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This study aimed to investigate the oncologic outcomes of video-assisted thoracoscopic (VATS) left upper trisegmentectomy (LTS) vs left upper lobectomy (LUL) for patients presenting with stage I non-small cell lung cancer (NSCLC).A retrospective analysis identified 1543 consecutive patients presenting to Shanghai Pulmonary Hospital (Shanghai, China) with NSCLC for VATS LTS or LUL from 2013 to 2017. After propensity-score matching for patient demographics and tumor characteristics, 273 pairs were identified. Disease-free survival (DFS) and overall survival (OS) were estimated by the Kaplan-Meier method and compared using the log-rank test.The median follow-up time was 51.5 months. There were no significant differences in operative duration (2.11 ± 0.64 hours vs 2.49 ± 5.96 hours; P = .30), total blood loss (106.19 ± 170.83 mL vs 97.07 ± 149.34 mL; P = .51), and operative complications (10% vs 8%; P = .37) between the LUL and LTS groups. Patients undergoing LUL had longer postoperative hospital stays (5.55 ± 3.00 days vs 4.87 ± 2.33 days; P = .003), greater tumor margin distance (3.3 ± 1.2 cm vs 3.1 ± 0.9 cm; P.001), and greater number of lymph nodes harvested (8.0 ± 3.2 vs 6.8 ± 3.3; P.001) than patients undergoing LTS, but the margin-to-tumor ratio was not statistically different (2.5 ± 1.6 vs 2.3 ± 1.1; P = 0.11). Median DFS (49.5 months vs 54.3 months; P = .77) and OS (49.5 months vs 55.0 months; P = .88) were not significantly different between patients undergoing LTS and those undergoing LUL, and similar outcomes were noted across subgroups of patients stratified by tumor stage, pathologic type, and radiographic manifestations.VATS LTS and LUL had comparable oncologic outcomes for stage I NSCLC, regardless of tumor pathologic types and radiologic findings, as long as negative margins were confirmed.

Pulmonary aspergilloma is chronic and invasive, potentially leading to life-threatening massive hemoptysis. The role of surgery for treating pulmonary aspergilloma and its effect on long-term survival needs more study.We reviewed 166 patients with aspergillomas treated at Shanghai Pulmonary Hospital from 2004 to 2017. Surgery indications included destroyed lung parenchyma, recurrent hemoptysis, despite appropriate medical treatment, and isolated pulmonary nodules suspected to be aspergilloma. Pulmonary aspergillomas are classified as simple (in an isolated thin-walled cavity, ≤3 mm) or complex (a thick-walled cyst,3 mm) based on computed tomographic scan findings.Aspergilloma was complex in 100 patients (60.2%) and simple in 66 (39.8%). The median (interquartile range) size of complex aspergillomas (2.5 [0.3-8.0] cm) was larger than that (2.0 [0.2-6.0] cm) of simple types (P.001). Hemoptysis occurred in 72 patients (72%) with complex disease and in 35 (53%) with simple disease (P = .014). Video-assisted thoracoscopic surgery was performed in 42 patients (63.6%) with simple aspergillomas, and 75 patients (75%) with of complex aspergillomas underwent thoracotomy. Prolonged air leakage (7 days) was the most common (17 [10.2%]) postoperative complication. A bronchopleural fistula developed postoperatively in 1 patient (0.6%). One patient (0.6%) died of respiratory failure within 30 days postoperatively. Two patients (1.2%) experienced recurrence during follow-up. The overall 10-year survival rates were 87.7% for complex aspergillomas and 94.97% for simple aspergillomas (P = .478). Diabetes (12 [7.2%]; hazard ratio, 13.15; 95% CI, 1.12-154.46) was associated with a worse prognosis.The perioperative morbidity and mortality of pulmonary aspergillomas are acceptable. Overall survival rates of simple and complex types are comparable.

Extended sleeve lobectomy (ESL) is a feasible alternative to pneumonectomy; however, the survival benefit is unclear, and preoperative selection of potential candidates for ESL remains a problem.ESL was performed on selected candidates with double sleeve lobectomy for more than 1 lobe (eg, left upper lobe and S6 segment resection). Three-dimensional (3-D) reconstruction was routinely validated. Patients were candidates for ESL if the predicted distal stump length was6 mm and the pulmonary vein of the remaining segments was not invaded.Of the 1809 patients with centrally located lung cancer for surgical resection, 86 patients with tumors invading more than 1 lobe were enrolled in the study. After evaluation by 3-D reconstruction, 22 (95.7%) of 23 selected candidates underwent ESL, and 63 patients were deemed unsuitable for ESL and underwent pneumonectomy (43 cases) or thoracic exploration (20 cases). Surgical outcomes between the ESL and pneumonectomy groups were similar in terms of complications, blood loss and surgical duration, but the 6-minute walking distance was significantly improved in the ESL group (371 ± 111 m vs. 191 ± 55 m, respectively; P .001). The mean forced expiratory volume in 1 second was 1.6 ± 0.3 L at the 1-year follow up examination in the ESL group. In the survival analysis, no difference was observed between the ESL and pneumonectomy groups in terms of 3-year overall survival (85% vs. 89%, respectively; P = .626) and 3-year disease-free survival (75% vs. 76%, respectively; P = .625).ESL is a feasible and superior surgical procedure in terms of its short-term and long-term outcomes, and we suggest 3-D reconstruction to identify candidates for ESL.

