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Tracheobronchial tuberculosis is one of the conditions causing long segment tracheal stenosis and is a clinically challenging scenario. This report describes a successful tracheal reconstruction in a 44-year-old man with long-segment post-tuberculosis tracheobronchial stenosis, utilizing a stented cryopreserved aortic allograft. The procedure was necessitated by the failure of conventional treatments. The stenotic segment was resected and replaced with a cryopreserved aortic allograft, supported by a metallic stent to maintain airway patency. Post-surgery, the patient experienced resolution of dyspnea without major complications. Currently, at 33 months post-operation, the patient enjoys an enhanced quality of life with effective breathing, speaking, swallowing abilities, and has resumed normal daily activities, with regular bronchoscopic follow-ups. This report demonstrates a novel approach for managing challenging tuberculosis-induced long segment airway stenosis. [ABSTRACT FROM AUTHOR]

No published studies to date have evaluated the detailed pathologic and genetic features of lung adenocarcinoma after epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) therapy and salvage surgery. We aimed to evaluate the pathologic and genetic changes of tumors in patients with advanced lung adenocarcinoma treated with EGFR TKI therapy and salvage surgery. This study retrospectively collected data from 29 advanced lung adenocarcinoma patients who underwent EGFR TKI therapy, followed by salvage operation, between January 2010 and December 2018. All patients had partial response or stable disease without evidence of progressive disease. Next-generation sequencing was used to determine whether acquired resistant mutations in morphologically treatment-sensitive and morphologically treatment-resistant regions of tumor existed. There were 3, 22, and 4 patients with clinical stage IIIB, IVA, and IVB, respectively. After a mean TKI treatment duration of 134 days, 27 patients had partial response, 2 had stable disease, and 27.6% of patients were downstaged before salvage surgery. All patients had residual viable tumor cells in their tumor bed; 5 patients (17.2%) had a major pathologic response. Acquired T790M mutations (n = 4), histologic transformations (n = 2), and acquired T790M mutation with histologic transformation (n = 1) were identified in the morphologically treatment-resistant regions of tumors. The 3-year overall survival was 75.9%. The presence of morphologically treatment-resistant tumor regions with acquired T790M mutations and histologic transformations demonstrate the existence of resistant subclones in TKI-treated tumors before disease progression. Salvage surgery performed in selected patients before disease progression may improve survival by removing TKI-resistant subclones. [Display omitted] [ABSTRACT FROM AUTHOR]

Although thoracoscopic stapled bullectomy is a standard procedure for primary spontaneous pneumothorax (PSP), the postoperative recurrence rate is high. We investigated whether using a Vicryl (Ethicon, Somerville, NJ) mesh to cover the staple line after bullectomy reduces the postoperative recurrence rate. Our single-blind, parallel-group, prospective, randomized controlled trial at 2 medical centers in Taiwan studied patients with PSP who were aged 15 to 50 years and required thoracoscopic bullectomy. On the day of operation, patients were randomly assigned (1:1) to receive Vicryl mesh (mesh group) or not (control group) after thoracoscopic bullectomy with linear stapling and mechanical apical pleural abrasion. Randomization was achieved using computer-generated random numbers in sealed envelopes. Our primary end point was the pneumothorax recurrence rate within 1 year after the operation (clinicaltrials.gov number, NCT01848860.) Between June 2013 and March 2016, 102 patients were assigned to the mesh group and 102 to the control group. Within 1 year after operation, recurrent pneumothorax was diagnosed in 3 patients (2.9%) in the mesh group compared with 16 (15.7%) in the control group (P =.005). The short-term postoperative results and hospitalization duration were comparable between the groups. For thoracoscopic bullectomy with linear stapling and mechanical apical pleural abrasion, the use of a Vicryl mesh to cover the staple line is effective for reducing the postoperative recurrence of pneumothorax. Vicryl mesh coverage can be considered an optimal adjunct to the standard surgical procedure for PSP. [ABSTRACT FROM AUTHOR]

Although the use of the uniportal thoracoscopic technique has spread exponentially recently, a comparison of nonintubated and intubated uniportal thoracoscopic segmentectomies for lung tumors has not been reported. We aimed to compare the feasibility, safety, and short-term postoperative outcomes between the 2 methods. From January 2014 to June 2019 we retrospectively reviewed 185 consecutive patients with lung tumors who underwent uniportal thoracoscopic segmentectomy at our institute. A body mass index of ≥25 kg/m2 was considered a contraindication for the nonintubated anesthetic approach. For the remaining cases the anesthetic approach was made at the discretion of each individual anesthesiologist. A propensity-matched analysis incorporating sex and body mass index was used to compare the clinical outcomes of the nonintubated and intubated groups. Fifty patients (27.0%) underwent the procedure with the nonintubated anesthetic approach. The nonintubated group was more likely to be female (P <.001) and with a lower body mass index (P <.001). Other clinical features showed no significant difference. There was no significant difference between the 2 groups in the type of segmentectomy according to the difficulty classification system. After propensity matching 43 matched patients in each group were included. Anesthetic induction duration (12.0 vs 15.3 minutes, P =.014) was shorter in the nonintubated group. No other significant differences in perioperative, postoperative, and anesthetic results were noted between the 2 matched groups. The nonintubated anesthetic approach can be a safe and feasible alternative to intubated uniportal thoracoscopic segmentectomy. [ABSTRACT FROM AUTHOR]

