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Background: Uniportal thoracoscopic right middle lobectomy (RML) poses greater technical challenges than other lobectomies. Although two-port thoracoscopy offers convenience, it results in heightened surgical trauma and scarring. The periareolar incision is rarely used in lobectomy while known for its cosmetic advantages. This study presents the periareolar access (combining a periareolar port and a 1-cm port) for video-assisted thoracoscopic surgery (VATS) in RML, comparing it with the traditional uniportal technique in both male and female patients. Methods: Eighty patients who underwent RML were randomly divided into two groups: the periareolar VATS (PV) approach (n = 40) and the uniportal VATS (UV) approach (n = 40) from August 2020 to February 2023. All patients were followed up for 1 year and clinical data were collected and analyzed. Results: No significant differences in complications, blood loss, duration of chest tube placement, and length of postoperative hospital stay were observed between two methods. However, the PV group exhibited significantly shorter operative time, reduced postoperative visible scarring and lower visual analogue scores (VAS) for postoperative pain (P < 0.05). Additionally, the PV group demonstrated significantly higher cosmetic and satisfaction scores at the 6-month postoperative assessment (P < 0.05). Notably, breast ultrasound follow-up revealed two cases injuries of the mammary glands in female patients, and sensory function of most nipple and areola remained intact except two cases in all PV group patients. Conclusions: Periareolar VATS emerges as a promising alternative approach for RML, providing clear benefits in pain management and cosmetic outcomes, while maintaining safety and convenience. [ABSTRACT FROM AUTHOR]

Background: The use of sublobar resection has increased with advances in imaging technologies. However, it is difficult for thoracic surgeons to identify small lung tumours intraoperatively. Radiofrequency identification (RFID) lung-marking systems are useful for overcoming this difficulty; however, accurate placement is essential for maximum effectiveness. Methods: We retrospectively reviewed patients who underwent RFID tag placement via fluoroscopic bronchoscopy under virtual bronchoscopic navigation (VBN) guidance before our institution's sublobar resection of lung lesions. Thirty-one patients with 31 lung lesions underwent RFID lung-marking with fluoroscopic bronchoscopy under VBN guidance. Results: Of the 31 procedures, 26 tags were placed within 10 mm of the target site, 2 were placed more than 10 mm away from the target site, and 3 were placed in a different area from the target bronchus. No clinical complications were associated with RFID tag placement, such as pneumothorax or bleeding. The contribution of the RFID lung-marking system to surgery was high, particularly when the RFID tag was placed at the target site and tumour was located in the intermediate hilar zone. Conclusions: An RFID tag can be placed near the target site using fluoroscopic bronchoscopy in combination with VBN guidance. RFID tag placement under fluoroscopic bronchoscopy with VBN guidance is useful for certain segmentectomies. [ABSTRACT FROM AUTHOR]

To evaluate survival outcomes of pulmonary resection for isolated metachronous pancreatic cancer metastasis. A systematic search of electronic data sources and reference lists were conducted. Proportion meta-analysis model was constructed to quantify 1- to 5-year survival after pulmonary resection for isolated metachronous pancreatic cancer metastasis. Random-effects modelling was applied to calculate pooled outcome data. Twenty-four retrospective studies were included reporting a total of 168 patients who underwent pulmonary resection for isolated pancreatic cancer metastasis. The nature of the index pancreatic surgery included 65% pancreaticoduodenectomies, 17.5% distal pancreatectomies, 0.5% total pancreatectomy, and 17% unspecified. Adjuvant chemotherapy was given to 88% of the patients. The median disease-free interval was 35 (8–96) months. The type of pulmonary resection included 54% wedge resections, 26% lobectomies, 4% segmentectomies, 1% pneumonectomies, and 15% unspecified. Pulmonary resection was associated with 1-year survival of 91.1% (95% CI 86.6%–95.5%), 2-year survival of 77.5% (95% CI 68.9%–86.0%), 3-year survival of 65.0% (95% CI 50.7%–79.3%), 4-year survival of 52.0% (95% CI 37.2%–66.9%), and 5-year survival of 37.0% (95% CI 25.0%–49.1%). Pulmonary resection for isolated pancreatic cancer metastasis is associated with acceptable overall patient survival. We recommend selective pulmonary resection for isolated pulmonary metastasis from pancreatic cancer. Our findings may encourage conduction of better-quality studies in this context to help establishment of definitive treatment strategies. [ABSTRACT FROM AUTHOR]

Background: The goal of the research was to examine the value of peripheral blood indicators in forecasting survival and recurrence among people suffering central‐type non‐small cell lung cancer (NSCLC) undergoing sleeve lobectomy (SL). Methods: Clinical information was gathered from 146 individuals suffering from NSCLC who had SL at our facility between January 2014 and May 2023. Peripheral blood neutrophil lymphocyte ratio (NLR), monocyte lymphocyte ratio (MLR), and platelet lymphocyte ratio (PLR) levels were determined by receiver operating characteristic (ROC) curve to establish the threshold points. Kaplan–Meier survival analysis was employed to evaluate the prognostic value of different groupings, and both univariate and multivariate Cox proportional hazards model (referred to as COX) were performed. Results: The disease‐free survival (DFS) and overall survival (OS) cutoff values were carried out via ROC analysis. Kaplan–Meier survival analysis revealed notable differences in OS for NLR (≥2.196 vs. <2.196, p = 0.0009), MLR (≥0.2763 vs. <0.2763, p = 0.0018), and PLR (≥126.11 vs. <126.11, p = 0.0354). Similarly, significant differences in DFS were observed for NLR (≥3.010 vs. <3.010, p = 0.0005), MLR (≥0.2708 vs. <0.2708, p = 0.0046), and PLR (≥126.11 vs. <126.11, p = 0.0028). Univariate Cox analysis showed that NLR (hazard ratio [HR]: 2.469; 95% confidence interval [CI]: 1.416–4.306, p < 0.001), MLR (HR: 2.192, 95% CI: 1.319–3.643, p = 0.002) and PLR (HR: 1.696, 95% CI: 1.029–2.795, p = 0.038) were correlated alongside OS. Multivariate Cox analysis showed that NLR (HR: 2.036, 95% CI: 1.072–3.864, p = 0.030) was a separate OS risk variable. Additionally, the pN stage (HR: 3.163, 95% CI: 1.660–6.027, p < 0.001), NLR (HR: 2.530, 95% CI: 1.468–4.360, p < 0.001), MLR (HR: 2.229, 95% CI: 1.260–3.944, p = 0.006) and PLR (HR: 2.249, 95% CI: 1.300–3.889, p = 0.004) were connected to DFS. Multivariate Cox analysis showed that pN stage (HR: 3.098, 95% CI: 1.619–5.928, p < 0.001) was a separate DFS risk variable. Conclusion: The study demonstrates that NLR, MLR, and PLR play a convenient and cost‐effective role in predicting survival and recurrence among individuals alongside central‐type NSCLC having SL. [ABSTRACT FROM AUTHOR]