Objectives To compare the perioperative and oncologic outcomes following pneumonectomy performed by uniportal video-assisted thoracoscopic surgery (U-VATS) and thoracotomy in patients with centrally located non–small cell lung cancer (NSCLC). Materials and methods Patients with NSCLC who underwent pneumonectomy at the Shanghai Pulmonary Hospital (SPH) and Sun Yat-sen University Cancer Center (SYUCC) with the U-VATS approach or open approach between 2011 and 2016 were selected. Propensity score matching (1:3) was performed to balance the baseline covariates. Overall survival (OS) rates and recurrence-free survival (RFS) rates were estimated and compared using the Kaplan–Meier method, respectively. Results The enrollees in the study were 579 patients in the SPH cohort, with 501 (86.5%) in the open group and 48 (13.5%) in the U-VATS group, and 271 patients in the SYUCC cohort, with 245 (90.4%) in the open group and 26 (9.6%) in the U-VATS group. After propensity score matching, morbidity rates and 30-day mortality rates were found to be similar between the U-VATS group and open group in both the SPH and SYUCC cohorts. The long-term OS rate of patients who underwent U-VATS pneumonectomy did not significantly differ compared with the patients who underwent open pneumonectomy in both cohorts (SPH, p = .900; SYUCC, p = .240). Cox regression analysis revealed that the surgical option was not a risk factor for the OS rate (SPH: hazard ratio [HR], 0.925; 95% confidence interval [CI], 0.555 to 1.542; SYUCC: HR, 1.524; 95% CI, 0.752 to 3.087). Conclusion U-VATS can be used to safely perform pneumonectomy in patients with centrally located NSCLC without compromising the perioperative and oncologic outcomes compared with an open approach.

Objective: This study aimed to evaluate the therapeutic efficacy of thymectomy through a subxiphoid video ethoracoscopic approach with double elevation of the sternum compared with traditional intercostal uniportal video-assisted thoracic surgery for stage IeII thymic epithelial tumors (using the Masaoka-Koga staging system). Method: Patients with thymic tumors underwent resection through intercostal video-assisted thoracic surgery or subxiphoid videoethoracoscopic approach. Only those with pathologically confirmed thymic epithelial tumors were enrolled. Perioperative short-term/long-term outcomes were compared between 2 groups after propensity-score matching. Results: A total of 141 patients diagnosed with thymic epithelial tumors and scheduled for minimally invasive surgery were included. In the intercostal video-assisted thoracic surgery group, the prevalence for conversion to open surgery was higher than in the subxiphoid videoethoracoscopic approach group for stage III thymic tumors (P ¼ .019). After propensity-score matching for 122 patients undergoing video-assisted thoracic surgery, significantly larger resected specimens were found in the subxiphoid videoethoracoscopic approach group compared to the intercostal video-assisted thoracic surgery group (11.7 ± 3.8 vs 7.1 ± 2.7 cm, P < .001). The pain score on the first postoperative day (1.6 ± 0.6 vs 2.0 ± 0.7, P ¼.011) and the day of hospital discharge (1.2 ± 0.7 vs 1.6 ± 0.6, P ¼ .017) in the subxiphoid videoethoracoscopic approach group were significantly lower. The operation time (168.4±59.3 vs 92.5±46.0min,P

Background: Our study aims to describe the experience of a single team in terms of the potential and benefits of subxiphoid thymectomy using a double sternum hook retractor. Methods: From November 2016 to July 2018, 34 patients have been undergone subxiphoid thymectomy at our Department. Twenty patients were diagnosed with Masaoka Stage I–III thymomas, 12 with thymic hyperplasia or cysts of the thymus, 2 with thymic tumors. All patients underwent a chest computed tomography (CT) with enhancement. 18-Fludeoxyglucose positron emission tomography (18FDG-PET) was performed when recurrence was suspected. Neurological examinations were set. Patients underwent video-assisted thoracoscopic surgery (VATS) subxiphoid thymectomy with a double sternum retractor. A retrospective analysis of clinical, perioperative data, and follow-up was performed. Incidence rates for death or recurrence were calculated. Average pain score (NRS scale), average mental health, and physical health scores (SF-12) were analyzed. Results: Thirty-four patients (mean age 54; 12 men and 22 women) with thymic neoformation (from 1.0 cm × 1.0 cm × 1.0 cm to 14.0 cm × 9.0 cm × 4.5 cm) were enrolled. All patients underwent subxiphoid thymectomy. No mortality or recurrence was observed. Median follow-up time was 17.9 months (range, 2.2–23.3 months). The morbidity rate was 9.7 events per 100 person-years. Average pain scores after surgery and after follow-up were 1.7±0.4 and 0.1±0.4, respectively; average mental health and physical health scores on the SF-12 scale were 45.6±2.4 and 33.6±2.4, respectively. Conclusions: Subxiphoid thymectomy is a high satisfaction approach with positive aesthetic outcomes and low pain. Double sternum retractors are especially useful for creating space during thymectomy. However, the qualified experience is needed.

Background This study explored the safety and feasibility of uniportal video-assisted thoracoscopic (VATS) decortication in patients presenting with stage III tuberculous empyema with severe rib crowding. Methods From August 2017 to January /2019, 33 patients with stage III tuberculous empyema and severe rib crowding underwent uniportal VATS decortication with partial rib resection and the use of a customized periosteal stripper. Preoperative and postoperative chest computed tomography (CT) imaging and pulmonary function testing were analyzed to evaluate the clinical significance of certain imaging findings and surgical efficacy. Results There was 1 conversion to open thoracotomy. Median operative time was 3.5 hours (range, 2.1-4.5 hours) and the median blood loss was 500 mL (range, 250-1000 mL). There were no perioperative mortalities. The incidence of prolonged air leaks (>5 days) was 81.8%. Median postoperative hospital stay was 4 days (range, 4-5 days). All patients were discharged with 2 chest tubes, and median duration drainage was 39 days (range, 30-60 days). The presence of a low-density line between the parietal fibrous pleural rind and chest wall was demonstrated on chest CT in 13 patients. Intraoperative blood loss was considerably lower in these patients compared with those without this imaging finding. Follow-up was complete in all patients over a median of 8 months (range, 6-11.5 months). All patients recovered well and achieved notable improvement in pulmonary function. Conclusions Uniportal VATS decortication is safe and effective. Patients presenting with a low-density line around the thickened fibrous pleural rind on preoperative chest CT scan may be good candidates.

