac surgery grew tremendously during the 1950s, and many pioneering open-heart procedures utilized the bilateral incision for safe exposures with satisfactory results. Median sternotomy became the incision of choice for open-heart surgery by the early 1960s; however, thoracotomy remained important to the trauma surgeon’s repertoire. Transsternal conversion was only briefly mentioned in trauma literature through the 1980s, although up to one-half of reported emergency thoracotomies at busy trauma centers were clamshells. The moniker clamshell thoracotomy came in 1994 when thoracic surgical oncology and lung transplantation flourished with complex operations requiring larger incisions. The twenty-first century has brought two iterations of evidence-based guidelines for emergency thoracotomy, but incision choice has not been formally discussed. Renewed conversation in recent years has advocated for the clamshell as arguably the best approach for patients in extremis. Given these trends, the tortuous history of this controversial incision deserves attention.

Blunt cardiac injury (BCI) increases with traffic accidents and is an important cause of death in trauma patients. In particular, for patients who need surgical treatment, the mortality rate is extremely high unless the patient is promptly operated on. This study aimed to explore early recognition and expeditious surgical intervention to increase survival. All patients with BCIs during the past 15 years were reviewed, and those who underwent operative treatment were analyzed retrospectively regarding the mechanism of injury, diagnostic and therapeutic methods, and outcome. A total of 348 patients with BCIs accounted for 18.3% of 1903 patients with blunt thoracic injury (BTI). Of 348 patients, 43 underwent operative treatment. The main cause of injury was traffic accidents, with an incidence of 48.8%. Of them, steering wheel injuries occurred in 15 patients. In 26 patients, a preoperative diagnosis was obtained by echocardiography, CT scanning, etc. In the remaining 17, who had to undergo urgent thoracotomy without any preoperative imaging, a definitive diagnosis of BCI was proven during the operation. The volume of preoperative infusion or crystalloid was

In patients undergoing resuscitative thoracotomy (RT) for traumatic cardiac arrest, focused assessment with sonography for trauma (FAST) is often used to look for intraperitoneal fluid. These findings can help determine whether abdominal exploration is warranted once return of spontaneous circulation is achieved; however, the diagnostic accuracy of FAST in this clinical scenario has yet to be evaluated. The purpose of this study was to assess the performance of FAST in identifying intra-abdominal hemorrhage following RT. We performed a 3-year retrospective study at a high-volume level 1 trauma center from 2014 to 2016. We included patients who underwent RT in the Emergency Department. All FAST examinations were performed by non-radiologists. Operative findings, computed tomography reports, diagnostic peritoneal aspirate (DPA) results, and autopsy findings were used as reference standards to calculate the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the FAST. A total of 158 patients met our inclusion criteria. The median age was 35 years (interquartile range [IQR]: 23–53), 86.1% were male, and 60.1% sustained blunt trauma. Most patients suffered severe injuries with a median injury severity score of 27 (IQR: 18–38). The sensitivity, specificity, PPV, NPV, and accuracy of FAST for identifying intra-abdominal hemorrhage were 66.0%, 84.8%, 68.6%, 83.2%, and 78.5%, respectively. Among the 107 patients with a negative FAST, 22 (20.6%) underwent DPA, which was positive in 5 patients. FAST can be utilized in the diagnostic workup of trauma patients after RT. In patients with a positive FAST, exploratory laparotomy is warranted, whereas other diagnostic adjuncts such as DPA or mandatory abdominal exploration may be considered in patients with a negative FAST.