Background: Data on the efficacy and safety of balloon pulmonary angioplasty (BPA) in Taiwanese patients with chronic thromboembolic pulmonary hypertension (CTEPH) are lacking. In this study, we evaluated the effects of BPA on clinical parameters including hemodynamics, echocardiography and functional status in patients with inoperable CTEPH in Taiwan.Methods: We retrospectively collected the clinical data of inoperable CTEPH patients who underwent ≥3 BPA sessions. Pulmonary hemodynamic parameters of right heart catheterization, echocardiography, 6-min walk distance and World Health Organization (WHO) functional class were collected and analyzed before and after BPA treatment.Results: A total of 59 BPA sessions were performed in 13 inoperable CTEPH patients. No periprocedural deaths or major complications requiring tracheal intubation with mechanical ventilation occurred. WHO functional class significantly improved in all 13 patients (P < 0.001), and 6-min walk distance improved from 344 ± 147 to 450 ± 120 m (P = 0.014). Additionally, the plasma level of N-terminal pro-brain natriuretic peptide significantly decreased (P = 0.007). Hemodynamic data were available in 11 patients after ≥3 BPA sessions. Both mean pulmonary artery pressure and pulmonary vascular resistance significantly decreased from 44.6 ± 11.7 mmHg to 32.6 ± 5.1 mmHg (P = 0.005) and 745 ± 389 dyn·s·cm-5 to 366 ± 120 dyn·s·cm-5 (P = 0.002), respectively. Cardiac output also increased from 3.69 ± 1.12 L/min to 4.33 ± 0.94 L/min (P = 0.021).Conclusion: BPA improved both clinical symptoms and hemodynamic data in inoperable CTEPH Taiwanese patients without major periprocedural complications. [ABSTRACT FROM AUTHOR]

Background and Objectives: Uniportal thoracoscopic segmentectomy under intubated general anesthesia with one-lung ventilation has recently been introduced for the management of lung cancer patients with small tumors or compromised cardiopulmonary function. However, uniportal thoracoscopic segmentectomy without endotracheal intubation had rarely been performed. Therefore, in this study, we aimed to evaluate the feasibility and safety of this novel technique.Methods: From January 2014 to November 2018, 32 lung cancer patients were treated using nonintubated uniportal thoracoscopic segmentectomy under a combination of target-controlled infusion of propofol, nasal high-flow oxygen therapy, intrathoracic intercostal nerve blockade, and vagal nerve blockade. Sixty-two other lung cancer patients who underwent initial planning nonintubated multiportal thoracoscopic segmentectomy during the same period were included as the control group.Results: Preoperative dye localization was required in 18 (56.3%) patients of uniportal group. No patients required conversion to tracheal intubation or thoracotomy. Two patients were converted from the one-port to the two-port approach due to severe adhesions in the pleural cavity. The mean durations of anesthetic induction and surgery were 12.7 min and 101.1 min, respectively. Postoperative complications were noted in two patients (2/32, 6.3%) of uniportal group: one had subcutaneous emphysema and the other had prolonged air leaks over 3 days. The median durations of postoperative chest drainage and hospital stay were 1 and 3 days in uniportal group, respectively.Conclusion: Nonintubated uniportal thoracoscopic segmentectomy is technically feasible and safe for selected patients. It can be an attractive alternative to intubated thoracoscopic segmentectomy for patients with early lung cancer. [ABSTRACT FROM AUTHOR]

Although drainage tube placement after thoracoscopic pulmonary resection is considered mandatory, the drainless approach after pulmonary resections may be feasible in selected patients. We aimed to determine whether a drainless approach is safe and associated with shorter hospital stay after thoracoscopic surgery for peripheral lung nodules. This single-center, open-label, parallel-group, prospective, randomized, controlled trial enrolled patients with peripheral lung nodules treated with uniportal thoracoscopic wedge resection. After confirming the absence of air leaks and before closing the wound, patients were allocated to receive or not receive drainage using a chest tube, according to a preestablished randomization sequence provided in sealed envelopes. The primary end point was the length of postoperative hospital stay. Of 107 patients who agreed to participate in the study between August 2016 and September 2017, 100 were randomized to the drainage group (n = 50) or drainless group (n = 50) for intention-to-treat analysis. Patients in the drainless group had shorter postoperative hospital stay (mean, 1.2 versus 2.6 days; P <.001), shorter surgery duration (mean, 59.0 versus 73.7 minutes; P =.001), and lower pain on postoperative day 1 (mean, 0.9 versus 1.2 points; P =.011). In the drainless group, residual pneumothorax was noted in 31 patients at 6 hours (62%), in 18 patients at 1 day (36%), and in 1 patient at 10 to 14 days after surgery (2%). Medical costs were also substantially lower in the drainless group. Uniportal thoracoscopic wedge resection without drainage is feasible and safe for selected patients with peripheral lung nodules. [ABSTRACT FROM AUTHOR]

Non-small cell lung cancer (NSCLC) presenting as subcentimeter lung tumor was increasing due to the popularity of low dose CT in recent years. However, the ideal surgical management is still controversial. We utilized our lung cancer surgery database to study the important issue, aiming to find the optimal treatment with VATS. From January 2010 to December 2015, we retrospectively reviewed the clinical characteristics, staging, operation methods, and outcomes of 424 patients with subcentimeter lung cancer. Three groups distinguished by surgical methods were compared. There are 273, 57, and 94 undergoing VATS wedge resection, segmentectomy, and lobectomy, respectively. Of the nine recurrence or metastasis events, seven and two occurred within the wedge resection and lobectomy groups, respectively. The average follow-up time is 779 days (2.16 years). Furthermore, 97.4%, 100%, and 97.9% of patients in the wedge resection, segmentectomy, and lobectomy groups, respectively remained tumor-free during follow-up. The complication rate of approximately 1.5% did not differ significantly between the three groups. An obvious difference in disease-free survival between the three groups (p -value = 0.027; −2 log likelihood score and chi-square test). No cases of recurrence or metastasis were observed in the segmentectomy group. Lung cancer with subcentimeter size will be more and more encountered. VATS plays an important role in the management with good post-operative outcome, whether with wedge resection, segmentectomy and lobectomy. However, VATS segmentectomy can deliver 100% overall survival and progression-free survival in our series. Further randomized controlled trial should be conducted to prove the concept. [ABSTRACT FROM AUTHOR]