Post-tracheotomy tracheoesophageal fistula remains a challenge because it frequently involves a considerable length of the trachea. We report a case in which a modified slide tracheoplasty was successfully used to repair a long-segment, subglottic post-tracheotomy tracheoesophageal fistula. This technique not only shortened the length of the resected tracheal segment but also maintained the patency of the tracheal lumen.

OBJECTIVES To investigate the impact of lung window (LW) and mediastinal window (MW) settings on the clinical T classifications and prognostic prediction of patients with subsolid nodules. METHODS Seven hundred and nineteen surgically resected subsolid nodules were reviewed, grouping into pure ground-glass nodules (n = 179) or part-solid nodules (n = 540) using LW. Interobserver agreement on nodule classifications was assessed via kappa-value, and predictive performance of the solid portion measurement in LW and MW for pathological invasiveness and malignancy were compared using receiver-operating characteristic analysis. Cox regression was used to identify prognostic factors. Prognostic significance of T classifications based on LW (c[l]T) and MW (c[m]T) was evaluated by Kaplan–Meier method after propensity score matching. The performance of c(m)T for discrimination survival was estimated via the concordance index (C-index), net reclassification improvement and integrated-discrimination improvement. RESULTS By adopting MW, 124 part-solid nodules were reclassified as pure ground-glass nodules, and interobserver agreement improved to 0.917 (95% confidence interval 0.888–0.946). The solid portion size under MW more strongly predicted pathological invasiveness (P = 0.030), but did not better predict pathological malignancy. For remaining 416 part-solid nodules, c(l)T and c(m)T were both independent risk factors. c(m)T led to T classifications shifts in 321 nodules (14 upstaged and 307 downstaged) with no significant prognostic difference existing between the shifted c(m)T and matching c(l)T group after propensity score matching. The corrected C-index was improved to 0.695 (0.620–1.000) when adopting c(m)T with no significant difference in net reclassification improvement (P = 0.098) and integrated-discrimination improvement (P = 0.13) analysis. CONCLUSIONS As there is no significant benefit provided by MW in evaluating clinical T classification and prognosis, the current usage of LW is appropriate for assessing subsolid nodules.

OBJECTIVES The goal of this study was to compare the feasibility and safety of uniportal thoracoscopic segmentectomy (UTS) with that of multiportal thoracoscopic segmentectomy (MTS). METHODS From January 2014 to December 2015, a total of 1056 patients who underwent thoracoscopic segmentectomy were identified, including 375 and 681 who had simple and complex segmentectomies, respectively. A propensity matched analysis was applied to compare perioperative indicators. Survival outcomes, which included disease-free survival and overall survival, were assessed by Kaplan–Meier estimates and Cox hazards regression analysis. RESULTS Propensity matching generated 454 paired patients for the UTS and MTS cohorts; the perioperative results were comparable. Survival analysis indicated that the surgical approach (UTS versus MTS) was not an independent risk factor in either disease-free survival (P = 0.247) or overall survival (P = 0.870) of patients with invasive adenocarcinoma. A shorter operative time was observed in patients who had a UTS (P CONCLUSIONS Although minor differences could be found in the simple and complex segmentectomy groups, respectively, these results were clinically irrelevant. Our study supports UTS as a feasible and safe surgical technique.

OBJECTIVES This study aimed to investigate the efficacy of bronchial sleeve lobectomy with pulmonary arterioplasty by uniportal video-assisted thoracoscopic surgery (UniVATS) in centrally located non-small-cell lung cancer. METHODS One hundred and two thoracotomy and 31 UniVATS cases were included in this retrospective, single-centre study. Baseline characteristics, perioperative performance and survival outcomes were compared between the 2 groups. RESULTS Compared with the thoracotomy group, the UniVATS group was associated with lower postoperative blood transfusion rate (P = 0.043), decreased postoperative hospital stays (P = 0.008), shorter drainage duration (P = 0.003) and less drainage volume during the first postoperative 24 h (P = 0.005). Besides, the 3-year overall survival and recurrence-free survival were comparable between the 2 groups (log-rank, P = 0.81 and P = 0.78, respectively). In addition, squamous cell carcinoma was proved to be the independent favourable predictor for overall survival [hazard ratio (HR) 0.44, 95% confidence interval (CI) 0.24–0.80; P = 0.008], and advanced pathological stage was found to be independently associated with worse overall survival (IIIB stage: HR 3.21, 95% CI 1.13–9.12; P = 0.028) and recurrence-free survival (IIIB stage: HR 3.54, 95% CI 1.32–9.51; P = 0.012). CONCLUSIONS With appropriate patient selection, UniVATS sleeve lobectomy with pulmonary arterioplasty is feasible and safe for centrally located lung cancer in the hands of thoracic surgeons with extensive thoracoscopy experience.