Smoking is a known risk factor for perioperative complications after lung resection; however, little data exists looking at the impact of smoking status (current versus former) on long-term oncologic outcomes after lung cancer surgery. We sought to compare overall survival (OS), progression-free survival (PFS), and cancer-specific mortality (CSM) in current and former smokers using data from the National Lung Screening Trial (NLST). Additionally, we performed subset analysis in current smokers in order to evaluate the effect of modern surgical techniques on long-term outcomes. Patients with clinical stage IA or IB NSCLC who underwent upfront resection within 180 days of diagnosis were identified in the NLST database. Cox proportional hazard regression models were used to assess differences in patient and treatment characteristics with respect to OS and PFS, with a cause-specific hazard model used for CSM. A total of 593 patients were included in the study (269 former smokers, 324 current smokers). Lobar resection (LR) was performed more often than sublobar resection (SLR) (481 vs. 112), and thoracotomy was performed more often than thoracoscopy (482 vs. 86). Comparison of current versus former smokers showed no difference in OS or PFS after resection. Higher CSM was seen in current smokers (p = 0.049). Subset analysis of current smokers revealed no difference in OS or PFS between sub-lobar and lobar resection or thoracotomy and thoracoscopy. Although higher CSM was associated with thoracoscopy versus thoracotomy in this group, this finding was limited by a relatively small thoracoscopy sample size of 44 patients (p = 0.026). Our analysis of the NLST database shows no significant difference in OS and PFS when comparing current and former smokers undergoing resection for stage I NSCLC. Active smoking status was associated with higher CSM. Subset analysis of current smokers showed no difference in OS or PFS between sub-lobar and lobar resection or thoracotomy and thoracoscopy. Higher CSM was seen in current smokers who underwent thoracoscopy compared to thoracotomy; however, this finding was limited by a small sample size.

Esophagectomy has a high risk of postoperative morbidity, and pulmonary complications are the most common causes of serious morbidity. Thoracoscopic esophagectomy has been reported to reduce postoperative pulmonary complications; however, it remains unclear whether laparoscopic gastric mobilization can reduce the occurrence of postoperative pulmonary complications after open thoracotomy or thoracoscopic esophagectomy. The present meta-analysis assessed the ability of laparoscopic gastric mobilization to prevent postoperative complications after open thoracotomy or thoracoscopic esophagectomy. Studies reported between January 2000 and April 2019 in the PubMed and the Cochrane Library databases that analyzed the impact of laparoscopy on postoperative complications were systematically reviewed. In the meta-analysis, data were pooled and the primary outcome was postoperative pulmonary complications. The secondary outcomes were other postoperative complications, operative details, length of hospital stay and postoperative mortality. A total of 13 studies (1915 patients; 1 randomized trial, 1 prospective study and 11 observational studies) were included. Laparoscopic gastric mobilization after open thoracotomy resulted in significantly reduced postoperative pulmonary complications (OR = 0.47, 95% confidence interval (CI): 0.27–0.82, p = 0.008) and postoperative mortality (OR = 0.49, 95%CI: 0.25–0.94, p = 0.03). Similarly, laparoscopic gastric mobilization after thoracoscopic esophagectomy resulted in significantly reduced postoperative pulmonary complications (OR = 0.56, 95%CI: 0.37–0.84, p = 0.005) and anastomotic leakage (OR = 0.59, 95%CI: 0.39–0.91, p = 0.02). Laparoscopic gastric mobilization could be recommended for reducing postoperative pulmonary complications after esophagectomy irrespective of the thoracic approach.

Endoscopic placement of oesophageal stents may be used in benign oesophageal perforation and oesophageal anastomotic leakage to control sepsis and reduce mortality and morbidity by avoiding thoracotomy. This updated systematic review aimed to assess the safety and effectiveness of oesophageal stents in these two scenarios. A systematic literature search of all published studies reporting use of metallic and plastic stents in the management of post-operative anastomotic leaks, spontaneous and iatrogenic oesophageal perforations were identified. Primary outcomes were technical (deploying ≥ 1 stent to occlude site of leakage with no evidence of leakage of contrast within 24–48 h) and clinical success (complete healing of perforation or leakage by placement of single or multiple stents irrespective of whether the stent was left in situ or was removed). Secondary outcomes were stent migration, perforation and erosion, and mortality rates. Subgroup analysis was performed for plastic versus metallic stents and anastomotic leaks versus perforations separately. A total of 66 studies (n = 1752 patients) were included. Technical and clinical success rates were 96% and 87%, respectively. Plastic stents had significantly higher migration rates (24% vs 16%, p = 0.001) and repositioning (11% vs 3%, p