Respiratory failure occurs more frequently after thoracic surgery than abdominal surgery. Although the etiology for this complication is frequently attributed to underlying lung disease present in patients undergoing thoracic surgery, this notion is often unfounded because many patients with normal preoperative pulmonary function often require prolonged oxygen supplementation even after minimal resection of lung tissue. Using a murine model of pulmonary resection and peripheral blood samples from patients undergoing resection of the lung or abdominal organs, we demonstrated that lung surgery initiates a proinflammatory loop that results in damage to the remaining lung tissue, noncardiogenic pulmonary edema, hypoxia, and even death. Specifically, we demonstrated that resection of murine lung tissue increased concentrations of the homeostatic cytokine interleukin-7, which led to local and systemic activation of type 2 innate lymphoid cells. This process activated lung-resident eosinophils and facilitated stress-induced eosinophil maturation in the bone marrow in a granulocyte-macrophage colony-stimulating factor–dependent manner, resulting in systemic eosinophilia in both mice and humans. Up-regulation of inducible nitric oxide synthase in lung-resident eosinophils led to tissue nitrosylation, pulmonary edema, hypoxia, and, at times, death. Disrupting this activation cascade at any stage ameliorated deleterious outcomes and improved survival after lung resection in the mouse model. Our data suggest that repurposing US Food and Drug Administration–approved eosinophil-targeting strategies may potentially offer a therapeutic intervention to improve outcomes for patients who require lung resection for benign or malignant etiology. Editor's summary: Respiratory failure frequently occurs after lung resection and may not be fully explained by underlying respiratory disease or the size of the resection. Here, Mei and colleagues used patient samples and mouse models of pneumonectomy to show that lung resection specifically leads to increased percentages of eosinophils through a mechanism involving production of IL-7 by γδ T cells, leading to granulocyte-macrophage colony-stimulating factor production by type 2 innate lymphoid cells, ultimately resulting in increased eosinophil maturation, activation, and production of reactive oxygen species that injure the remaining lung. Targeting different points in this pathway reduced lung damage and improved survival of mice after lung resection, suggesting that perioperative administration of agents that target eosinophils or neutralize nitric oxide synthase could potentially reduce the risk of respiratory failure after lung resection. —Melissa L. Norton [ABSTRACT FROM AUTHOR]

Background: Pneumonectomy is a radical surgical procedure associated with significant morbidity and mortality. Its application in the context of pulmonary neuroendocrine tumours, including carcinoid tumours, requires meticulous preoperative planning and intraoperative precision. This study aims to assess the safety and efficacy of pneumonectomy in the management of these rare and challenging neoplasms. Methods: A retrospective analysis of patients who underwent pneumonectomy for pulmonary carcinoid tumours at our institution over a specified period was conducted. Data regarding patient demographics, tumour characteristics, surgical techniques, intraoperative complications, perioperative management, and long-term outcomes were collected and analysed. Results: Between March 2001 and October 2022, 21 patients (7 male, 14 female) with carcinoid tumours underwent pneumonectomy on a total of 459 surgical operations for carcinoid. Preoperative bronchoscopic procedures were conducted in 90.4% of cases, leading to histological diagnoses for most. The median hospital stay was eight days, with no reported perioperative deaths. Median follow-up after surgery was 73 months, with a five-year overall survival of 65.4 months. Recurrences occurred in 28.6% of cases, primarily in atypical carcinoids. Conclusion: Despite the rarity of bronchial carcinoids, pneumonectomy is effective for low-grade malignancies, demonstrating positive short—and longterm outcomes. Radical lymph node dissection is fundamental in pathological staging and overall survival. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Neoadjuvant therapy has gained widespread acceptance as the standard modality for locally advanced non-small cell lung cancer. However, the clinical benefit of sleeve lobectomy (SL) or pneumonectomy (PN) following neoadjuvant therapy remains controversial. METHODS The clinical and pathological characteristics of non-small cell lung cancer patients who underwent SL or PN after neoadjuvant therapy at a high-volume single centre between December 2019 and March 2023 were retrospectively collected. The SL group was matched 4:1 with the PN group by propensity score matching. The surgical outcomes were systematically collected and analysed. RESULTS During a 5-year study period, the majority of patients (175 of 215, 81.4%) underwent the SL procedure, while 40 patients (18.6%) underwent PN. Following propensity score matching, the SL group exhibited lower postoperative arrythmia (4.8% vs 26.9%, P  <   0.001), lower 30-day mortality (1.0% vs 7.7%, P  =   0.046) and a shorter length of postoperative hospital stay (6.0 days vs 10.0 days, P  <   0.001), compared with the PN group. In addition, no significant difference was observed between the two groups in terms of disease-free survival or overall survival (P  =   0.977 and P  =   0.913, respectively). CONCLUSIONS SL stands as a safe and feasible option for patients with centrally located non-small-cell lung cancer who have undergone neoadjuvant therapy, in comparison to PN. This finding suggests that SL remains the preferable choice when feasible in the context of the widespread utilization of neoadjuvant therapy. [ABSTRACT FROM AUTHOR]

Purpose: We evaluated the surgical outcomes of salvage extended surgery after definitive medical treatment with an immune-checkpoint inhibitor (ICI) for locally advanced or unresectable non-small-cell lung cancer (NSCLC). Methods: The subjects of this single-center retrospective analysis were 14 patients who underwent salvage surgery after ICI treatment between May, 2017 and April, 2023 at our institute. We reviewed the comprehensive surgical outcomes, including operative procedures, intraoperative findings, and postoperative morbidities. Overall survival (OS) was calculated using a Kaplan–Meier estimation. Results: The initial clinical stage before medical treatment (c-stage) was stage III in eight patients, stage IV in five patients, and one patient had postoperative lung cancer recurrence. The indications for surgery were as follows: local control for relapse or residual tumor in ten patients and discontinuation of systemic therapy because of treatment-related complications in four patients. The surgical modes were segmentectomy (n = 1), lobectomy (n = 4), bilobectomy (n = 3), pneumonectomy (n = 6), and bronchoplasty (n = 7). Grade 3 or higher postoperative morbidities were observed in six patients, including only one case of 90-day mortality. Conclusions: Our series demonstrated that the surgical outcome of salvage extended surgery after ICI therapy may be positive with careful selection of the procedure and indication. [ABSTRACT FROM AUTHOR]

Background: Associations between procedure volumes and outcomes can inform minimum volume standards and the regionalization of health services. Robot-assisted surgery continues to expand globally; however, data are limited regarding which hospitals should be using the technology. Study design: Using administrative health data for all residents of Ontario, Canada, this retrospective cohort study included adult patients who underwent a robot-assisted radical prostatectomy (RARP), total robotic hysterectomy (TRH), robot-assisted partial nephrectomy (RAPN), or robotic portal lobectomy using 4 arms (RPL-4) between January 2010 and September 2021. Associations between yearly hospital volumes and 90-day major complications were evaluated using multivariable logistic regression models adjusted for patient characteristics and clustering at the level of the hospital. Results: A total of 10,879 patients were included, with 7567, 1776, 724, and 812 undergoing a RARP, TRH, RAPN, and RPL-4, respectively. Yearly hospital volume was not associated with 90-day complications for any procedure. Doubling of yearly volume was associated with a 17-min decrease in operative time for RARP (95% confidence interval [CI] − 23 to − 10), 8-min decrease for RAPN (95% CI − 14 to − 2), 24-min decrease for RPL-4 (95% CI − 29 to − 19), and no significant change for TRH (− 7 min; 95% CI − 17 to 3). Conclusion: The risk of 90-day major complications does not appear to be higher in low volume hospitals; however, they may not be as efficient with operating room utilization. Careful case selection may have contributed to the lack of an observed association between volumes and complications. [ABSTRACT FROM AUTHOR]