Pathology arising from the intrathoracic portion of the trachea (distal trachea), the carina and the main bronchi is usually neoplastic and is mainly treated with surgery. Resection of the intrathoracic portion of the trachea, the carina and the main bronchi for neoplastic lesions does not necessitate lung resection and is traditionally being conducted via open surgery. Video-assisted thoracic surgery (VATS) is witnessing an exponential growth and is the treatment of choice for early-stage non-small cell lung cancer (NSCLC). The experience accumulated over the past two decades along with the introduction of reliable and ergonomic technology, has led to the expansion of its indications. In this article we provide a detailed description of lung sparing distal tracheal, carinal and main bronchi resection for primary neoplasms of the airway, without involvement of the lung, with the uniportal video-assisted technique. The chest is entered through the fourth intercostal space, mid-axillary line. Dissection of the paratracheal space anteriorly, the tracheoesophageal groove posteriorly and the subcarinal space and division of the azygos arch are essential to mobilize the distal trachea and carina. Lateral dissection should be avoided beyond the points of division of the airway, as it may hinder the blood supply to the anastomosis. Any tension to the anastomosis should be relieved by release maneuvers. Ventilation is achieved through an endobronchial catheter, inserted into the left main bronchus through which a high-frequency jet ventilation catheter can be also inserted through it. The rationale of applying a minimally invasive technique for the conduction of tracheal and carinal resections, is to exploit its advantages, namely less pain, earlier mobilization and lower morbidity. Uniportal video-assisted resections of the distal trachea, carina and the main bronchi, are safe when conducted by experienced surgical and anesthetic teams.

Repairing a large tracheoesophageal fistula with extensive involvement of the membranous wall of the trachea is sometimes troublesome because of the lack of an ideal replacement for the large defect. We report the successful use of a pedicled sternocleidomastoid musculocutaneous flap to repair a large tracheoesophageal fistula in which the cutaneous component was applied to the defect of the membranous trachea after tracheal resection and the muscular component was interposed between the tracheal and esophageal walls.

Background Enterogenic empyema is an uncommon complication of colobronchial fistula (CBF). We reported a case of enterogenic empyema patient after surgery for CBF. Case presentation A 66-year-old gentleman presented with persistent fever and repeated hemoptysis for 8 months. Computed tomography of the thorax confirmed the presence of a consolidation mass located in the right middle lobe and an air space near the right rib angle. During exploration, CBF was found. The patient underwent right middle and lower lobectomy together with closure of colonic and diaphragmatic perforation. The colon closure and diaphragm closure ruptured after surgery, leading to enterogenic empyema. Adequate drainage, sustained high protein diet, and antibiotic treatment eventually resulted in full recovery. Conclusion This is the first report of enterogenic empyema complicating CBF.

Background The superiority of robot-assisted thoracic surgery (RATS) over video-assisted thoracic surgery (VATS) and thoracotomy remains controversial for lung cancer. Methods A network meta-analysis (NMA) and pairwise meta-analysis (PMA) were performed to evaluate the perioperative outcomes using five databases. Results Thirty-two studies involving 6593 patients were included for analysis. The NMA showed that RATS had similar operative time, conversion rate to thoracotomy, number of lymph node, postoperative morbidity, and length of hospital stay with VATS, except for lower 30-day mortality. Compared with thoracotomy, longer operative time and shorter hospital stay were observed in RATS, but no significant difference was observed in number of lymph node, postoperative morbidity, and 30-day mortality in both NMA and PMA. In lobectomy/segmentectomy subgroup, all outcomes, except for operative time of RATS vs VATS and number of lymph node, were similar with overall analyses. Conclusions RATS had comparable perioperative outcomes with VATS and open surgery.

Background The destroyed lung has been a challenge in the clinical practice of thoracic surgery, and severe adhesions and massive bleeding during surgery are the main obstacles faced by surgeons. This study aimed to investigate the efficacy of the preoperative embolization of blood vessels in adhesions during surgery for the destroyed lung. Methods A total of 7 patients underwent preoperative embolization for lung resection of destroyed lungs between June 2016 and February 2019. Preoperative embolization was performed for 45 min to 2 h within 48 h before surgery. The embolized arteries included the intercostal artery, radial artery, subclavian artery and their branches, and the number of embolized arteries ranged from 5 to 13. Results A posterolateral incision was made in these patients, and endoscope-assisted separation of the adhesions at the top of the chest wall and on the lateral chest wall was performed. The operation time ranged from 3.5 to 8 h, and the blood loss was 1,200-5,000 mL. The postoperative drainage was in the normal range. One patient developed multiple organ failure and bronchopleural fistulas (BPF) one month after surgery, which was resolved after active drainage and argon cauterization; another patient developed BPF 7 months after surgery, which was resolved after placement of a nonreturn valve in the subsegmental bronchi via bronchoscopy. Conclusions Surgery of the destroyed lung is a great challenge in clinical practice, mainly due to the risk of the blood supply in the adhesions. Preoperative embolization may reduce intraoperative blood loss and surgical difficulty.

BACKGROUND: Thymic carcinoma is a type of rare and highly malignant tumor. Limited information was available on prognostic factors of late-stage thymic carcinoma. The aim of this study was to identify factors that impact prognosis and to define the relationship between survival and surgical intervention in patients with Masaoka stage IV thymic carcinoma. METHODS: From 1973 to 2015, a total of 311 consecutive patients were enrolled in this study with pathologic confirmed Masaoka stage IV thymic carcinoma from the Surveillance, Epidemiology, and End Results database. Kaplan-Meier analyses, Cox-regression analyses and propensity score matching (PSM) were performed to evaluate prognosis. RESULTS: In the multivariate analysis, larger tumor size, distant metastasis and positive lymph node status were associated with poorer outcome. After PSM, no receipt of surgery was the prognostic factor indicating poorer survival [hazard ratio (HR) 1.985, 95% confidence interval (CI) 1.007–3.913, P=0.048 for overall survival (OS); HR 1.649, 95% CI: 1.009–2.697, P=0.046 for disease-specific survival (DSS)]. Subgroup analysis indicated that significantly improved survival with surgery was observed in patients who were

Summary Double sleeve, bronchial and vascular reconstructions are challenging procedures indicated for centrally located tumours to avoid pneumonectomy. Traditionally, these resections have been performed by thoracotomy, but thanks to advances in imaging systems, better surgical instruments and the gained experience in video-assisted thoracic surgery (VATS), the scenario now is different. During the last decade, we have seen a rapid evolution of the uniportal VATS technique from simple lobectomies to advanced double sleeve bronchovascular procedures and carinal resections. The advantages of VATS over open surgery for major lung resections in terms of postoperative pain and morbidity, length of hospital stay and quality of life have prompted experienced surgeons to adopt uniportal VATS for cases requiring a sleeve resection. However, when a double bronchial and vascular sleeve resection is required, the adoption rate of minimally invasive surgery is still very low even for very experienced VATS surgeons. The difficulty of tumour mobilization, complexity of the suturing technique and the concern about possible uncontrolled massive bleeding during VATS are the main reasons for this low rate of adoption. In this article, we describe the technical aspects and tricks of this procedure when it is done by the uniportal VATS approach.