Background Resuscitative emergency thoracotomy is a potential life-saving procedure but is rarely performed outside of busy trauma centers. Yet the intervention cannot be deferred nor centralized for critically injured patients presenting in extremis. Low-volume experience may be mitigated by structured training. The aim of this study was to describe concurrent development of training and simulation in a trauma system and associated effect on one time-critical emergency procedure on patient outcome. Methods An observational cohort study split into 3 arbitrary time-phases of trauma system development referred to as ‘early’, ‘developing’ and ‘mature’ time-periods. Core characteristics of the system is described for each phase and concurrent outcomes for all consecutive emergency thoracotomies described with focus on patient characteristics and outcome analyzed for trends in time. Results Over the study period, a total of 36 emergency thoracotomies were performed, of which 5 survived (13.9%). The “early” phase had no survivors (0/10), with 2 of 13 (15%) and 3 of 13 (23%) surviving in the development and mature phase, respectively. A decline in ‘elderly’ (>55 years) patients who had emergency thoracotomy occurred with each time period (from 50%, 31% to 7.7%, respectively). The gender distribution and the injury severity scores on admission remained unchanged, while the rate of patients with signs on life (SOL) increased over time. Conclusion The improvement over time in survival for one time-critical emergency procedure may be attributed to structured implementation of team and procedure training. The findings may be transferred to other low-volume regions for improved trauma care.

Whether video-assisted thoracoscopic surgery (VATS) sleeve lobectomy could be an alternative to traditional thoracotomy sleeve lobectomy in treating centrally located non-small cell lung cancer (NSCLC) remains unclear. Therefore, we conducted the first meta-analysis to compare the effects of VATS sleeve lobectomy with thoracotomy sleeve lobectomy. We systematically searched relevant studies from Pubmed, Embase, and Web of Science on May 12, 2020. Data for analysis included short-term outcomes (blood loss, lymph node dissected, operation time, hospital stay, complications) and long-term outcomes (3-year overall survival (OS) and progression-free survival (PFS) rates). We calculated the weighted mean differences (WMDs) for continuous data and risk ratio (RR) for pooling categorical data. We finally included 5 retrospective cohort study consisting of 436 patients. VATS sleeve lobectomy yielded significantly less blood loss (WMD = −37.83; 95% confidence intervals (CIs) = [−58.56, −17.11]; P

Video-assisted thoracoscopic surgery (VATS) is a new area of exploration and evolution in thoracic minimal invasive surgery. The uniportal VATS approach has become popular during lung resection for small nodules and ground glass lesions. Our objective is to investigate the efficacy, availability and safety of uniportal VATS anatomical segmentectomy compared with conventional VATS in patients for lung resection. Surgical patients of perioperative period who admitted and underwent uniportal, two-port and conventional three-port VATS segmentectomy were analyzed and compared retrospectively during the year 2017 to 2018. During the research period, of 111 patients who had VATS anatomical segmentectomy, 38 underwent uniportal, 43 underwent two-port, and 30 underwent three-port VATS. Four patients underwent conversion to thoracotomy. There were no postoperative mortalities, and there were no significant differences among the three groups in surgical outcomes, including operative time, blood loss, conversions to thoracotomy, drainage time and volume, lymph node dissection, postoperative complications and hospital stay. The pain scores of visual analog scale (VAS) significantly decreased in uniportal group when operation is finished (P

Systemic inflammation is a potentially debilitating complication of thoracic surgeries with significant physical and economic morbidity. There is compelling evidence for the role of the central nervous system in regulating inflammatory processes through humoral mechanisms. Activation of the afferent vagus nerve by cytokines triggers anti-inflammatory responses. Peripheral electrical stimulation of the vagus nerve in vivo during lethal endotoxemia in rats inhibited tumor necrosis factor synthesis and prevented shock development. However, the vagal regulatory role of systemic inflammation after lung lobectomy is unknown. One hundred patients who underwent lobectomy via thoracotomy were recruited and equally randomized to treated group or controls. Intermittent stimulation of the auricular branch of vagus nerve in the triangular fossa was applied in the treated group using neurostimulator V (Ducest®, Germany), starting 24 h preoperatively and continued till the 4th postoperative day (POD). Inflammatory interleukins (IL) were analyzed using ELISA preoperatively, on the 1st and 4th POD. On the 1st POD, patients who underwent neurostimulation had reduced serum concentrations of CRP (p = 0.01), IL6 (p = 0.02) but elevated IL10 (p = 0.03) versus controls. On the 4th POD, serum concentrations of CRP, IL6 and IL10 were similar in both groups. Moreover, the treated group was associated with lower incidence of pneumonia (p = 0.04) and shorter hospitalization time (p = 0.04) versus controls. Modulations in the brain stem caused by noninvasive transcutaneous stimulation of the vagus nerve after lung lobectomy attenuate the acute postsurgical inflammatory response by the regulation of IL6 and IL10, resulting in reduced incidence of postoperative pneumonia and short hospitalization time. NCT03204968.