Pulmonary veno-occlusive disease (PVOD) is a rare but fatal cause of pulmonary hypertension reported to be linked to mutations of eukaryotic initiation factor 2 alpha kinase 4 (EIF2AK4), also known as general control nonderepressible 2 kinase (GCN2). PVOD is difficult to diagnose and often initially misdiagnosed as other types of idiopathic pulmonary arterial hypertension (IPAH). To rapidly and correctly identify PVOD patients and explore the possible pathogenesis, we thoroughly investigated histopathological features and GCN2 protein levels in non-PAH, PVOD and PAH patients. Lung specimens were examined for histopathological changes, including those of pulmonary arteries and veins, by Masson's trichrome, modified Verhoeff's and α-SMA staining in the PVOD, IPAH, and non-PAH groups. GCN2 and α-SMA expression in lung tissue was examined by immunohistochemistry and western blotting. PVOD and IPAH patients showed significant intimal and medial thickening of muscular pulmonary arteries compared with non-PAH patients. PVOD patients had more prominent intimal and medial thickening of muscular pulmonary veins than the other two groups. Interestingly, specialized muscle bundles surrounding the tunica adventitia of the pulmonary artery and vein were observed in PVOD patients. A significant decrease in GCN2 expression in the PVOD group was confirmed by immunohistochemistry and western blotting. Our study is the first to show remarkable histological structures, including the wreath-like arrangement of a hyperplastic muscle bundle in the adventitia of pulmonary arteries, in PVOD patients as a diagnostic clue and to disclose the biological difference between PAH and PVOD in a Taiwanese population. [ABSTRACT FROM AUTHOR]

Pulmonary arterial hypertension (PAH) is characterized as a progressive and sustained increase in pulmonary vascular resistance, which may induce right ventricular failure. In 2014, the Working Group on Pulmonary Hypertension of the Taiwan Society of Cardiology (TSOC) conducted a review of data and developed a guideline for the management of PAH.4 In recent years, several advancements in diagnosis and treatment of PAH has occurred. Therefore, the Working Group on Pulmonary Hypertension of TSOC decided to come up with a focused update that addresses clinically important advances in PAH diagnosis and treatment. This 2018 focused update deals with: (1) the role of echocardiography in PAH; (2) new diagnostic algorithm for the evaluation of PAH; (3) comprehensive prognostic evaluation and risk assessment; (4) treatment goals and follow-up strategy; (5) updated PAH targeted therapy; (6) combination therapy and goal-orientated therapy; (7) updated treatment for PAH associated with congenital heart disease; (8) updated treatment for PAH associated with connective tissue disease; and (9) updated treatment for chronic thromboembolic pulmonary hypertension. [ABSTRACT FROM AUTHOR]

Nonintubated thoracoscopic surgery for lung tumor is not widely performed. This study assessed the safety, outcome, and risk factors for conversion to tracheal intubation of nonintubated thoracoscopic surgery for lung tumor resection. We retrospectively reviewed the records of 1,025 patients who underwent lung tumor resection by nonintubated thoracoscopic surgery from August 2009 to December 2016 at our institution. Using univariable and multivariable analyses, we focused on the operative procedures, complications, conversion rate, surgical outcome, and risk factors for conversion to tracheal intubation. Most patients (73% [n = 748]) were women, and 14.3% (n = 147) of all patients were smokers. The average body mass index was 22.6 kg/m2. We performed 315 lobectomies, 111 segmentectomies, and 598 wedge resections. Postoperative complications included prolonged air leak for more than 5 days (20 patients [2%]), arrhythmia (2 [0.2%]), hemothorax (3 [0.3%]), pneumonia (4 [0.4%]), and chylothorax (2 [0.2%]). No surgical deaths occurred. During the operation 20 patients (2%) were converted to tracheal intubation. The main reason for conversion was considerable mediastinal movement. Multivariable analysis revealed that a body mass index of 25 kg/m2 or higher (p < 0.001) and pulmonary anatomical resection (p < 0.001) were risk factors for conversion to intubation. Nonintubated thoracoscopic surgery was a safe and effective technique for lung tumor resection. Clinicians should be aware that patients with a body mass index of 25 kg/m2 or higher or who require pulmonary anatomical resection have a higher risk of conversion to tracheal intubation. [ABSTRACT FROM AUTHOR]

Purpose: Uniportal video-assisted thoracoscopic surgery (VATS) has recently been reported as an alternative to conventional VATS. However, preoperative image-guided localization is usually required for small nodules. The present study evaluated the efficacy of preoperative computed tomography-guided dye localization prior to uniportal VATS for small undetermined pulmonary nodules.Methods: We retrospectively reviewed 298 consecutive patients who underwent uniportal VATS to treat undetermined pulmonary nodules (diameter ≤ 1.5 cm). Propensity score matching incorporating preoperative parameters was used to reduce the selection bias in a 1:1 manner. Comprehensive data including clinical features and perioperative variables were compared to evaluate the efficacy of preoperative computed tomography (CT)-guided dye localization prior to uniportal VATS.Results: A total of 232 patients received preoperative CT-guided dye localization (localization group) and 66 did not (direct surgery group), and the propensity score matching analysis generated 55 pairs of patients in both groups. The demographics and operative outcomes, including clinical nodule size, depths of the nodule, were comparable for both groups. The complication rates were low in both groups (3.6% and 1.8%, respectively). The uniportal to multi-portal VATS conversion rate was significantly higher in the direct surgery group than in the localization group (12.7% vs 1.8%, P = 0.030). 5 cases were converted due to failure in tumor identification (7.3% vs 1.8%, P = 0.182).Conclusion: Uniportal VATS is a feasible, effective, and safe procedure for the treatment of undetermined pulmonary nodules. The use of preoperative computed tomography-guided dye localization may be associated with a lower risk of conversion of uniportal VATS. [ABSTRACT FROM AUTHOR]