OBJECTIVES As evidence has proven that sublobar resection is oncologically contraindicated by tumour spread through air spaces (STAS), its preoperative recognition is vital in customizing surgical strategies. We aimed to assess the value of radiomics in predicting STAS in stage I lung adenocarcinoma. METHODS We retrospectively reviewed the patients with stage I lung adenocarcinoma, who accepted curative resection in our institution between January 2011 and December 2013. Using ‘PyRadiomics’ package, 88 radiomics features were extracted from computed tomography (CT) images and a prediction model was consequently constructed using Naïve Bayes machine-learning approach. The accuracy of the model was assessed through receiver operating curve analysis, and the performance of the model was validated both internally and externally. RESULTS A total of 233 patients were included as the training cohort with 69 (29.6%) patients being STAS (+). Patients with STAS had worse recurrence-free survival and overall survival (P CONCLUSIONS CT-based radiomics is valuable in preoperatively predicting STAS in stage I lung adenocarcinoma, which may aid surgeons in determining the optimal surgical approach.

This study aimed to validate the R classification including uncertain resection (R-un) proposed by the International Association for the Study of Lung Cancer (IASLC) in a Chinese non-small cell lung cancer (NSCLC) population.The study retrospectively investigated a 2009-2013 single-institutional NSCLC resection cohort in China. After reclassification, recurrence-free survival (RFS) and overall survival (OS) were calculated using survival analyses and compared with those using the 2005 version IASLC R classification.Under the proposed stratification, 3819 (72.1%) individuals were classified as R0, 1371 (25.9%) as R-un, 71 (1.3%) as R1, and 32 (0.6%) as R2. The 5-year OS probabilities for the R0, R-un, and R1/R2 groups were 71%, 46%, and 34%, respectively. The prognostic stratification remained significant in the fully adjusted Cox models (p 0.001). Compared with the original classification, Harrell's concordance index of reclassification improved significantly, from 0.508 to 0.679 for RFS and from 0.510 to 0.692 for OS (RFS: p = 0.007; OS: p = 0.001). The survival analysis showed that R-un patients with highest mediastinal lymph node station metastasis had significantly worse survival than R0 patients with mediastinal nodal metastasis (RFS: 44 vs. 36 months, hazard ratio [HR]: 1.29, p 0.001; OS: 59 vs. 50 months, HR: 1.34, p 0.001). Cox proportional hazards regression analysis showed that highest mediastinal lymph node station metastasis was an independent risk factor for RFS (HR: 1.22) and OS (HR: 1.25).The proposed R classification showed valid prognostic stratification, including highest mediastinal nodal station metastasis.

Background With the development of the surgical technique and experience of surgeons, uniportal VATS has been used in double sleeve lobectomy to treat non-small cell lung cancer (NSCLC). This retrospective study aims to evaluate the efficacy and safety of uniportal VATS in NSCLC treatment. Methods We reviewed 42 NSCLC patients who underwent double sleeve lobectomy in Shanghai Pulmonary Hospital from June 2015 to November 2017. 21 patients received double sleeve lobectomy through uniportal VATS and 21 through conventional thoracotomy with large incision. Results The characteristics of patients were similar between the two groups. The operation time was longer in the uniportal VATS group (p=0.021) and the drainage on postoperation day 1 was significantly less in the uniportal VATS group (p=0.004). Patients reported a lower postoperative pain level in the uniportal VATS group than in the thoracotomy group (p=0.002). No statistically significant difference showed in other aspects. Conclusion Uniportal VATS double sleeve lobectomy for NSCLC treatment is safe and effective. Lower postoperative pain level was found in the uniportal VATS group. Its complication rate and postoperation survival were similar to the conventional thoracotomy approach with large incision. But a large randomized clinical trial is still necessary for further investigation.

Thymoma is the most common tumor of the anterior mediastinum and surgical resection for thymoma has been recommended as the principal treatment. Bleeding control remains as a challenging task under minimally invasive approach. Subxiphoid approach with double elevated of sternum was a novel method which might provide good surgical view and space for operating. In this study we reported a case of bleeding control with this approach after unexpected damage to innominate vein to address the advantage of bleeding control using this specific surgical approach. The case was a 66-year-old female patient with an anterior mediastinal mass incidentally detected during physical examination and was diagnosed with thymoma with a diameter of 5 cm. Injury to the joint of innominate vein and the vena cava occurred during a subxiphoid approach with double elevation of the sternum. It was well managed by controlling the bleeding site with Alice forceps and suture under thoracoscope view without conversion to median sternotomy. A 4-0 PROLENE line was used with an elbow needle holder under the thoracoscope to suture continuously. Intraoperative blood loss was 350 mL. The drainage tubes were removed on postoperative day (POD) 2, and the patient was discharged on POD 3. This case indicated that thymectomy by subxiphoid approach with double elevation of the sternum has more advantages when there is an emergency for bleeding during the operation compared with traditional intercostal approach or subxiphoid approach with carbon dioxide inflation.