In the last decade, robotic video-assisted thoracic surgery (R-VATS) has grown significantly and consolidated as an alternative to video-assisted thoracic surgery. The objective of this study is to present the implementation as well as the experience with R-VATS accumulated by 2 Brazilian groups. We also compared the outcomes of procedures performed during the learning curve and after a more mature experience. Retrospective cohort study included all R-VATS procedures performed since April 2015 until April 2018. We describe the process of implantation of robotic surgery, highlighting the peculiarities and difficulties found in a developing country. Moreover, we reported our descriptive results and compared the first 60 patients to the subsequent cases. Two hundred and five patients included 101 females/104 males. Mean age was 61.7 years. There were hundred and sixty-four pulmonary resections, 39 resections of mediastinal lesions, 1 diaphragmatic plication, and 1 resection of a hilar tumor. Median operative times were 205 min for lung resections and 129 min for mediastinal. There was no conversion to VATS or thoracotomy or major intraoperative complications. Median length of stay was 3 days for pulmonary resections and 1 day for mediastinal. Postoperative complications occurred in 35 cases (17.0%)—prolonged air leak was the most common (17 cases). One fatality occurred in an elderly patient with pneumonia and sepsis (0.4%). Comparison of the first 60 patients (learning curve) with subsequent 145 patients (consolidated experience) showed significant differences in surgical and ICU time, both favoring consolidated experience. Our results were comparable to the literature. Robotic thoracic surgery can be safely and successfully implemented in tertiary hospitals in emerging countries provided that all stakeholders are involved and compromised with the implementation process.

Resuscitative thoracotomy (RT) can be a lifesaving treatment, but it has not yet been performed in Korea. In this study, we review our experience of RT after a regional trauma center was constructed. This is a retrospective study of RT conducted at a single Korean trauma center from May 2014 to March 2018. The primary outcome was survival, and the secondary outcome was return of spontaneous circulation (ROSC). The clinical characteristics of the patients were compared between the ROSC and non-ROSC groups. Survivors were also reviewed. A total of 62 patients were reviewed, and 60 patients had experienced blunt injury. Thirty-nine patients had ROSC. The ROSC group had short cardiopulmonary resuscitation (CPR) time (6 [2–10] min vs 11 [8–12] min, p

Post-burn oesophageal stricture is a late complication, which may require surgical intervention. The aim of the study was to compare gastric and colonic conduits and to evaluate the safety, efficacy and complications of these techniques. Retrospective analysis of all patients treated for burn-related oesophageal strictures between 1989 and 2013. Oesophagectomy was performed via laparotomy and right thoracotomy, and/or cervical incision. Forty-six patients, including 29 men, aged 17–67 years (mean: 41 years), had burn-related oesophageal strictures. The post-operative follow-up period ranged between 3 months and 30 years. Colonic transposition was used in 23 patients. In 21 patients, the oesophageal substitute was introduced through the posterior mediastinum, and in two patients the retrosternal route was used. Gastric conduit in was used in 21 patients and jejunal interposition in one patient. One patient underwent segmental oesophageal resection with end-to-end anastomosis. One patient had necrosis of the colonic conduit with anastomotic leakage, two patients had oesophago-colonic anastomosis leakage, five developed anastomotic stenosis, and two had respiratory insufficiency. Among patients with a gastric conduit, anastomotic leakage occurred in four, cervical anastomotic stenosis occurred in two, and respiratory insufficiency occurred in three, and one patient had impaired gastric emptying that required surgical re-intervention. Operative mortality was three patients (6.5%). The use of colonic and gastric conduit is an effective and safe method for restoring the continuity of the gastrointestinal tract, with an acceptable rate of post-operative complications. Patients who undergo oesophageal resection for post-burn stricture require post-operative systematic endoscopic control.