Background Preoperative computed tomography (CT)-guided dye localization is essential for the surgical treatment of small lung nodules and is mostly performed by radiologists in the CT room. Several studies reported their early experiences of preoperative localization in the hybrid operating room. A comparison between localization in the CT room and hybrid room has not been reported. Therefore, we compared the outcomes of preoperative localization in the hybrid and CT rooms. Methods This study included patients who underwent preoperative CT-guided dye localization for thoracoscopic lung tumor surgery in the hybrid operation room (n = 25) and CT room (n = 283) at our institute. Propensity matched analysis, incorporating nodule size, number, and depth, and operation method, was used to compare the short-term outcomes of these two groups. Each patient in the hybrid room group was matched with 2 patients in the CT room group. Results Localization was successfully performed in 23 patients (92%) and 50 patients (100%) in the hybrid room and CT room groups, respectively. There was no significant difference in demographics between groups. In the hybrid room group, the global time was shorter (192.6 versus 244.1 minutes, p = 0.003), and the localization time was longer (33.1 versus 22.3 minutes, p < 0.001). All lung nodules were successfully resected in both groups, but the hybrid room group had a relatively higher morbidity rate. Conclusions The hybrid operating room may be associated with a shorter global time and similar perioperative and postoperative outcomes compared with the CT room. Localization in the hybrid operating room seems an effective alternative method for managing small lung nodules. [ABSTRACT FROM AUTHOR]

The broad application of low-dose computed tomography screening has resulted in the detection of many more cases of early lung cancer than ever before in modern history. Recent advances in the management of early-stage non-small cell lung cancer have focused on making therapy less traumatic, enhancing recovery, and preserving lung function. In this review, we discuss several new modalities associated with minimally invasive surgery for lung cancer. Firstly, less lung parenchyma resection via sublobar resection has become an acceptable alternative to lobectomy in patients with tumors less than 2 cm in size or with poor cardiopulmonary reserve. Secondly, thoracoscopic surgery using a single-portal or needlescopic approach to decrease chest wall trauma is becoming common practice. Thirdly, less invasive anesthesia, using nonintubated techniques, is feasible and safe and is associated with fewer intubation- and ventilator-associated complications. Fourthly, preoperative or intraoperative image-guided localization is an effective modality for identifying small and deep nodules during thoracoscopic surgery. [ABSTRACT FROM AUTHOR]

Background/purpose: Lung transplantation in Taiwan began in 1991, but the experience was limited and diverse in the early years. We examined the cumulative institutional experience of the largest lung transplant cohort in Taiwan.Methods: A retrospective review of lung transplantations performed at a single institution from December 1995 through August 2016 was conducted. For comparative purposes, the cohort was divided into halves, with an early group (undergoing lung transplantation in the first decade) vs a late group (undergoing lung transplantation in the second decade). Standardized donor selection, organ procurement, and preservation protocols for brain-dead donors were applied. The outcomes measured were 30-day mortality and actuarial survival using the Kaplan-Meier method.Results: The cohort included 50 recipients in the early group and 42 recipients in the late group. Compared with the early group, recipients in the late group were significantly older (38.8 ± 11.6 vs 44.8 ± 13.4 years, p = 0.024) and more of them required mechanical ventilation before transplant (26.0% vs 66.7%, p < 0.001). There were more female donors (12.0% vs 33.3%, p = 0.021) and gender-matched donors (34.0% vs 61.9%, p = 0.012) in the late group. A total of 87 recipients (94.6%) had cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation (ECMO) support during transplant, and CPB was used significantly less in the late group. Graft procedures (14.0% vs 47.6%, p < 0.001), delayed chest closure (0% vs 21.4%, p < 0.001), and early tracheostomy (24.0% vs 52.4%, p = 0.005) were performed more in the late group. The durations of hospital and ICU stays were comparable in both groups, but the 30-day mortality was significantly lower in the late group (30.0% vs 2.4%, p = 0.001).Conclusion: Although the results were undesirable in the first decade of the transplant program, the cumulative institutional experience led to significantly improved outcomes in the second decade of the transplant program. [ABSTRACT FROM AUTHOR]

Background Endotracheal intubation and chest tube drainage are considered mandatory for thoracoscopic pulmonary resection. The management of peripheral lung nodules by tubeless uniportal thoracoscopic surgical repair has not been reported previously. Methods From October 2015 through January 2016, 30 consecutive patients with peripheral lung nodules underwent uniportal thoracoscopic wedge resection without endotracheal intubation and chest tube drainage (tubeless group). The clinical outcomes were compared with the outcomes in 30 consecutive patients with peripheral lung nodules who underwent uniportal thoracoscopic wedge resection with chest tube drainage from April through October 2015 (chest tube group). Results The demographic, anesthetic, and operative characteristics of the patients were comparable in both groups. No major adverse events occurred after operation. A small residual pneumothorax was noted in 12 (40.0%) patients at 6 hours and day 1 and in 2 (6.6%) patients on day 14 in the tubeless group. No patient required reintervention or readmission to the hospital. Patients in the tubeless group had lower pain scale scores on postoperative day 1 (mean, 1.0 vs 1.5, p = 0.012) and shorter postoperative hospital stays (mean, 3.1 days vs 4.4 days, p = 0.011) than did those in the chest tube group. Conclusions Tubeless uniportal thoracoscopic wedge resection is feasible and safe and may be a less invasive alternative for treating selected patients with peripheral lung nodules. [ABSTRACT FROM AUTHOR]

Background/purpose: Pulmonary endarterectomy (PEA) is a potentially curative surgical procedure for patients with chronic thromboembolic pulmonary hypertension. The aim of this study is to review our institutional experience with this operation.Methods: We conducted a retrospective review of PEA performed at our institution between January 2005 and December 2013. The measured outcomes were inhospital complications, improvement in cardiac function and exercise capacity, and actuarial survival after PEA.Results: Ten consecutive patients (7 women, 3 men) underwent PEA with a mean age of 59.9 ± 12.9 years. The preoperative New York Heart Association functional class (NYHA FC) for these patients was either Class III (n = 6) or Class IV (n = 4). The period from symptom onset to diagnosis was 34.3 ± 37.9 months, and that from diagnosis to operation was 31.4 ± 46.8 months. After PEA, the duration of intensive care unit stay and hospital stay prior to discharge were 9.7 ± 5.7 days and 18.7 ± 7.4 days, respectively. Postoperative complications included reperfusion lung edema (n = 3) and pneumonia (n = 1), and all recovered with medical therapy. After a mean follow-up of 48.4 ± 35.1 months, all patients showed marked improvements in their clinical status and were still alive without evidence of disease recurrence.Conclusion: With proper patient selection, the cooperation of a multidisciplinary team, and meticulous postoperative management, PEA can be conducted safely with relatively low risk at a center with limited experience with the procedure. [ABSTRACT FROM AUTHOR]