Accurately identifying the branches of pulmonary segmental vessels and bronchi, as well as adjacent structures, and determining the spatial location of lesions within pulmonary segments, are major challenges for thoracic surgeons. The application of three-dimensional reconstruction technology holds promise in addressing this issue. To evaluate the clinical value of three-dimensional reconstruction in thoracoscopic segmental surgery. Seventy-seven patients who underwent thoracoscopic segmental surgery combined with three-dimensional reconstruction at our hospital from January 1, 2020, to August 31, 2023, were retrospectively analyzed. Preoperative chest enhanced CT scans were conducted, and MIMICS software aided in reconstructing DICOM format original data for patients with pulmonary nodules to facilitate intraoperative nodule localization. Accurate segmental pneumonectomy was performed by comparing preoperative anatomical identification of target segmental arteries, veins, and bronchi, with surgical details and postoperative outcomes recorded, including intraoperative pulmonary resection distribution, operation time, blood loss, chest tube drainage, extubation time, hospital stay, and complications. Following preoperative three-dimensional reconstruction, successful segmental lung surgeries were performed, predominantly with single segmental resection (92.2%), and a minority with combined segmentectomy (7.8%). Median operation time was 130225 minutes, with intraoperative blood loss at 70100 mL and postoperative chest tube drainage at 347 mL (159690 mL). Median extubation time and hospital stay were 4 days and 7 days, respectively. Complications within the 3-month follow-up affected 11.7% of cases, including persistent pulmonary leakage (7.1%), pulmonary infection (4.3%), atelectasis (4.3%), and pleural effusion (1.4%), with no fatalities. Preoperative 3D reconstruction can help the operator to perform safe, efficient and accurate thoracoscopic segmental pneumonectomy, which is worth popularizing in clinic. [ABSTRACT FROM AUTHOR]

In the field of pulmonary hypertension (PH), a well-established protocol to induce severe angioproliferation in rats (SuHx) involves combining the VEGF-R inhibitor Sugen 5416 (SU5416) with 3 wk of hypoxia (Hx). In addition, injecting monocrotaline (MCT) into rats can induce inflammation and shear stress in the pulmonary vasculature, leading to neointima-like remodeling. However, the SuHx protocol in mice is still controversial, with some studies suggesting it yields higher and reversible PH than Hx alone, possibly due to species-dependent hypoxic responses. To establish an alternative rodent model of PH, we hypothesized mice would be more sensitive to hemodynamic changes secondary to shear stress compared with Hx. We attempted to induce severe and irreversible PH in mice by combining SU5416 or monocrotaline pyrrole (MCTP) injection with pneumonectomy (PNx). However, our experiments showed SU5416 administered to mice at various time points after PNx did not result in severe PH. Similarly, mice injected with MCTP after PNx (MPNx) showed no difference in right ventricular systolic pressure or exacerbated pulmonary vascular remodeling compared with PNx alone. These findings collectively demonstrate that C57/B6 mice do not develop severe and persistent PH when PNx is combined with either SU5416 or MCTP. NEW & NOTEWORTHY: We attempted to establish a mouse model of severe and irreversible pulmonary hypertension by substituting hypoxia with pulmonary overcirculation. To do so, we treated mice with either SU5416 or monocrotaline pyrrole after pneumonectomy and performed hemodynamic evaluations for PH. Despite this "two-hit" protocol, mice did not exhibit signs of severe pulmonary hypertension or exacerbated pulmonary vascular remodeling compared with PNx alone. [ABSTRACT FROM AUTHOR]

The clinical significance of lung tumor spread through air spaces (STAS) has been extensively studied, and is recognized as a unique pattern of invasion. Previous studies of STAS have focused primarily on STAS in alveolar spaces, whereas STAS in the bronchiolar spaces (bronchiolar STAS) has been described in only a few case reports only. Here, we examined 306 cases of primary lung adenocarcinoma and found that bronchiolar STAS was present in 18%. Bronchiolar STAS was associated with an inferior prognosis, more advanced stage, and higher histologic grade. No significant difference in clinicopathological factors or prognosis was observed between cases with bronchiolar STAS and those with alveolar STAS alone. Notably, bronchiolar STAS often occurred simultaneously with alveolar STAS and endobronchial spread of adenocarcinoma, particularly when bronchiolar STAS was present outside the main tumor. We also identified cases where bronchiolar STAS and endobronchial spread of adenocarcinoma occurred simultaneously in the same bronchi or bronchioles located outside the main tumor, as well as cases with bronchiolar STAS adjacent to intrapulmonary metastatic nodules. Our results highlight the significant role of bronchiolar STAS in the aerogenous spread of adenocarcinoma cells. Bronchiolar STAS can be regarded as a histologic variant of alveolar STAS. This study also supports the idea that STAS is not a tissue processing artifact, but a true biological process with clinical implications, offering histologic evidence of aerogenous spread in lung adenocarcinoma. [ABSTRACT FROM AUTHOR]

Objectives: Uniportal video-assisted thoracoscopic surgery pneumonectomy (U-VATS-P) is feasible and safe from a perioperative standpoint. How to choose the proper chest tube and drainage method is important in enhanced recovery after surgery (ERAS) protocols. In this study, we aimed to assess the safety of one 8.5-Fr (1Fr = 0.333 mm) pigtail catheter for postoperative continuous open gravity drainage after U-VATS-P. Methods: We retrospectively reviewed a single surgeon's experience with U-VATS-P for lung cancer from May 2016 to September 2022. Patients were managed with one 8.5-Fr pigtail catheter for postoperative continuous open gravity drainage after U-VATS-P. The clinical characteristics and perioperative outcomes of the patients were retrospectively analyzed. Results: In total, 77 patients had one 8.5-Fr pigtail catheter placed for postoperative continuous open gravity drainage after U-VATS-P for lung cancer. The mean age was 60.9 7.39 (40–76) years; The mean FEV1 was 2.1 0.6 (l/s), and the mean FEV1% was 71.2 22.7. The median operative time was 191.38 59.32 min; the mean operative hemorrhage was 109.46 96.56 ml; the mean duration of postoperative chest tube drainage was 6.80 2.33 days; the mean drainage volumes in the first three days after operation were 186.31 50.97, 321.97 52.03, and 216.44 35.67 ml, respectively; and the mean postoperative hospital stay was 7.90 2.58 days. No patient experienced complications resulting from chest tube malfunction. Ten patients experienced minor complications. One patient with nonlife-threatening empyema and bronchopleural fistula required short rehospitalization for anti-inflammatory therapy and reintubation. Three patients with chylothorax were treated with intravenous nutrition. Four patients had atrial fibrillation that was controlled by antiarrhythmic therapy. Two patients had more thoracic hemorrhagic exudation after the operation, which was found in time and was cured effectively, so they were discharged from the hospital uneventfully after early hemostatic therapy and nutritional support. Conclusions: All patients in this study received early postoperative rehabilitation, and the rate of relevant complications was low. We therefore recommend a single 8.5-Fr pigtail catheter for postoperative continuous open gravity drainage as an effective, safe and reliable drainage method for the management of U-VATS-P. [ABSTRACT FROM AUTHOR]

Background: Penetrating thoracic injuries have a significant risk of morbi-mortality. Despite the advancements in damage control methods, a subset of patients with severe pulmonary vascular lesions and bronchial injuries persists. In some of these cases, post-traumatic pneumonectomy is required, and perioperative extracorporeal membrane oxygenation (ECMO) support may be required due to right ventricular failure and respiratory failure. Case description: A male was brought to the emergency department (ED) with a penetrating thoracic injury, presenting with massive right hemothorax and active bleeding that required ligation of the right pulmonary hilum to control the bleeding. Subsequently, he developed right ventricular dysfunction and ARDS, necessitating a dynamic hybrid ECMO configuration to support his condition and facilitate recovery. Conclusions: Penetrating thoracic injuries with severe pulmonary vascular lesions may need pneumonectomy to control bleeding. ECMO support reduces the associated mortality by decreasing the complications rate. A multidisciplinary team is essential to achieve good outcomes in severe compromised patients. [ABSTRACT FROM AUTHOR]