Major surgeries are associated with postoperative morbidity and mortality. Current preoperative evaluation fails to identify patients at increased risk of postoperative complications. This study is aimed to determine whether the Short Form-36 health survey (SF-36) and the 6-minute walk test (6-MWT) are useful predictors of postoperative complications after major surgery. All patients scheduled to undergo major surgery were eligible for the study. Major surgeries include patients undergoing thoracotomy, sternotomy, or upper abdominal laparotomy. The SF-36 health survey and 6-MWT were administered prior to surgery. Spirometry and other preoperative testing, ordered by the surgeon, like echocardiography were included in the study. Patients were then followed-up for postoperative complications for 30 days. One-hundred and seventeen subjects undergoing major surgery were recruited to the study. The mean age was 58 years and 66 (56.4 %) were male. Physical Functioning as a component of the SF-36 positively correlated with decreased length of hospital stay (LOS). The 6-MWT had a negative correlation with LOS (p

Generally, in retrospective studies, favourable short- and long-term outcomes for patients after lung lobectomy for early stage non-small cell lung cancer (NSCLC) using video-assisted thoracoscopic surgery (VATS) have been reported. However, the interpretation of lung lobectomy outcomes may be biased in retrospective settings. We retrospectively reviewed patients who underwent lung lobectomy for cT1-2N0M0 NSCLC from 2001 to 2010. The outcomes of patients who underwent VATS lobectomy were compared to those who underwent open lobectomy before and after performing propensity score matching. Preoperative covariates were entered when developing the propensity score-matching model. This study reviewed the outcomes of 101 VATS patients and 184 open lobectomy patients. Before propensity score matching, the VATS group had a higher mean age (p

Laparoscopic sleeve gastrectomy is a common surgical management of morbid obesity. Major complication rate is 3–8%. Staple line leak is one of the most serious complications. In a small group of patients, a gastro-pulmonary fistula is formed. Endoscopic and minimally invasive measures are the first line of treatment with considerable success rate. There are very poor data in the literature what should be done in cases of failure. In this paper, we report our positive experience with definitive surgical repair. Retrospective evaluation of 13 consecutive patients referred to the general thoracic surgery department for gastro-pulmonary fistula following sleeve gastrectomy. Prior to their referral, all patients underwent surgical or percutaneous drainage and multiple treatment attempts including stent insertion, pyloric dilatation, endo-clip/ring closure, endoscopic argon ablation and glue injection. Two patients underwent emergency thoracotomy for sepsis and bile empyema. One died in the early postoperative period. Eleven patients underwent semi-elective definitive surgery. Surgery included left lower lobectomy, partial diaphragmectomy and digestive system reconstruction. There was no mortality or major complications in this group. Complication rate was 45% mostly local wound infection and pneumonia. Gastro-pulmonary fistula is a rare devastating complication of sleeve gastrectomy. When minimally invasive measures fail, there is no place for nihilism. Surgical repair is possible and safe. The data presented herein support this treatment policy.

Total pharyngolaryngoesophagectomy (PLE) is used as a curative treatment for synchronous laryngopharyngeal and thoracic esophageal cancer or for multiple cancers in the cervical and thoracic esophagus. Gastric pull-up is commonly used after PLE, but postoperative complications are common. The present study evaluated these procedures in patients with esophageal cancer. Fourteen patients (7 with synchronous pharyngeal and thoracic esophageal cancer, 4 with synchronous cervical and thoracic esophageal cancer, and 3 with cervicothoracic esophageal cancer) underwent reconstructive surgery after PLE involving gastric pull-up combined with free jejunal graft between 2004 and 2015. Esophagectomy via right thoracotomy was performed in 9 patients, and transhiatal esophagectomy was used in 5. The posterior mediastinal route was used in 13 patients, excluding one patient with early gastric cancer. Interposition of a free jejunal graft included microvascular anastomosis using two arteries and two veins in all patients. Anastomotic leakage and graft necrosis did not occur in any of the 14 patients who underwent the above surgical procedures. Tracheal ischemia close to the tracheostomy orifice occurred in 4 patients (28.6%), but none of these patients developed pneumonia. No hospital deaths were recorded. The results indicate that gastric pull-up combined with free jejunal graft is a feasible reconstructive surgery after PLE. This procedure is a promising treatment strategy for synchronous pharyngeal and thoracic esophageal cancer or multiple cancers in the cervical and thoracic esophagus. Larger series are needed to show the distinct advantages of this procedure in comparison with conventional methods of reconstruction after PLE.