Highlights • Carinal resection with lung parenchyma sparing is a challenging issue in thoracic surgery. • It is usually not used for the difficulty of the technique. • It is replaced by pneumonectomy when the patient conditions allow this approach. • Complications after carina resection are quite frequent. • A high expertise and good coordination are mandatory to prevent severe complications., Introduction Carinal resection (CR) with or without lung parenchyma sparing is one of the challenging issues in thoracic surgery and performed rarely. It is usually not used for the difficulty of the technique, or, in the majority of the situations, it is replaced by pneumonectomy when the patient conditions and the tumor characteristics allow the radical surgical approach. The difficulty includes the dissection of the trachea and main bronchi, the resection of the carina and the reconstruction of the trachea and bronchus. In spite of the knowledge of the technique, one of the most important problem is the incidence of postoperative complications which is higher compared to standard resections. Clinical cases We show two cases of carina resection for a bronchogenic tumor with lung parenchyma sparing and good postoperative outcomes. Conclusion Our results demonstrate that this type of surgery is possible in selected centers with good quality of life for the patient after surgery.

Pleurectomy/decortication serves as a major component of therapy for malignant pleural mesothelioma (MPM), but the procedure is time consuming. We tentatively applied carbon dioxide (CO2) blower into pleurectomy/decortication for a patient with local relapse of MPM. The blower can help increase the potential subpleural place thanks to the positive pressure by CO2, while the mist of saline could clean the potential bleeding to increase visibility. Thereby, the procedure was greatly facilitated in a more precise manner, with blood loss of 100ml and acceptable postoperative air leak and thorax drainage. Therefore, CO2 blower may be considered in pleurectomy/decortication for MPM.

Evidence of neoadjuvant chemoimmunotherapy for locally advanced non-small cell lung cancer remains investigational and requires prospective validation. This phase II trial (https://www.chictr.org.cn/historyversionpub.aspx?regno=ChiCTR1900023758) aimed to investigate the safety and effectiveness of neoadjuvant PD-1 inhibitor sintilimab in addition to chemotherapy in the management of resectable stage IIIA non-small cell lung cancer.Eligible patients received two to four 21-day cycles of neoadjuvant therapy: sintilimab (200 mg) and carboplatin (area under the curve 5) on day 1, gemcitabine (1000 mg/mFifty patients were enrolled, and 23 (46%) achieved partial response after neoadjuvant chemoimmunotherapy. Four (8%) patients experienced grade 3 to 5 adverse events. Thirty patients received surgery, none of whom experienced treatment-related surgery delays, and 13 (43.3%) of 30 patients achieved major pathological response (viable tumor ≤10%). With a median follow-up of 13.6 months, 85.3% of patients were disease-free at 1 year (N = 50).Neoadjuvant sintilimab with platinum-containing dual-agent chemotherapy was feasible and safe for patients with resectable stage IIIA non-small cell lung cancer.

Synovial sarcoma (SS) is an uncommon malignant tumor associated with poor prognosis, and SS arising from the trachea is even rarer, with only 3 cases reported previously. We present the case of a 19-year-old man for whom imaging studies revealed a mass of soft tissue density in the lower trachea. An en bloc trachea segmental resection and postoperative proton beam therapy were performed. Diagnosis was confirmed by the SS18-SSX gene rearrangement. The patient was alive without tumor recurrence for 18 months. This case report presents tracheal SS successfully treated with surgery and postoperative proton therapy.

OBJECTIVESPulmonary carcinosarcoma (PCS) is a rare neoplasm. This study explored the clinicopathological characteristics and survival outcomes of PCS.METHODSThe Surveillance, Epidemiology and End Results (SEER) database (1988–2014) was queried for PCS. Overall survival (OS) was evaluated by multivariable Cox regression and nomograms were constructed to predict 3-year OS for PCS. Prognostic performance was evaluated using concordance index and area under the curve analysis. In M0 surgically treated patients, interaction assessments were performed using likelihood ratio tests. Subgroup analysis was performed according to patient age. The clinical features of PCSs were further compared to other non-small-cell lung cancers (NSCLCs).RESULTSMultivariable analysis identified age [hazard ratio (HR) 1.03, 95% confidence interval (CI) 1.01–1.04], surgery (HR 0.53, 95% CI 0.36–0.77) and chemotherapy (HR 0.51, 95% CI 0.36–0.73) as significantly associated with OS. The nomogram had a concordance index of 0.747 and an area under the curve of 0.803. The association between age and OS was stronger in those receiving pneumonectomy (P = 0.04 for interactions) compared to those that did not (HR 5.14, 95% CI 1.64–16.07), and was associated with a poorer outcome compared to lobectomy amongst the elderly (age ≥ 70 years). Patients with PCS were more likely to receive surgical treatment and had lower lymphatic metastasis compared to adenocarcinoma, squamous cell carcinoma and large cell carcinoma (all P CONCLUSIONSPCS had unique clinical features compared to common types of NSCLCs in terms of lymphatic invasion and surgical treatment. Pneumonectomy was associated with poorer survival in elderly patients.