Background: Robotic‐assisted thoracoscopic surgery (RATS) can achieve traditional clinical outcomes comparable to those of video‐assisted thoracoscopic surgery (VATS). However, patient‐reported outcomes (PROs) during the early period after RATS and VATS remain unclear. This study aimed to utilize longitudinal electronic PRO (ePRO) assessments to evaluate symptom burden and functional status between these approaches from patients' perspective. Methods: This study comprised patients who underwent lobectomy via RATS or VATS for non‐small cell lung cancer. We collected multiple‐time‐point PROs data from the prospective longitudinal study via an ePRO system. Symptom severity and function status were assessed using the perioperative symptom assessment for patients undergoing lung surgery and were analyzed between groups using linear mixed‐effects models. Results: Of the 164 patients, 42 underwent RATS and 122 underwent VATS. After propensity score matching (PSM), 42 RATS and 84 VATS exhibited similar baseline characteristics. During the 7‐day postoperative period, participants underwent RATS reported milder pain (p = 0.014), coughing (p < 0.001), drowsiness (p = 0.001), and distress (p = 0.045) compared with those underwent VATS. Moreover, participants in RATS group showed less functional interference with walking (p < 0.001) and general activity (p < 0.001). RATS exhibited a shorter postoperative hospitalization (p = 0.021) but higher hospital cost (p < 0.001). Meanwhile, short‐term clinical outcomes of operative time, dissected lymph node stations, chest tube drainage, and postoperative complication rates were comparable. Conclusion: PROs are important metrics for assessing patients' recovery after lobectomy. Compared with VATS, RATS may induce less symptom burden and better functional status for patients in the early postoperative period. [ABSTRACT FROM AUTHOR]

Background: To elucidate the treatment and surgery outcomes with or without perioperative therapies in Japanese patients with clinical stage III non‐small cell lung cancer (NSCLC) in real‐world settings. Methods: We performed subset analyses of the SOLUTION study, a multicenter, noninterventional, observational study of Japanese patients diagnosed with clinical stage III NSCLC, for those who started first‐line treatment (surgery±perioperative therapy) between January 2013 and December 2014 (study registration: UMIN000031385). Follow‐up data were obtained using medical records from diagnosis to March 1, 2018. Results: Of 149 eligible patients, 67 underwent surgery alone (median age 71 years) and 82 underwent surgery+perioperative therapy (median age 63 years). Lung resection was performed in 137 patients and the others underwent exploratory thoracotomy or other procedures. Perioperative therapies included adjuvant therapy only (n = 41), neoadjuvant therapy only (n = 24), and neoadjuvant+adjuvant therapy (n = 17). The median overall survival (OS) and 3‐year OS rate were 29.3 months and 44.0%, respectively, in patients who underwent surgery alone, and not reached and 61.1%, respectively, in patients who underwent surgery+perioperative therapy. The 3‐year progression‐free survival (PFS) and disease‐free survival (DFS) rates were 42.4% and 47.1%, respectively, in patients who underwent surgery+perioperative therapy and 28.5% and 28.9%, respectively, in patients who underwent surgery alone. In multivariable Cox regression, perioperative therapy was associated with improved OS (hazard ratio [95% confidence interval] 0.49 [0.29–0.81]), PFS (0.62 [0.39–0.96]), and DFS (0.62 [0.39–0.97]) versus surgery alone. Conclusions: Our study suggested that perioperative therapy may be associated with better survival among patients undergoing surgical treatment of clinical stage III NSCLC. [ABSTRACT FROM AUTHOR]

Pulmonary fibrosis is characterized by pathological accumulation of scar tissue in the lung parenchyma. Many of the processes that are implicated in fibrosis, including increased extracellular matrix synthesis, also occur following pneumonectomy (PNX), but PNX instead results in regenerative compensatory growth of the lung. As fibroblasts are the major cell type responsible for extracellular matrix production, we hypothesized that comparing fibroblast responses to PNX and bleomycin (BLM) would unveil key differences in the role they play during regenerative versus fibrotic lung responses. RNA‐sequencing was performed on flow‐sorted fibroblasts freshly isolated from mouse lungs 14 days after BLM, PNX, or sham controls. RNA‐sequencing analysis revealed highly similar biological processes to be involved in fibroblast responses to both BLM and PNX, including TGF‐β1 and TNF‐α. Interestingly, we observed smaller changes in gene expression after PNX than BLM at Day 14, suggesting that the fibroblast response to PNX may be muted by expression of transcripts that moderate pro‐fibrotic pathways. Itpkc, encoding inositol triphosphate kinase C, was a gene uniquely up‐regulated by PNX and not BLM. ITPKC overexpression in lung fibroblasts antagonized the pro‐fibrotic effect of TGF‐β1. RNA‐sequencing analysis has identified considerable overlap in transcriptional changes between fibroblasts following PNX and those overexpressing ITPKC. [ABSTRACT FROM AUTHOR]

Middle lobe torsion (MLT) is an unusual complication in lung surgery that is usually associated with upper lobe lobectomy and rarely develops postlower lobectomy. In the case of MLT, urgent surgical intervention is required to decrease the risk of mortality and morbidity, and diagnosis is challenging due to the nonspecific symptoms of MLT. In this article, we present a case of a recurring lung abscess treated by the right lower lobectomy, complicated by the right MLT and to our knowledge MLT consider rarest complication postright lower lobectomy. [ABSTRACT FROM AUTHOR]

To compare and analyze postoperative short-term and long-term prognosis of destroyed lung (DL) disease patients undergoing left versus right pneumonectomy and to identify potential key factors associated with poor treatment outcomes. Retrospective analysis was conducted on clinical data of 128 DL patients who underwent pneumonectomy in the thoracic surgery department of the Beijing Chest Hospital from November 2001 to May 2022. Cases were assigned to two groups according to lesion site: a left pneumonectomy group (104 cases) and right pneumonectomy group (24 cases). Postoperative short-term and long-term DL disease clinical features and prognostic factors were analyzed and compared between groups. As compared with the left pneumonectomy group, the right pneumonectomy group experienced greater rates of preoperative diabetes, chronic pulmonary aspergillosis, intraoperative blood loss, postoperative respiratory failure, rehospitalization, tuberculosis (TB) recurrence, bronchopleural fistula (BPF) and empyema. Binary logistic regression analysis revealed a potential correlation between chronic pulmonary aspergillosis and increased odds of developing secondary respiratory failure (adjusted odds ratio: 5.234, 95% confidence interval [CI]: 1.768-15.498). Results of Cox Proportional Hazards Model regression analysis suggested that right pneumonectomy was correlated with increased odds of TB recurrence (adjusted hazard ratio: 4.017, 95% CI: 1.282-12.933) and BPF/empyema (adjusted hazard ratio: 5.655, 95% CI: 1.254-25.505). Compared to the group undergoing left pneumonectomy, patients with DL who undergo right-sided pneumonectomy may be at a heightened risk of experiencing secondary postoperative TB recurrence and BPF or edema. It is advised to exercise utmost caution and deliberate consideration of these potential risks when contemplating pneumonectomy, with the intention of proactively preventing adverse events. [ABSTRACT FROM AUTHOR]

Postpneumonectomy syndrome (PPS) is a rare, life-threatening complication characterized by dynamic airway obstruction due to mediastinal rotation at any time point following pneumonectomy. This can produce life-threatening respiratory and cardiovascular complications. We report a case who developed PPS following right pneumonectomy in a 55-year-old female patient with small cell carcinoma (SCC) right lung. [ABSTRACT FROM AUTHOR]

Abstract Objective This study aims to compare the perioperative outcomes and disease-free survival (DFS) between pneumonectomy after immunochemotherapy and chemotherapy. Methods We retrospectively identified patients who received neoadjuvant immunotherapy (n = 15) or chemotherapy alone (n = 12) in our single center between 2021 and 2023. The primary end point was 30-day major complications. The secondary end point was major pathologic response. Results There was no significant difference in operation time, blood loss and postoperative stay time between ICI (Received immune checkpoint inhibitor treatment including PD-1 and PD-L1 inhibitors) and Chemo cohort. There were also no difference in postoperative complications including complications > grade III, 90-day death and bronchial fistula. The pCR rate was 40.0% (6/15) in the ICI cohort versus 0.0% (0/12) in the chemo cohort (p = 0.020). The MPR or pCR rate was 60.0% (9/15) in the ICI cohort versus 8.3% (1/12) in the chemo cohort (p = 0.014). ICI cohort was associated with an improved overall 1, 2, and 3-year disease-free survival(DFS)compared with chemo cohort. At the same time, both patients received ICI and Chemo were grouped according to whether pCR occurred or not, and it was found that DFS in the pCR group was better than DFS in the non-pCR group. Conclusions Based on our results, we argue that compared with pneumonectomy after isolated chemotherapy, pneumonectomy after immunochemotherapy not added 90-day mortality, postoperative, morbidity, but improved DFS; thus, it should be the induction therapy choice for anatomically eligible centrally located lung cancers.