Enhanced recovery programs (ERPs) have been developed in various surgical fields and have been shown to accelerate postoperative recovery without increasing the incidence of adverse events. Whether ERP can be safely applied to patients undergoing complex liver surgery with a risk of liver failure remains unclear. We created an ERP by rearranging our conventional postoperative treatments and applied this program to patients undergoing major hepatectomy between 2008 and 2013. The ERP elements included greater perioperative education, individualized postoperative fluid therapy, and early mobilization. The success of the ERP was evaluated on postoperative day (POD) 6 based on the criterion of independence from continuous medical intervention with the exception of an abdominal drainage tube. Adherence to each item in the ERP was evaluated, and risk factors for delayed accomplishment were analyzed. Altogether, 200 patients were included, and 165 patients (82.5 %) completed the ERP. Multivariate analyses showed that (1) an age of 65 years or older and (2) a red blood cell transfusion were independent risk factors for delayed accomplishment. The performance of thoracotomy or choledocojejunostomy did not significantly affect accomplishment of the ERP. Oral intake starting on POD 1 was achieved in 179 patients (89.5 %), and termination of intravenous drip infusions on POD 5 was feasible in 72.5 %. An ERP for major hepatectomy was completed in more than 80 % of the patients. Earlier bowel movement can be challenged. The liquid in–out balance should be adjusted on an individual basis, rather than uniformly, especially for patients over 65 years of age or who required a red blood cell transfusion.

Liver resection is the mainstay of curative treatment for localized hepatocellular carcinoma (HCC). However, the impact of surgery for HCC on quality of life (QOL) has not been well assessed. Health-related QOL was assessed using the Short Form-36 questionnaire in 108 patients who underwent a liver resection for HCC between January 2004 and January 2008. The QOL assessment was scheduled before and every 3 months after the operation. Patients were divided into two groups based on patient-, tumor-, and surgery-related variables. The physical component summary (PCS) and mental component summary (MCS) were compared between the two groups. Altogether, 69 patients (64 %) completed the consecutive QOL assessments until 6 months after surgery. At 3 months, the PCS scores were significantly lower for women and for patients who had undergone thoracotomy than among men (p = 0.010) and patients who had not undergone thoracotomy (p = 0.048), respectively. No significant differences in any of the PCS scores were observed at 6 months. No significant differences in the MCS scores were observed between the groups throughout the investigation, and improvement relative to the preoperative status was observed at 6 months. Physical impairments in the QOL after surgery had returned to the baseline at 6 months, and the postoperative mental QOL improved relative to the preoperative state. The surgical candidates were expected to have a satisfactory QOL regardless of the preoperative status and surgical outcomes. A thoracoabdominal approach had a transient negative impact on the physical health status.

We developed a hybrid of the prone and left lateral decubitus positions for thoracoscopic esophagectomy (TE) in 2009. This study aimed to evaluate the feasibility of applying this novel TE position. We retrospectively analyzed 78 patients who underwent TE at our institution between 2005 and 2010. Altogether, 33 patients underwent TE in the left lateral decubitus position (LD-TE) from 2005 to 2008, and 45 underwent TE in the hybrid position (hybrid-TE) from 2009 to 2010. Radical lymphadenectomy along the bilateral recurrent laryngeal nerves was performed in both groups. The thoracic duct was preserved in the LD-TE group and resected in the hybrid-TE group. In the LD-TE group, all thoracic procedures were performed with the patient in the left lateral decubitus position. In the hybrid-TE group, the upper mediastinal procedure was performed with the patient in the left lateral decubitus position, and procedures at the middle and lower mediastinum were performed with the patient in the prone position under CO2 pneumothorax. Hybrid-TE was associated with increased operating time. The number of harvested mediastinal nodes and the PaO2/FiO2 ratio on postoperative day 1 were both greater in this position. Although vocal cord palsy was observed more frequently in the hybrid-TE group, there was no significant difference in the rate of other complications or in-hospital mortality between the two groups. The novel hybrid position is believed feasible for use during TE. We believe that this position facilitates a more radical mediastinal lymphadenectomy with minimal intraoperative pulmonary damage.