Background Uniportal video-assisted thoracoscopic surgery (VATS) has recently been introduced for various thoracic diseases. However, management of peripheral lung nodules by uniportal VATS without tracheal intubation has rarely been attempted. We evaluated the feasibility and safety of nonintubated uniportal VATS for peripheral lung nodules. Methods From January to March 2014, 32 patients with indeterminate peripheral lung nodules underwent uniportal VATS without tracheal intubation using a combination of intercostal nerve block, intrathoracic vagal block, and target-controlled sedation. Computed tomography-guided dye localization was sometimes used to identify small or ground-glass opacity lesions. Results A definite diagnosis was obtained in all 32 patients. A wedge resection was performed in 31 patients and a lobectomy in 1. Conversion to nonintubated multiport VATS was required in 4 patients (13%), in 3 because of primary lung cancer requiring further resection for adequacy of margins and in 1 because of difficulty in identifying a small nodule. Conversion to intubated 1-lung ventilation was required in 1 patient (3%) because of vigorous mediastinal movement. Operative complications developed in 2 patients who had air leaks for more than 3 days postoperatively. The median durations of postoperative chest tube drainage and hospital stay were 1 and 3 days, respectively. Postoperative neuralgia that required occasional use of analgesics occurred in only 1 patient (3%), and 97% of patients were very satisfied or satisfied with the resulting scars at 1 month. Conclusions Nonintubated uniportal VATS is technically feasible and safe for selected patients and is a less invasive alternative in managing indeterminate peripheral lung nodules. [ABSTRACT FROM AUTHOR]

Background/purpose: The role computed tomography (CT) performed prior to thoracoscopic surgery for primary spontaneous pneumothorax (PSP) remains unclear.Methods: We retrospectively reviewed medical records of all patients who underwent thoracoscopic surgery for PSP during 2008-2012. Patients were stratified into two groups: CT group (patients who received preoperative CT scanning) and control group (patients who did not receive preoperative scanning). Short-term postoperative results and long-term pneumothorax recurrence rates were compared.Results: A total of 298 patients were studied. Preoperative CT scanning was performed in 140 of them. The duration of operation, incidence of bullae formation, number of excised specimens, rate of complications, and postoperative hospital stay were similar between the two groups. After a mean follow-up of 20 months, the recurrence rates were 8.6% (12/140) in the CT group and 5.7% (9/158) in the control group (p = 0.371). In the CT group, five patients had unexpected pulmonary findings and three of them (60%) developed pneumothorax recurrence, the rate of which was significantly higher than that in patients without unexpected pulmonary findings (9/135, 6.7%, p = 0.004). Unexpected pulmonary lesions were more commonly noted in females (4/19, 21.1%) than in males (1/121, 0.8%; p < 0.001).Conclusion: Preoperative CT scanning was not associated with better results after thoracoscopic surgery for PSP and is, therefore, not justified as a routine examination prior to the operation. In female patients, however, preoperative CT scanning might be needed because these patients tended to have a higher incidence of unexpected pulmonary lesions, which were associated with a higher rate of recurrence. [ABSTRACT FROM AUTHOR]

Background/Purpose: Prolonged air leak is the most common complication after thoracoscopic operation for primary spontaneous pneumothorax (PSP), and the role of chemical pleurodesis in treating air leaks remains unclear. This study evaluated the safety and efficacy of chemical pleurodesis with a comparison between minocycline and OK-432. Methods: Between 1994 and 2011, 1083 PSP patients were treated by thoracoscopic operation. After the operation, patients with persistent air leak for 3 days or more were managed by minocycline or OK-432 pleurodesis. The demographic and outcome data for these patients were collected by retrospective chart review. Results: Seventy-nine patients (7.3%) with prolonged air leak after thoracoscopy underwent minocycline pleurodesis (60 patients) or OK-432 pleurodesis (19 patients) as the primary treatment. The primary success rate was 63% (38/60) for minocycline pleurodesis and 95% (18/19) for OK-432 pleurodesis (p = 0.009). Postpleurodesis pain was common and comparable between the two groups. No major complications were noted after a total of 121 treatments. Patients undergoing primary OK-432 pleurodesis had shorter durations of postpleurodesis chest drainage (mean 8.5 vs. 2.3 days; p < 0.001) and postoperative hospital stay (mean 11.9 vs. 6.8 days; p < 0.001) than those undergoing primary minocycline pleurodesis. After a median follow-up of 16 months, recurrence was noted in one patient in the OK-432 group and none in the minocycline group. Long-term pulmonary function in the two groups was comparable. Conclusion: Chemical pleurodesis using OK-432 or minocycline is safe and convenient for prolonged air leak after thoracoscopic treatment for PSP. Our experience suggested that OK-432 may be more effective than minocycline in reducing air leak. [Copyright &y& Elsevier]

Background/Purpose: Acute thoracic empyema is a common clinical problem worldwide, resulting in substantial morbidity and mortality. The objective of this study was to report its clinical characteristics and to evaluate whether thoracoscopic surgery is associated with a lower rate of in-hospital mortality compared with nonoperative drainage. Methods: Between 2001 and 2010, we retrospectively reviewed the clinical characteristics, bacteriological studies, and treatment outcomes of 602 patients with acute thoracic empyema. Thoracoscopic surgery was performed in 417 (69.2%) patients, while the remaining patients underwent nonoperative drainage. After treatment, 77 patients (12.8%) died in the hospital. A propensity score-based process, matched on potential risk factors for in-hospital mortality, was performed to select patients with equalized potential prognostic factors in the thoracoscopy and nonoperative groups. The log-rank test was used to compare the survival time with discharge between the two matched groups. Results: Multivariate analysis showed that age, malignancy, chronic lung disease, chronic renal insufficiency, liver cirrhosis, polymicrobial infection, and positive bacterial culture were risk factors for in-hospital mortality. The propensity score-matched analysis showed that the in-hospital mortality difference was significant (p = 0.014) and the Kaplan–Meier survival analysis revealed a higher survival rate to discharge (p < 0.001 by log-rank test), both favoring thoracoscopy over nonoperative drainage. Conclusion: Acute thoracic empyema carries a high mortality rate, especially in elderly patients with coexisting medical conditions and polymicrobial and positive bacterial cultures. Our study results also showed that thoracoscopy is feasible and might provide better chances for survival in borderline operable patients than nonoperative drainage. [Copyright &y& Elsevier]