Objectives: Patients with non–small cell lung cancer treated with immunotherapy and modern chemoradiation regimens show improved progression-free and overall survival. However, patients with limited oligo-progression represent a potential population in which local therapy such as surgery may have a potential role as salvage treatment. The objectives of our study were to evaluate the feasibility and safety of salvage lung resection after immunotherapy in patients with non–small cell lung cancer. Methods: The National Cancer Database was queried for patients diagnosed and treated for non–small cell lung cancer stage I to IV, from 2013 to 2020. Patients who underwent surgery as salvage after immunotherapy were defined as undergoing surgery >5 months from the initiation of immunotherapy. As a sensitivity analysis, patients who underwent surgery as salvage after chemoradiation were also analyzed in a similar fashion. Surgical outcomes such as type of surgery, complete resection (R0) rates, and complete pathologic response rates were determined for feasibility. Length of stay, 30-day readmission rates, and 30-day mortality rates were determined and overall survivals were estimated with Kaplan-Meier analysis to evaluate for safety. Results: Of the 934,093 patients diagnosed with non–small cell lung cancer stage I to IV from 2013 to 2020, 164 patients received immunotherapy and after 5 months underwent surgery. Lobectomy was the most commonly performed operation (74%) and pneumonectomy was required in 9% (n = 15). R0 resection was achieved in 89% (n = 146) and of these patients, 23% (n = 37) had complete pathologic response. Median length of stay was 4 days, 30-day readmission was 5%, and 30-day mortality was 0.6%. In our sensitivity analysis of chemoradiation patients (n = 445), the above data were similar to previously reported cohort studies of patients undergoing chemoradiation and subsequently salvage surgery. Conclusions: Lung resection after immunotherapy appears to be a feasible salvage treatment option, with lobectomy being most common and with high R0 resection rates. Low patient morbidity and mortality rates also suggest the safety of this approach. Salvage surgery may be considered in patients who have oligo-progression after immunotherapy within the context of a comprehensive multidisciplinary treatment plan.

Abstract Objectives Uniportal video-assisted thoracoscopic surgery pneumonectomy (U-VATS-P) is feasible and safe from a perioperative standpoint. How to choose the proper chest tube and drainage method is important in enhanced recovery after surgery (ERAS) protocols. In this study, we aimed to assess the safety of one 8.5-Fr (1Fr = 0.333 mm) pigtail catheter for postoperative continuous open gravity drainage after U-VATS-P. Methods We retrospectively reviewed a single surgeon’s experience with U-VATS-P for lung cancer from May 2016 to September 2022. Patients were managed with one 8.5-Fr pigtail catheter for postoperative continuous open gravity drainage after U-VATS-P. The clinical characteristics and perioperative outcomes of the patients were retrospectively analyzed. Results In total, 77 patients had one 8.5-Fr pigtail catheter placed for postoperative continuous open gravity drainage after U-VATS-P for lung cancer. The mean age was 60.9 $$\pm$$ 7.39 (40–76) years; The mean FEV1 was 2.1 $$\pm$$ 0.6 (l/s), and the mean FEV1% was 71.2 $$\pm$$ 22.7. The median operative time was 191.38 $$\pm$$ 59.32 min; the mean operative hemorrhage was 109.46 $$\pm$$ 96.56 ml; the mean duration of postoperative chest tube drainage was 6.80 $$\pm$$ 2.33 days; the mean drainage volumes in the first three days after operation were 186.31 $$\pm$$ 50.97, 321.97 $$\pm$$ 52.03, and 216.44 $$\pm$$ 35.67 ml, respectively; and the mean postoperative hospital stay was 7.90 $$\pm$$ 2.58 days. No patient experienced complications resulting from chest tube malfunction. Ten patients experienced minor complications. One patient with nonlife-threatening empyema and bronchopleural fistula required short rehospitalization for anti-inflammatory therapy and reintubation. Three patients with chylothorax were treated with intravenous nutrition. Four patients had atrial fibrillation that was controlled by antiarrhythmic therapy. Two patients had more thoracic hemorrhagic exudation after the operation, which was found in time and was cured effectively, so they were discharged from the hospital uneventfully after early hemostatic therapy and nutritional support. Conclusions All patients in this study received early postoperative rehabilitation, and the rate of relevant complications was low. We therefore recommend a single 8.5-Fr pigtail catheter for postoperative continuous open gravity drainage as an effective, safe and reliable drainage method for the management of U-VATS-P.

Pulmonary Tuberculosis (PTB) is a significant cause of morbidity, especially in patients with underlying health conditions. The present case highlights the complex management in a patient with intricate medical history, marked by tuberculosis, multiple Intercostal Chest Drain (ICD) procedures, and pyopneumothorax with long-standing diabetes mellitus and a history of smoking, adding to the uniqueness of the case. The authors present a case of a 67-year-old male, admitted for a right Pneumonectomy (PE) due to a complex combination of pyopneumothorax, right trapped lung and post-decortication status. However, due to the fragile nature of the tissue and the existence of vascular adhesions, it was decided to choose “physiological lung exclusion” by separating the affected lung from the tracheobronchial tree by cutting the bronchus and tying off the pulmonary artery, without removing any lung tissue, while keeping the pulmonary veins intact. The present report highlights the challenges faced, the multidisciplinary approach employed, and the successful surgical outcome, underscoring the importance of collaborative management.

Chaojun Tang, Yalan Li, Yong Lai Department of Anesthesiology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, People’s Republic of ChinaCorrespondence: Chaojun Tang, Department of Anesthesiology, The First Affiliated Hospital of Jinan University. 613 West Huangpu Avenue, Guangzhou, 510630, Guangdong Province, People’s Republic of China, Tel +86-751-6926690, Email tangchaojungz@163.com Yalan Li, Department of Anesthesiology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, People’s Republic of China, Tel +86-751-6926690, Email liyalangzjn@163.comPurpose: This study aims to investigate whether dexmedetomidine could prevent postoperative cognitive dysfunction and delirium in patients with lobectomy.Patients and Methods: Patients with lung cancer who underwent thoracoscopic lobectomy under general anesthesia were enrolled in this study and divided into dexmedetomidine group or control group. Propensity-score match (PSM) was used to reduce the bias and imbalance of confounding variables. After PSM, 87 patients in each group were included. Primary outcomes were postoperative cognitive function and delirium. Secondary outcomes include plasma TNF-α, IL-6, and S100 β protein concentrations. Adverse events were also collected.Results: There were no significant differences in the demographic characteristics and hemodynamic parameters between the two groups. Compared with the control group, the MoCA scores were significantly higher (P< 0.01), while the incidence of delirium (P< 0.01) and the plasma TNF-α (P< 0.01), IL-6 (P< 0.01), and S100 β protein (P< 0.01) concentrations were significantly lower in the dexmedetomidine group at 7 days post-operatively. The incidences of adverse events were similar between the two groups.Conclusion: Dexmedetomidine could prevent postoperative cognitive dysfunction and delirium in patients with lobectomy by decreasing neuroinflammation.Keywords: Dexmedetomidine, pneumonectomy, cognitive dysfunction, postoperative cognitive complications, inflammation

Abstract Background Bronchopleural fistula (BPF) is a rare but fatal complication after pneumonectomy. When a BPF occurs late (weeks to years postoperatively), direct resealing of the bronchial stump through the primary thoracic approach is challenging due to the risks of fibrothorax and injury to the pulmonary artery stump, and the surgical outcome is generally poor. Here, we report a case of late left BPF following left pneumonectomy successfully treated using a right thoracic approach assisted by extracorporeal membrane oxygenation (ECMO). Case presentation We report the case of a 57-year-old male patient who underwent left lower and left upper lobectomy, respectively, for heterochronic double primary lung cancer. A left BPF was diagnosed at the 22nd month postoperatively, and conservative treatment was ineffective. Finally, the left BPF was cured by minimally invasive BPF closure surgery via the right thoracic approach with the support of veno-venous extracorporeal membrane oxygenation (VV-ECMO). Conclusions Advanced BPF following left pneumonectomy can be achieved with an individualized treatment plan, and the right thoracic approach assisted by ECMO is a relatively simple and effective method, which could be considered as an additional treatment option for similar patients.