Thoracoscopic repair of congenital diaphragmatic hernia (CDH) is now widely performed by pediatric surgeons. We compare our experience with this operation versus the results for a group of CDH patients treated by laparotomy at the same center over the same period. From January 2008 to December 2011, we reviewed the medical records of 50 neonates who underwent surgery for posterolateral CDH (34 by laparotomy, 16 by thoracoscopy). Two thoracoscopic operations (12.5 %) were converted to thoracotomy. Eight patients treated with extracorporeal membrane oxygenation (ECMO) underwent laparotomy. There were no significant differences in demographic characteristics between the two groups. Both nitric oxide (p = 0.13) and high-frequency oscillatory ventilation (p = 0.06) tended to be required more frequently in the laparotomy group than in the thoracoscopy group. A patch was applied to nine patients (five laparotomy, four thoracoscopy, p = 0.42). Mean operation time was longer for the thoracoscopy group, but not significantly so (p = 0.06). Times to feeding and lengths of hospital stays were similar, as were days of postoperative ventilator use and of total ventilator use. CDH recurred in two patients, both in the thoracoscopy group (p = 0.08), and intestinal obstruction occurred in five patients in the laparotomy group. Of eight patients who received ECMO treatment, only three survived. Except in patients receiving ECMO treatment, thoracoscopic repair is useful and feasible regardless of defect size or need for patching. Operation time is longer, but cosmetic appearance is better and intestinal obstruction uppers to be less frequent. However, intensive training is needed to prevent the recurrence.

Background There are contrary opinions regarding the surgical treatment of pulmonary hydatid cysts. We report our experience performing a modified version of uncapitonnage surgery, called “saucerization,” for treating pulmonary hydatid cysts.

Background Emergency thoracotomy (ET) is a procedure that provides rapid access to intrathoracic structures for thoracic trauma patients arriving at the hospital in extremis. This study assesses the accessibility of intrathoracic structures provided by six different ET incisions. We hypothesize that the bilateral anterior thoracotomy (“clamshell” incision) provides the most rapid and definitive accessibility to intrathoracic structures.

Postoperative pleural empyema following liver resection has not been thoroughly described in the literature yet. Hence, we aimed to describe characteristics of patients experiencing this complication. Characteristics and outcomes of 21 patients who developed pleural empyema after hepatectomy, defined as a bacteriologically proven pleural infection with clinical and biological inflammatory signs requiring antibiotherapy and thoracic drainage, from 2001 to 2014, were retrospectively analyzed. Overall incidence of pleural empyema was 1 %. Nineteen (90.5 %) patients underwent right or extended right hepatectomy. All 21 patients developed postoperatively pleural effusion and 13 (62 %) infected abdominal collection. They had significantly more bile leakage and intra-abdominal abscesses compared to a matched control group of patients undergoing a right hepatectomy. Accidental diaphragmatic opening was observed in six patients (intra-operatively n = 4, transdiaphragmatic abdominal drainage n = 2). Treatment included percutaneous pleural drainage and in six (29 %) patients a thoracotomy for surgical drainage. Three patients (14 %) died due to sepsis and multiorgan failure. No patient treated by thoracotomy died postoperatively. Postoperative pleural empyema is a rare but serious complication occurring mostly after right hepatectomy complicated with intraabdominal sepsis. Pleural paracentesis for diagnosis and treatment should be rapidly considered. Early thoracotomy for optimal drainage would reduce postoperative mortality.

Video-assisted thoracic surgery (VATS) was considered the gold standard approach in recurrent spontaneous pneumothorax, with unanimous consensus of opinions. The cost-effectiveness analysis in the surgical treatment of recurrence of primary spontaneous pneumothorax (PSP) was carried out comparing VATS with muscle-sparing axillary minithoracotomy (MSAM). Between July 2006 and October 2012 we treated 56 patients with a second episode of PSP by VATS or open approach. Time of intervention, prolonged air leaks, duration of pleural drainage, length of hospitalization, and long-term morbidity were evaluated, establishing the relationship between costs and quality-adjusted life for each technique. The assessment of pain and threshold of tenderness was more favorable in VATS in respect to MSAM during the 5 years of follow-up (p = 0.004 and