Pneumothorax is defined as the presence of air in the pleural cavity. Spontaneous pneumothorax, occurring without antecedent traumatic or iatrogenic cause, is sub-divided into primary and secondary. The severity of pneumothorax could be varied from asymptomatic to hemodynamically compromised. Optimal management of this benign disease has been a matter of debate. In addition to evacuating air from the pleural space by simple aspiration or chest tube drainage, the management of spontaneous pneumothorax also focused on ceasing air leakage and preventing recurrences by surgical intervention or chemical pleurodesis. Chemical pleurodesis is a procedure to achieve symphysis between the two layers of pleura by sclerosing agents. In the current practice guidelines, chemical pleurodesis is reserved for patients unable or unwilling to receive surgery. Recent researches have found that chemical pleurodesis is also safe and effective in preventing pneumothorax recurrence in patients with the first episode of spontaneous pneumothorax or after thoracoscopic surgery and treating persistent air leakage after thoracoscopic surgery. In this article we aimed at exploring the role of chemical pleurodesis for spontaneous pneumothorax, including ceasing air leakage and preventing recurrence. The indications, choice of sclerosants, safety, effects, and possible side effects or complications of chemical pleurodesis are also reviewed here. [Copyright &y& Elsevier]

Highlights: [•] Two mediators (cyclooxygenase metabolites and ATP) and three types of pharmacological receptors (the TRPV1, TRPA1 and P2X receptors) are involved in the sensory transduction of pulmonary ROS by vagal lung C-fibers. [•] The functioning of the TRPV1 and TRPA1 in producing this sensory stimulation is at least in part mediated through the actions of cyclooxygenase metabolites. [•] The functioning of P2X receptors is mediated through the action of ATP. [ABSTRACT FROM AUTHOR]

Background: Intubated general anesthesia with one-lung ventilation is considered mandatory for anatomical pulmonary resections. Nonintubated thoracoscopic segmentectomy for management of lung tumors, which is technically challenging, has not been reported previously. The goal of this study was to evaluate the feasibility and safety of thoracoscopic anatomical segmentectomy without endotracheal intubation. Methods: From August 2009 to December 2012, 21 patients with lung tumors were treated using thoracoscopic anatomical segmentectomy without endotracheal intubation using a combination of thoracic epidural anesthesia, intrathoracic vagal blockade, and target-controlled sedation. Results: There were 16 patients with primary or metastatic lung cancers and 5 patients with nonmalignant tumors. Left upper lobe apical trisegmentectomy was most commonly performed (n = 6), followed by superior segmentectomy of the right lower lobe (n = 4) and left lower lobe (n = 4). One patient required conversion to intubated single-lung ventilation because of vigorous mediastinal and diaphragmatic movement. No patient required conversion to a thoracotomy or lobectomy. Operative complications developed in 1 patient who had an air leak for more than 3 days postoperatively. The mean duration of postoperative chest tube drainage and mean hospital stay were 2.5 days and 6.0 days, respectively. Anesthetic induction and the operation required a mean 26.5 minutes and 148.0 minutes, respectively. Conclusions: Nonintubated thoracoscopic segmentectomy is technically feasible and safe. It can be an alternative to intubated single-lung ventilation for management of lung tumors in selected patients. [Copyright &y& Elsevier]

Lobar torsion is a rare complication after lung transplantation. Here we report a case of right middle lobe (RML) torsion after bilateral sequential lung transplantation (BLTx). This 30-year-old lady underwent BLTx for bronchiolitis obliterans due to paraneoplastic pemphigus. The right lower lobe of the donor lung was resected due to inflammatory change during procurement. The postoperative chest X-ray showed persisting RML infiltrates. Fever and leukocytosis were noted 1 week later. RML lobectomy was performed after the reconstructed chest computed tomography confirmed the diagnosis of RML torsion. Adult respiratory distress syndrome with unstable vital signs, refractory hypoxemia and respiratory acidosis occurred thereafter. After venoarterial extracorporeal membrane oxygenation support, the patient recovered slowly and was discharged 5 months after BLTx. [Copyright &y& Elsevier]

Objective: Thoracic empyema in cirrhotic patients is a challenging situation, and the clinical characteristics are rarely reported. The objective of this study was to report the clinical characteristics among this group and to evaluate whether thoracoscopic intervention would affect clinical outcomes. Methods: Between 2001 and 2010, we retrospectively reviewed the clinical characteristics, bacteriologic studies, and treatment outcomes of 63 cirrhotic patients with thoracic empyema. A propensity-score based process, matched on age, sex, diabetes mellitus, malignancy, cause, and Child-Pugh classification (A, B, or C), was performed to equalize potential prognostic factors in thoracoscopy and nonthoracoscopy groups. The Kaplan–Meier curve and log-rank test were applied to compare the survival to discharge between the 2 matched groups. Results: The median patient age was 61 years. Thirty-two patients (51%) underwent thoracoscopic management, and the remaining patients underwent thoracocentesis or tube thoracostomy. The median hospital stay was 28 days, and 19 patients (30%) had in-hospital mortality. Multivariate analysis showed that Child-Pugh C disease and positive blood cultures were risk factors for in-hospital mortality (P = .016 and .027, respectively), whereas thoracoscopic management may be favorable for survival (P = .041). The propensity score–matched analysis showed a significant reduction in intensive care unit stay (P = .044) in the thoracoscopy group. Kaplan–Meier survival analysis revealed a higher survival to discharge, favoring thoracoscopy over non-thoracoscopy treatment (P = .035). Conclusions: Management of thoracic empyema in cirrhotic patients is complicated and associated with a high mortality. With proper patient selection, thoracoscopic management is feasible and may provide a better chance of survival. [ABSTRACT FROM AUTHOR]