Abstract Background Although pneumonectomy has relatively high mortality and morbidity rates, it remains valid in the surgical treatment of lung cancer. This study aims to evaluate the prognostic significance of postoperative complications after pneumonectomy and demonstrate the risk factors related to early postoperative complications. Methods Patients who underwent pneumonectomy for non-small cell lung cancer between January 2008 and May 2021 were included in the study. Factors related to the development of early postoperative complications and overall survival were evaluated by univariate and multivariate analyses. Results A total of 136 patients were included in the study. Early postoperative complications were seen in 33 (24.3%) patients and late postoperative complications in 7 (5.1%) patients. The amount of cigarette smoking, and the operation side were the independent variables that affect the development of early postoperative complications. In multivariate analysis, smoking amount and pericardial invasion were associated with the development of postoperative hemorrhage, and advanced age was associated with the development of postoperative pneumonia. Conclusions Early postoperative complications have a negative effect on the prognosis after pneumonectomy therefore careful patient selection and preoperative risk assessment are essential to minimize the occurrence of complications and improve patient outcomes. Trial registration This observational study was approved by the (Ethical Committee of Dr. Suat Seren Chest Diseases and Chest Surgery Education and Research Center) Institutional Review Board of our center (E-49109414-604.02.02-218625439).

Abstract Background Analysis of patient-reported outcomes (PROs) offers valuable insights into distinguishing the effects of closely related medical procedures from the patient’s perspective. In this study we compared symptom burden in patients undergoing uniportal thoracoscopic segmentectomy and wedge resection for peripheral small-sized non-small cell lung cancer (NSCLC). Methods This study included patients with peripheral NSCLC from an ongoing longitudinal prospective cohort study (CN-PRO-Lung 3) who underwent segmentectomy or wedge resection with tumor diameter ≤ 2 cm and consolidation tumor ratio (CTR) ≤ 0.5. PROs data were collected using the Perioperative Symptom Assessment for Lung Surgery questionnaire pre-operatively, daily post-surgery up to the fourth hospitalization day, and weekly post-discharge up to the fourth week. Propensity score matching and a generalized estimation equation model were employed to compare symptom severity. In addition, short-term clinical outcomes were compared. Results In total, data of 286 patients (82.4%) undergoing segmentectomy and 61 patients (17.6%) undergoing wedge resection were extracted from the cohort. No statistically significant differences were found in the proportion of moderate-to-severe symptoms and mean scores for pain, cough, shortness of breath, disturbed sleep, fatigue, drowsiness, and distress during the 4-day postoperative hospitalization or the 4-week post-discharge period before or after matching (all p > 0.05). Compared with segmentectomy, wedge resection showed better short-term clinical outcomes, including shorter operative time (p = 0.001), less intraoperative bleeding (p = 0.046), and lower total hospital costs (p = 0.002). Conclusions The study findings indicate that uniportal thoracoscopic segmentectomy and wedge resection exert similar early postoperative symptom burden in patients with peripheral NSCLC (tumor diameter ≤ 2 cm and CTR ≤ 0.5). Clinical trial registration Not applicable.

Abstract Background In patients with resectable stage III non-small cell lung cancer (NSCLC), induction chemoimmunotherapy followed by surgical resection has shown unprecedented rates of pathological response and event-free survival. However, a triple-induction including radiochemotherapy and immunotherapy followed by surgical resection has not been routinely established in clinical practice. Case presentation We report the case of a 47-year-old patient with stage IIIA NSCLC who was treated in a combined concept including induction concurrent radiochemotherapy, followed by 4 cycles of pembrolizumab and subsequent intrapericardial left-sided pneumonectomy. Histological analysis revealed a pathological complete response. Conclusions The case demonstrates that the combination of neoadjuvant chemo-, radio- and immunotherapy in advanced NSCLC may lead to a relevant down-staging and may enable a R0-resection of a borderline resectable tumor. However, the combination of four different treatment modalities requires resilience and a good performance status. A triple induction treatment may be a promising option for selected patients with locally advanced NSCLC and good performance status.

Abstract Background Pericardial defect that occurs after intrapericardial pneumonectomy can cause many fatal complications, and closing the defect with mesh is a widely used surgical method to prevent these complications. Methods Data of patients who underwent intrapericardial pneumonectomy and pericardial resection in our clinic between October 2010 and June 2022 were retrospectively reviewed. Patients were divided into two groups, those who had prolene mesh used to close the pericardial defect and those who underwent the “Rug Weave” technique we proposed as an alternative, and the results were compared. Results The study included 23 patients, one of whom was female. All patients underwent surgery due to malignancy. The vast majority of the patients had a diagnosis of squamous cell lung carcinoma (86.9%). Atrium was added to three patients and rib resection was added to one patient during intrapericardial pneumonectomy and pericardial resection. There was no significant difference between the two groups in terms of average age, gender, and length of hospital stay. There was no significant difference between the two groups in terms of complications, including atrial fibrillation, which is commonly seen in these patients (p = 0.795). The Rug Weave group had an average defect width of 23.96 cm2 and was found to be advantageous in terms of overall survival compared to the mesh group (p = 0.017). Conclusions The “Rug Weave” technique we proposed for closing pericardial defects after pneumonectomy can be used as a cheaper method safely and effectively that reduces complications as much as the traditional method of using mesh.

Cardiac herniation is a rare potentially life-threatening complication that can occur after pneumonectomy, involving displacement of the heart through a pericardial defect, which can lead to hemodynamic instability, impaired cardiac function, and in severe cases, death. We describe a case of delayed cardiac herniation 1-month post left pneumonectomy for pulmonary leiomyosarcoma.