Background Removal of tumors that invade the trachea or carina often results in a massive defect that exceeds the limits of end-to-end anastomosis. The purpose of this study is to discuss the clinical value of bronchial flap for the closure of central airway defects after noncircumferential tracheal or carinal resection. Methods From 1990 to 2016, 73 patients underwent noncircumferential tracheal or carinal resection. From size, location, and pulmonary function, there were six different types of bronchial flap reconstruction. Results We performed bronchial flap upturned reconstruction with right pneumonectomy (n = 45), right upper lobectomy (n = 9), left pneumonectomy (n = 7), left upper lobectomy (n = 3), and bronchial flap downturned reconstruction with right pneumonectomy (n = 5), left pneumonectomy (n = 4). The size of airway defects that were replaced by bronchial flap ranged from 0.5 × 2 to 2.5 × 7 cm and was at most 50% of the airway circumference. Postoperative major complications occurred in 17.8% (13 of 73) of patients: four bronchopleural fistulas (5.5%), five serious postoperative infections (6.8%), two pulmonary atelectasis (2.7%), and two airway stenosis (2.7%). However, no significant differences were found in postoperative complications between resection lengths shorter than 4 cm and longer than 4 cm (p = 0.295). The overall 30-day mortality rate was 2.7%. The overall survival rate was 63.5% and 23.6% at 2 and 5 years, respectively. Conclusions The six different types of bronchial flap reconstruction present an efficient therapeutic strategy to close massive central airway defects after noncircumferential tracheal or carinal resection when the patient has poor pulmonary function or when an end-to-end anastomosis is unfeasible and risky.

Background Video-assisted thoracoscopic surgery (VATS) has become the preferred approach for minimizing harm from thoracic operations. There is no report, however, which has discussed the feasibility of VATS in ipsilateral reoperation of major lung resection. Methods The present study included patients who had undergone ipsilateral reoperation of major lung resection by VATS from October 2009 to May 2017. Referring clinical data were recruited for analysis. Results Fourteen patients were recruited in the present study, including nine patients who underwent lobectomy and five who underwent segmentectomy during the second operation. Different hila were found in 6 patients, and pleural adhesions appeared in 10 patients. The average intraoperative blood loss was 203.6 ± 121.7 mL, and the mean operating room time was 2.2 ± 0.5 hours. There were no intraoperative deaths, and only one patient required conversion to thoracotomy. The average drainage time was 5.9 ± 4.6, and the mean hospital stay was 6.7 ± 4.2 days. Conclusion Though it is technically demanding to safely handle the changed hilum structure caused by the last operation, major lung resection by VATS is feasible for ipsilateral reoperation in appropriate candidates.

This study aimed to clarify differences in the prognostic impact of tumor spread through air spaces (STAS) in lobectomy versus sublobar resection (SR). The study also investigated the frequency and significance of STAS in residual lung segments. This study identified 752 patients with p-stage 1A non-small cell lung cancer (NSCLC) from 2010 to 2012. Recurrence-free survival (RFS) and overall survival (OS) were compared. For proactive simulation of SR, 100 consecutive lobectomy specimens of p-stage 1A NSCLC were selected. The study found STAS in 182 (28.7%) of 634 lobectomy cases and 43 (36.4%) of 118 SR cases. Multivariable analysis showed that STAS was not a prognostic factor in the lobectomy group, but showed a significantly worse prognostic effect for the SR group (RFS, P

Uniportal video‐assisted thoracic surgery (VATS) segmentectomy is a demanding technique but is safe and feasible in selected patients and confers favorable efficacy. It presents an acceptable alternative to conventional VATS. Lingulectomy is usually performed with left S4 + S5 segmentectomy. This report describes a case of uniportal VATS of left S4 anatomical segmentectomy alone.

The subxiphoid approach to video-assisted thoracic surgery (VATS) has been introduced as an alternative to intercostal VATS. There is some evidence that avoiding intercostal incision and instrumentation leads to reduced pain and facilitates early mobilisation and enhanced recovery. Access of the pleural cavities and anterior mediastinal space through a subxiphoid incision presents some challenges, particularly when accessing posterior pulmonary lesions. With increasing experience, a large range of thoracic surgical operations performed through the subxiphoid approach have been reported including anatomical segmentectomies, thymectomies. Another attraction is that bilateral procedures can be performed through a single incision. The experience of several surgeons passing through the learning curve of subxiphoid VATS surgery has resulted in overcoming many of the early challenges faced. In this paper, a series of tips and tricks are presented to enable surgeons considering adopting this technique into their practice to do so safely and with an appreciation of the difficulties that they may face.

Background The role of surgery in the multidisciplinary treatment of clinical stage IIIA small cell lung cancer is yet to be verified. This study was performed to determine the benefit of surgery in patients with stage IIIA small cell lung cancer. Methods Patients diagnosed with stage IIIA small cell lung cancer at Shanghai Pulmonary Hospital from 2005 to 2015 were included and divided into two groups: the surgery with neoadjuvant and adjuvant chemotherapy group and the concurrent chemo-radiotherapy group. Overall survival was compared between the two groups. A multivariate Cox regression model was constructed to evaluate factors associated with overall survival. Results Of 69 patients with stage IIIA small cell lung cancer during the study period, 40 patients (58%) underwent surgery with neoadjuvant and adjuvant chemotherapy, and 29 patients (42%) underwent concurrent chemo-radiotherapy. Patients in the surgery with neoadjuvant and adjuvant chemotherapy group had a longer overall survival compared with patients in the concurrent chemo-radiotherapy group (median survival: 33.1 vs. 16.2 months, respectively; 2-year overall survival: 44.2% vs. 14.9%, respectively; log-rank: P=0.045). A multivariate analysis revealed that surgery with neoadjuvant and adjuvant chemotherapy (hazard ratio: 0.374; 95% confidence interval: 0.173-0.808, P=0.012) was independently associated with overall survival. Conclusions Patients with stage IIIA small cell lung cancer treated with surgical resection plus chemotherapy demonstrated longer overall survival compared with those who underwent concurrent chemo-radiotherapy. Surgery may be an option for clinical stage IIIA small cell lung cancer after induction chemotherapy in selected patients.