Background: The possible mechanisms of simvastatin attenuating pulmonary hypertension (PH) have been widely investigated in pulmonary vascular and hemodynamic systems, but few studies have examined the difference in respiratory response mediated by pulmonary C fibers (PCF) in animal models of PH. We hypothesized that PCF sensitivity would differ from normal in monocrotaline-induced pulmonary hypertension (MCT-PH) rats and the effects of simvastatin treatment would involve not only the pulmonary circulatory system, but also PCF sensitivity. Methods: The PCF sensitivity was investigated by measuring the apneic durations evoked by 3 chemical stimulants: capsaicin; α,β-methylene-adenosine triphosphate; and phenylbiguanide. The effects of simvastatin on PCF sensitivity were evaluated in the MCT-PH rat model. Results: The sensitivity of PCF was increased significantly after monocrotaline (MCT) application for 21 days. Bilateral vagatomy and high-dose perivagal capsaicin (250 μg/ml) treatment both blocked the PCF hypersensitivity induced by MCT. Three days of simvastatin (5 mg/kg) treatment significantly reduced the hypersensitive status of PCF. In MCT-PH rats, reactive oxygen species (ROS) production was significantly elevated in both blood and bronchoalveolar lavage, but both showed a significantly decrease after simvastatin treatment. These potential benefits of simvastatin were all abolished by co-application of tin protoporphyrin-IX (SnPP), a specific heme oxygenase-1 (HO-1) inhibitor. Conclusion: Simvastatin treatment in MCT-PH rats not only attenuated pulmonary hypertension, but also desensitized PCF hypersensitivity and decreased the production of ROS. These cholesterol-independent effects were mainly through the HO-1 pathway and may all contribute to the therapeutic effects of PH treatment. [ABSTRACT FROM AUTHOR]

Background/purpose: Few studies have examined the surgical outcomes of mediastinal mature teratoma in Taiwan. In the present study, the clinicopathological characteristics of mature teratoma and their impact on surgical outcome were analyzed.Methods: From 1988 to 2005, 57 cases of mediastinal mature teratoma were reviewed. We collected and analyzed data about patient age, sex, symptoms, blood sugar, pulmonary function, diagnosis, tumor size, histopathological features, operative methods, operative time, tumor adhesion, blood loss, ventilator requirement, intensive care unit stay, chest tube requirement, and postoperative hospital stay.Results: There were 18 male and 39 female patients with a median age of 27 years. Forty-three patients received conventional open surgery, whereas 14 received video-assisted thoracoscopic surgery. The patients in the thoracoscopic group had a decreased operative time (106.4 +/- 35.7 min vs. 205.4 +/- 75.7 min, p = 0.038), fewer ventilator days (0.2 +/- 0.4 vs. 0.5 +/- 0.8, p = 0.034), and a shorter stay in the intensive care unit (0.6 +/- 0.8 days vs. 1.5 +/- 1.4 days, p = 0.030). Pancreatic tissue was identified in 21 of 57 tumors (36.8%). The patients with tumors that contained pancreatic tissue had more presenting symptoms and complicated surgery than those whose tumors were without pancreatic tissue (76.2%vs. 33.3%, p = 0.002, and 42.9%vs. 11.1%, p = 0.008). The patients with symptoms had a higher incidence of complicated surgery than those without (39.3%vs. 6.9%, p = 0.004).Conclusion: Mediastinal mature teratoma commonly occurs in young women. Thoracoscopic surgery is a feasible technique for mediastinal mature teratoma resection if no dense adhesions are found during preoperative assessment. The presence of symptoms might be a relative contraindication for thoracoscopic teratoma resection because of its association with surgical complications. [ABSTRACT FROM AUTHOR]

Objective: Thoracoscopy has become a favored modality in treating pediatric empyema. However, the factors affecting the outcome of thoracoscopic management remain unclear. In this study, we report our experience using thoracoscopy to treat empyema in pediatric patients and investigate the factors affecting outcome. Methods: We retrospectively reviewed the demographic data, clinical presentation, radiographic findings, laboratory studies, and hospital course of 101 pediatric patients who underwent thoracoscopy for empyema between 1995 and 2008. Results: Empyema was due to pneumococcus infection in 64 patients (63.4%), and 69% of the cultured microorganisms were penicillin nonsusceptible. Chest computed tomography scan was performed in 96 patients, in whom necrotizing pneumonia was noted in 35 (36.5%). Preoperative intensive care unit admission was required for 33 patients (32.7%). Preoperative chest tube drainage was performed in 36 patients (35.6%), and thoracoscopy was used as the primary treatment in the remaining 65 patients. Complications occurred in 10 patients (9.9%); there were no mortalities. The median postoperative hospital stay was 13 days. Multivariate analyses showed that necrotizing pneumonia was significantly associated with the presence of complications, and that necrotizing pneumonia, preoperative intensive care unit admission, and preoperative chest tube drainage were independent risk factors for a longer postoperative hospital stay. Conclusion: The clinical presentations of empyema in children requiring thoracoscopy are diverse. Patients with necrotizing pneumonia and those requiring preoperative intensive care unit admission and undergoing preoperative chest tube drainage are at high risk for developing complications and requiring longer hospital stay after thoracoscopy. [Copyright &y& Elsevier]