Patients with non-small cell lung cancer (NSCLC) in the postoperative recovery period often experience reduced exercise capacity and impaired lung function, which affects their overall quality of life. This paper investigated the effect of exercise interventions on exercise capacity, lung function, quality of life, and symptoms in these patients. Methods: We performed a literature search across Cochrane, Embase, PubMed, Web of Science, and EBSCO databases were comprehensively searched for randomized controlled trials (RCTs) from inception to September 2023, all English RCTs were eligible if they assessed the effects of exercise interventions on postoperative NSCLC patients. Results: Twelve articles met our inclusion criteria, evidencing that exercise interventions could significantly improve the functional capacity of NSCLC patients in postoperative recovery. Notably, Forced Expiratory Volume in 1 s (FEV1) was improved, indicating enhanced lung function. Furthermore, exercise improved the physical and mental health scores of SF-36, along with increased quadriceps strength and relieved dyspnea. However, fatigue levels were not significantly changed. Conclusions: Exercise interventions of NSCLC patients in the postoperative recovery are associated with improved functional capacity, lung function, quality of life, and quadriceps strength, as well as alleviated symptoms of dyspnea. These findings underscore the potential benefits of incorporating exercise into postoperative care for NSCLC patients. Nonetheless, further large-scale RCTs are required to solidify the evidence base on the clinical outcomes of exercise following pneumonectomy. [ABSTRACT FROM AUTHOR]

Simple Summary: Sublobar resection is commonly used for treating small-sized non-small-cell lung cancer (NSCLC) patients. The effectiveness of adjuvant chemotherapy for these patients, particularly those with pathological lymph node metastasis, remains unclear. A study using data from the National Cancer Database from 2004 to 2018 reviewed cases of NSCLC patients who had undergone sublobar resection with lymph node metastasis and met specific criteria, including tumor size ≤ 20 mm and no comorbidities. The study found that, after adjusting for age, sex, histologic type, and pathological lymph node status through propensity score matching, patients who received adjuvant chemotherapy had a notably longer survival than those who did not (median survival of 64.3 vs. 34.0 months). The results indicate that adjuvant chemotherapy significantly enhances survival in small-sized-NSCLC patients with lymph node involvement post-sublobar resection. Sublobar resection is a standard surgical procedure for small-sized non-small-cell lung cancer (NSCLC). However, the clinical role of adjuvant chemotherapy for small-sized NSCLC with pathological lymph node (LN) metastasis after sublobar resection is unknown. The National Cancer Database was queried for NSCLC patients between 2004 and 2018. Eligibility included sublobar resection with pathological LN metastasis, R0 resection, Charlson comorbidity score = 0, clinical stage T1a-b, and tumor size ≤ 20 mm. The Kaplan–Meier method with a log-rank test and multivariable Cox proportional hazards analyses were used for assessing survival. The samples were evaluated before and after propensity score matching (PSM) with respect to age, sex, histologic type, and pathological LN status. Of 810 patients who met the eligibility criteria, 567 (70.0%) underwent adjuvant chemotherapy. After PSM, patients with adjuvant chemotherapy had a significantly longer survival than those without (median survival: 64.3 vs. 34.0 months, hazard ratio for death: 0.61, p < 0.0001). Multivariate analyses after PSM showed that younger age (p = 0.0206), female (p = 0.0005), and adjuvant chemotherapy (p < 0.0001) were independent prognostic factors for longer survival. Adjuvant chemotherapy has a prognostic impact in patients with small-sized NSCLC and pathological lymph node metastasis who undergo sublobar resection. [ABSTRACT FROM AUTHOR]

Introduction: The objective of this study was to compare the survival after lobectomy (LR) and sub-lobar resection (SLR) of the left upper lobe (LUL) among non-small cell lung cancer (NSCLC) patients with stage IA. Methods: This retrospective cohort research analyzed public data collected by the Surveillance, Epidemiology, and End Results (SEER) database. Tumor characteristics were determined based on the International Classification of Diseases for Oncology, 3rd edition (ICD-O-3). Propensity score matching (PSM) analysis was performed with a ratio of 1:1. Univariate and multivariable Cox proportional regression analyses were used to assess the effects of LR and SLR on the survival of the patients, with hazard ratios (HRs) and 95% confidence intervals (95% CIs). The effects were further evaluated by different subgroups of age, gender, tumor grades, histologic types, T stages. Results: Of the total 2,649 patients, 1,907 underwent the LR and 742 received SLR. Totally, 998 patients died at the end of the follow-up. The median survival time of all patients was 66 (49, 87) months. After adjusting the age, gender, race, tumor grade, histologic type, T stage, examined lymph nodes, radiation, and chemotherapy, NSCLC patients with stage IA who received SLR had higher odds of death in comparison with these patients who received LR (HR = 1.424, 95% CI: 1.227–1.652). After PSM, SLR was associated with higher odds of death in the patients (HR = 1.35, 95% CI: 1.10–1.66). Similar results were discovered in different subpopulations. Conclusion: The SLR was inferior to LR on the survival of NSCLC patients with stage IA. [ABSTRACT FROM AUTHOR]

Purpose: Bronchopleural fistula (BPF) is a lethal complication, even in the modern era. Therefore, we investigated the details of patients with BPF to select an appropriate surgical strategy. Methods: This retrospective study included 4794 consecutive patients who underwent anatomical pulmonary resection between 2008 and 2022. We evaluated the predictors of BPF using a multivariable analysis and investigated the mortality and clinical course after BPF in detail. Results: BPF was observed in 32 patients (0.67%). In the multivariable analysis, the predictors for BPF were male sex (odds ratio [OR], 6.91), the body mass index (OR, 2.40), the vital capacity (%VC) (OR, 2.93), surgery performed (right lower lobectomy [OR, 10.92], right middle and lower lobectomy [OR, 6.97], and right pneumonectomy [OR, 16.68]), and additional resection of surrounding organs (OR, 3.47). Among the risk factors, surgery performed and male sex were very strong risk factors, with the frequency itself very low in females (0.1%). The 90-day mortality was 15.6%, and the 5-year overall survival in patients with BPF was 28.1%. Conclusion: Our study revealed that independent risk factors and consideration of the surgical methods and sex might help determine whether or not special attention should be given to the bronchial stump, which will be of great help in surgical strategies. [ABSTRACT FROM AUTHOR]

Background/Objectives: The surgical resection of pulmonary metastases is considered a therapeutic option in selected cases. In light of this, we present the results from a national multicenter prospective registry of lung metastasectomy. Methods: This retrospective analysis involves data collected prospectively and consecutively in a national multicentric Italian database, including patients who underwent lung metastasectomy. The primary endpoints were the analysis of morbidity and overall survival (OS), with secondary endpoints focusing on the analysis of potential risk factors affecting both morbidity and OS. Results: A total 470 lung procedures were performed (4 pneumonectomies, 46 lobectomies/bilobectomies, 13 segmentectomies and 407 wedge resections) on 461 patients (258 men and 203 women, mean age of 63.1 years). The majority of patients had metastases from colorectal cancer (45.8%). In most cases (63.6%), patients had only one lung metastasis. A minimally invasive approach was chosen in 143 cases (30.4%). The mean operative time was 118 min, with no reported deaths. Morbidity most frequently consisted of prolonged air leaking and bleeding, but no re-intervention was required. Statistical analysis revealed that morbidity was significantly affected by operative time and pulmonary comorbidities, while OS was significantly affected by disease-free interval (DFI) > 24 months (p = 0.005), epithelial histology (p = 0.001) and colorectal histology (p = 0.004) during univariate analysis. No significant correlation was found between OS and age, gender, surgical approach, surgical extent, surgical device, the number of resected metastases, lesion diameter, the site of lesions and nodal involvement. Multivariate analysis of OS confirmed that only epithelial histology and DFI were risk-factors, with p-values of 0.041 and 0.031, respectively. Conclusions: Lung metastasectomy appears to be a safe procedure, with acceptable morbidity, even with a minimally invasive approach. However, it remains a local treatment of a systemic disease. Therefore, careful attention should be paid to selecting patients who could truly benefit from surgical intervention. [ABSTRACT FROM AUTHOR]