Background Whether patients with non-small cell lung cancer (NSCLC) with unexpected pleural dissemination (UPD) could get survival benefit from tumor resection remained controversial. Methods Totally, 169 patients with NSCLC with UPD were included between 2012 and 2016. Patients were divided into the tumor resection and open-close group. Progression-free survival (PFS) and overall survival (OS) were compared with a log-rank test. The multivariable Cox analysis was applied to identify prognostic factors. Results Sixty-five patients received open-close surgery and 104 patients underwent main tumor and visible pleural nodule resection. Tumor resection significantly prolonged OS (hazard ratio [HR]: 0.408, P < 0.001), local PFS (HR: 0.283, P < 0.001), regional PFS (HR: 0.506, P = 0.005), and distant metastasis (HR: 0.595, P = 0.032). Multivariable Cox analysis confirmed that surgical method was an independent prognostic factor for OS, local PFS and regional PFS, except distant metastasis. Subgroup analyses indicated that tumor resection could not improve OS in the patients who received targeted therapy (HR: 0.649, P = 0.382), however, tumor resection was beneficial for the patients who received adjuvant chemotherapy alone (HR: 0.322, P < 0.001). In the tumor resection group, lobectomy (HR: 0.960, P = 0.917) and systematic lymphadenectomy (HR: 1.512, P = 0.259) did not show survival benefit for OS. Conclusions Main tumor and visible pleural nodule resection could improve prognosis in patients with UPD who could not receive adjuvant targeted therapy. Sublobar resection without systematic lymphadenectomy may be the optimal procedure.

BACKGROUND: The aim of this study was to investigate the feasibility and safety of simultaneous bilateral thoracoscopic lobectomy and compare perioperative and late outcomes between simultaneous and staged bilateral thoracoscopic lobectomy. METHODS: Between January 2013 and December 2017, the medical records of patients who underwent bilateral thoracoscopic lobectomy for synchronous bilateral multiple primary lung cancer (SPLC) were reviewed retrospectively. Univariate analysis was used to examine the factors associated with morbidity. Survival was estimated with the Kaplan-Meier method. RESULTS: In the simultaneous resection group (n=41) and the staged groups (n=66), 11 and 16 patients underwent postoperative complication, respectively, whereas no significant differences existed between two groups (P=0.850). Univariate analysis showed that preoperative comorbidities (P=0.009), FEV(1) 3 cm. CONCLUSIONS: Bilateral thoracoscopic lobectomy could be a feasible option for SPLC based on appropriate patient selection and careful perioperative management. Meanwhile, simultaneous resection has significantly advantaged in reducing the cost, preventing tumor progression compare to staged resection.

Objectives To illustrate our workflow for lung donation and transplantation during the COVID-19 crisis and report our preliminary experience with perioperative care. Methods We retrospectively analyzed data in the China Lung Transplantation Registration from January 23rd, 2020, to March 23rd, 2020 (2020 cohort), compared to the same period in 2019 (2019 cohort). Pre- and post-lung transplantation (LTx) management strategies, including measures aiming to prevent SARS-CoV-2 infection, were applied for all recipients, including five post-COVID-19 transplants during the COVID-19 pandemic period in China. Results Twenty-eight LTx procedures were performed, including LTx for five patients with acute respiratory distress syndrome (ARDS) due to COVID-19-related pulmonary fibrosis. Compared to the 2019 cohort, more patients with urgent conditions were transplanted in 2020, with a shorter pre-LTx admission time and early mobilization post-LTx. A large proportion (60%) of lung donations were transported on high-speed trains and commercial flights or commercial flights and highways. Grafts in the preservation containers were handed over to the receiving staff at the airport for 40% (10/25) of donations, which reduced the unnecessary quarantine of transporting staff entering the city. Listed candidates were urgently transferred to other qualified centers in 17.9% (5/28) of cases, which reduced the risk of SARS-CoV-2 exposure in COVID-19 designated hospitals. The 90-day survival rate of the recipients transplanted in 2020 was 85.7%, including 3 of 5 (60%) recipients who were critically severe COVID-19 patients. Conclusion LTx and lung donation amid COVID-19 can be performed safely with coordinated efforts on medical resource sharing and medical staff protection based on stratification of the infection risk. Outcomes were not compromised during the COVID-19 outbreak. LTx can be regarded as salvage therapy for critical COVID-19 patients with a confirmed positive-turned-negative virology status., Graphical abstract

BACKGROUND: Operative safety and oncologic adequacy of thoracoscopic sleeve lobectomy remain controversial. As such, the purpose of this meta-analysis was to evaluate evidence comparing thoracoscopy and thoracotomy in sleeve lobectomy for centrally located non-small cell lung cancer (NSCLC). METHODS: Electronic searches of PubMed and Web of Science databases were undertaken from inception to March 2020. Comparative studies about thoracoscopic and thoracotomy sleeve lobectomy, with evaluation for perioperative outcomes and oncological results were identified. The following outcomes were measured in this meta-analysis: operating time, blood loss, numbers of lymph node, postoperative hospital stay, chest drainage time, postoperative complication rate, mortality, overall survival (OS). The standardized difference (SMD), relative risk (RR) and hazard ratio (HR) with 95% confidence intervals (CI) were pooled using Stata software. RESULTS: Six studies generating 281 thoracoscopy and 369 thoracotomy cases were finally included. There was no significant difference in intraoperative blood loss, number of resected lymph nodes, chest drainage time, postoperative complication rate and mortality between two groups. However, thoracoscopic sleeve lobectomy was associated with longer operation time (SMD 0.59, 95% CI: 0.14 to 1.03, P=0.010). And shorter postoperative hospital stays (SMD −0.24, 95% CI: −0.51 to 0.03, P=0.078) were observed in the thoracoscopy group with marginal significance. Furthermore, sleeve lobectomy via thoracoscopy could achieve comparable OS compared to that via thoracotomy (HR 0.69, 95% CI: 0.38 to 1.00; P