Cervical stab wounds with a thoracic-inlet esophageal injury are extremely rare. A 30-year-old man presented with dysphagia and stridor. He had attempted suicide by stabbing his neck with a screwdriver followed by jumping from a building 10 days previously, when a cervical tracheal injury was found and surgically repaired. Physical examination was unremarkable. Lateral cervical radiography revealed an air-fluid level within an extensive retropharyngeal pocket. Follow-up radiography showed that the retropharyngeal lesion had shrunk spontaneously. Contrast esophagography demonstrated an extravasation at the thoracic inlet. The patient underwent surgical exploration of the esophagus via a lower neck incision. A thoracic-inlet esophageal slit was found and primary repair was performed. He resumed oral intake uneventfully on the 8th postoperative day. This was a rare case of esophageal injury secondary to cervical stabbing wounds, presenting with delayed occurrence and spontaneously shrunken retroesophageal pocket. Esophageal perforation can be easily missed if tracheal lesion is found. Both bronchoscopy and esophagoscopy are mandatory. In patients highly suspected to have esophageal injury but with a negative esophagoscopy result, contrast esophagography is indicated and can decrease the incidence of false-negative results. [Copyright &y& Elsevier]

Summary: Background: The optimal initial management of primary spontaneous pneumothorax (PSP) remains controversial. This study was to evaluate the safety and efficacy of intrapleural minocycline following aspiration for initial treatment of PSP. Methods: Between January 2004 and November 2006, 64 patients with a first episode of PSP were successfully treated by simple aspiration using pigtail or intravenous needle catheter. From December 2005, 31 of the patients also received 300mg of minocycline hydrochloride post lung expansion, instilled through the catheter into the pleural space (minocycline group). The control group consisted of the first 33 patients of the series who had successfully undergone simple aspiration alone between January 2004 and December 2005. Results: There was no significant difference between the two groups in terms of demographic data. Patients in the minocycline group had higher doses of meperidine injection. The group hospitalization rates and mean hospital stays were comparable. After a mean follow-up of 13 months (range 3–26), recurrence was noted in 4 of the minocycline group and 11 of the control group (12.9% versus 33.3%, p=0.045). Subsequent thoracoscopic surgery for the recurrent patients revealed that minocycline induced scant loose adhesions which did not significantly affect operation procedures. The long-term pulmonary function and rates of residual pain for the two groups were comparable. Conclusions: Although associated with immediate chest pain, intrapleural minocycline following simple aspiration is a simple, safe and convenient initial treatment for PSP that may reduce the rates of ipsilateral recurrence. [Copyright &y& Elsevier]

Background: Simple aspiration is recommended as first-line treatment for all primary spontaneous pneumothoraces requiring intervention. However, the optimal salvage treatment remains unclear when simple aspiration is unsuccessful for controlling symptoms. In this study, the safety, efficacy, and estimated costs of video-assisted thoracoscopic surgery (VATS) and chest tube drainage (CTD) were compared. Methods: Between 2002 and 2007, 164 patients with a first episode of spontaneous pneumothorax were managed by simple aspiration. Among them, 52 patients underwent subsequent VATS (30 patients) or CTD (22 patients) due to unsuccessful aspiration. The demographic data and treatment outcomes of the two groups were collected through retrospective chart review. Results: Postoperative analgesics use did not differ between groups. Complications developed in 2 of the VATS group (6.7%) and 6 of the CTD group (27.3%), with mean hospital stays of 4.8 and 6.1 days, respectively (p = 0.034). Patients in the VATS group had lower rates of overall failure, although the rates of immediate failure were not significantly different. After a mean follow-up of 16 months, recurrent ipsilateral pneumothorax was noted in 1 VATS patient and 5 CTD individuals (p = 0.038). The estimated total costs per patient were $1,273 in the VATS group and $865 in the CTD group. Conclusions: Although associated with higher costs, VATS rather than CTD is the preferred salvage treatment for unsuccessful aspiration of the first episode of primary spontaneous pneumothorax, because of shorter hospital stay and lower rates of overall failure and recurrence. [Copyright &y& Elsevier]

This report describes the clinical use of an extracorporeal membrane oxygenation system in a 23-year-old woman with severe pulmonary arterial hypertension due to end-stage systemic lupus erythematosus. The system was also used to provide a direct bridge from resuscitation to transplantation after acute onset of pulmonary crisis and maintenance of stable hemodynamics during the bilateral lung transplant, and also to provide optimal oxygenation until the transplanted lung recovered from severe primary graft dysfunction. [Copyright &y& Elsevier]

Summary: The pulmonary hypertension that develops in chronic pulmonary thromboembolic diseases is caused by both mechanical obstruction of the vascular lumen and vascular remodeling, with pathological features similar to those of idiopathic pulmonary arterial hypertension (IPAH). The therapeutic efficacy of pulmonary thromboendarterectomy (PTE) in surgical candidates with chronic thromboembolic pulmonary hypertension (CTEPH) is well-established [Doyle RL, McCrory D, Channick RN, Simonneau G, Conte J. Surgical treatments/interventions for pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines. Chest 2004;126:63S–71S]. For CTEPH patients who are ineligible for PTE, therapeutic effects of various vasodilators in treatment of IPAH have been demonstrated. Although sildenafil, a phosphodiesterase type-5 inhibitor, has been reported to have short- and long-term benefits in terms of hemodynamics and functional status for inoperable CTEPH patients [Ghofrani HA, Schermuly RT, Rose F, Wiedemann R, Kohstall MG, et al. Sildenafil for long-term treatment of nonoperable chronic thromboembolic pulmonary hypertension. Am J Respir Crit Care Med 2003;167:1139–41; Sheth A, Park JE, Ong YE, Ho TB, Madden BP. Early haemodynamic benefit of sildenafil in patients with coexisting chronic thromboembolic pulmonary hypertension and left ventricular dysfunction. Vascul Pharmacol 2005;42:41–5], its role in CTEPH treatment for PTE candidates unwilling to undergo operation has not been explored specifically. We present the case of a 50-year-old female CTEPH patient who was a traditional candidate for PTE with poor clinical response to 3 months of anticoagulant therapy, where dramatic improvements were achieved after adding on 4 months of sildanefil treatment. Her treatment course is detailed, and we discuss the potential therapeutic effects of sildenafil for CTEPH. [Copyright &y& Elsevier]