Introduction: Endoscopic lung volume reduction with endobronchial valves has been widely recognized for treating hyperinflation in advanced chronic obstructive pulmonary disease and emphysema patients. The main challenges include the technical complexity of upper lobe implantation and the number of endobronchial valves required. These issues might be addressed by placing larger diameter valves in the lobar bronchus. This study evaluated the feasibility, efficiency, and safety of the new valve PulmValve (model PV-13) in porcine models. Methods: Six PV-13 valves were bronchoscopically implanted into the caudal lobe bronchus of six healthy pigs. The procedure time, valve deployment, and removability were recorded. Follow-up examinations included blood tests, chest CT scans, and bronchoscopy at 30 min, 14 days, 28 days, and 84 days post-procedure, with necropsy and pathological evaluations after the final follow-up examination. Results: The successful in vivo deployment and removal of PV-13 valves was established, with a median procedure time of 6.5 min. The distal lung volume reduction was evident at 30 min post-operation and was persistently monitored on day 84. No migration or malfunction of any PV-13 valves was detected, but a mild angle deviation was found in 3 cases. Coughing was observed in four pigs within the first 7 days and localized granulation tissue was observed in all pigs. No cases of pneumothorax, diffuse pneumonia, or hemoptysis were detected. Conclusions: In this study, we report the successful implantation and removal of a new valve PulmValve in a short operation time. Complete lobar atelectasis was induced without device migration, malfunction, or severe complications. Further studies are warranted to evaluate the long-term, sustained effects and potential benefits in human patients. Plain Language Summary: Endoscopic lung volume reduction with endobronchial valves has been widely recognized as a treatment for advanced emphysema and chronic obstructive pulmonary disease. The main challenges include the technical complexity of implanting valves in the upper lobes and the number of valves required. These issues may be addressed by using larger diameter endobronchial valves in the lobar bronchi. The newly developed PulmValve System offers five variants of valves designed to accommodate airways with diameters ranging from 7.0 to 15.0 mm. The system is specifically designed for lobar bronchial implantation, with valve diameters within the range of 10.5–16.5 mm. Our study reports the successful implantation and subsequent removal post-placement of the PulmValve (PV-13) within a short operative time in healthy porcine models. During an 84-day follow-up period, significant atelectasis was induced in the distal lung without evidence of device migration, malfunction, or severe complications. [ABSTRACT FROM AUTHOR]

Background: Bronchopleural fistula (BPF) is a rare but fatal complication after pneumonectomy. When a BPF occurs late (weeks to years postoperatively), direct resealing of the bronchial stump through the primary thoracic approach is challenging due to the risks of fibrothorax and injury to the pulmonary artery stump, and the surgical outcome is generally poor. Here, we report a case of late left BPF following left pneumonectomy successfully treated using a right thoracic approach assisted by extracorporeal membrane oxygenation (ECMO). Case presentation: We report the case of a 57-year-old male patient who underwent left lower and left upper lobectomy, respectively, for heterochronic double primary lung cancer. A left BPF was diagnosed at the 22nd month postoperatively, and conservative treatment was ineffective. Finally, the left BPF was cured by minimally invasive BPF closure surgery via the right thoracic approach with the support of veno-venous extracorporeal membrane oxygenation (VV-ECMO). Conclusions: Advanced BPF following left pneumonectomy can be achieved with an individualized treatment plan, and the right thoracic approach assisted by ECMO is a relatively simple and effective method, which could be considered as an additional treatment option for similar patients. [ABSTRACT FROM AUTHOR]

Background: Curative intent surgery may be indicated for some patients with resectable early stage malignant pleural mesothelioma (MPM). However, sarcomatoid MPM is a highly aggressive subtype for which curative intent surgery is generally not recommended. Case presentation: We present the case of a 63-year-old man who presented with dyspnea and chest tightness. Computed tomography revealed pleural thickening and nodular lesions. A pleural biopsy confirmed lymphohistiocytoid MPM (cT1N0M0, stage IA), prompting surgical intervention. The patient underwent left extrapleural pneumonectomy (EPP), and the final diagnosis was sarcomatoid MPM (pT2N0M0, stage IB). Although post-operative chemotherapy was planned, the patient refused additional treatment, because of the introduction of home oxygen therapy, and has remained recurrence-free for 10 years after the surgery. Conclusions: This case presents a noteworthy instance of achieving long-term recurrence-free survival solely through curative intent surgery for sarcomatoid MPM. It highlights the potential efficacy of surgical intervention in managing this aggressive subtype, offering a glimmer of hope for improved outcomes. Further research is warranted to better define the role of surgery in the treatment of sarcomatoid MPM. [ABSTRACT FROM AUTHOR]

Background: The role of mechanical power on pulmonary outcomes after thoracic surgery with one-lung ventilation was unclear. We investigated the association between mechanical power and postoperative pulmonary complications in patients undergoing thoracoscopic lung resection surgery. Methods: In this single-center, prospective observational study, 622 patients scheduled for thoracoscopic lung resection surgery were included. Volume control mode with lung protective ventilation strategies were implemented in all participants. The primary endpoint was a composite of postoperative pulmonary complications during hospital stay. Multivariable logistic regression models were used to evaluate the association between mechanical power and outcomes. Results: The incidence of pulmonary complications after surgery during hospital stay was 24.6% (150 of 609 patients). The multivariable analysis showed that there was no link between mechanical power and postoperative pulmonary complications. Conclusions: In patients undergoing thoracoscopic lung resection with standardized lung-protective ventilation, no association was found between mechanical power and postoperative pulmonary complications. Trial registration: Trial registration number: ChiCTR2200058528, date of registration: April 10, 2022. [ABSTRACT FROM AUTHOR]

Background: Although pneumonectomy has relatively high mortality and morbidity rates, it remains valid in the surgical treatment of lung cancer. This study aims to evaluate the prognostic significance of postoperative complications after pneumonectomy and demonstrate the risk factors related to early postoperative complications. Methods: Patients who underwent pneumonectomy for non-small cell lung cancer between January 2008 and May 2021 were included in the study. Factors related to the development of early postoperative complications and overall survival were evaluated by univariate and multivariate analyses. Results: A total of 136 patients were included in the study. Early postoperative complications were seen in 33 (24.3%) patients and late postoperative complications in 7 (5.1%) patients. The amount of cigarette smoking, and the operation side were the independent variables that affect the development of early postoperative complications. In multivariate analysis, smoking amount and pericardial invasion were associated with the development of postoperative hemorrhage, and advanced age was associated with the development of postoperative pneumonia. Conclusions: Early postoperative complications have a negative effect on the prognosis after pneumonectomy therefore careful patient selection and preoperative risk assessment are essential to minimize the occurrence of complications and improve patient outcomes. Trial registration: This observational study was approved by the (Ethical Committee of Dr. Suat Seren Chest Diseases and Chest Surgery Education and Research Center) Institutional Review Board of our center (E-49109414-604.02.02-218625439). [ABSTRACT FROM AUTHOR]

Simple Summary: Pleural Mesothelioma is a rare and highly aggressive illness with a grim prognosis. Surgical procedures are crucial in achieving accurate diagnosis and staging. In selected patients, long-term survival is attained when several modalities, including surgery, are combined with the aim of macroscopic complete resection. Surgery plays a central role in the diagnosis, staging, and management of pleural mesothelioma. Achieving an accurate diagnosis through surgical intervention and identifying the specific histologic subtype is crucial for determining the appropriate course of treatment. The histologic subtype guides decisions regarding the use of chemotherapy, immunotherapy, or multimodality treatment. The goal of surgery as part of multimodality treatment is to accomplish macroscopic complete resection with the eradication of grossly visible and palpable disease. Over the past two decades, many medical centers worldwide have shifted from performing extra-pleural pneumonectomy (EPP) to pleurectomy decortication (PD). This transition is motivated by the lower rates of short-term mortality and morbidity associated with PD and similar or even better long-term survival outcomes, compared to EPP. This review aims to outline the role of surgery in diagnosing, staging, and treating patients with pleural mesothelioma. [ABSTRACT FROM AUTHOR]

Background: In patients with resectable stage III non-small cell lung cancer (NSCLC), induction chemoimmunotherapy followed by surgical resection has shown unprecedented rates of pathological response and event-free survival. However, a triple-induction including radiochemotherapy and immunotherapy followed by surgical resection has not been routinely established in clinical practice. Case presentation: We report the case of a 47-year-old patient with stage IIIA NSCLC who was treated in a combined concept including induction concurrent radiochemotherapy, followed by 4 cycles of pembrolizumab and subsequent intrapericardial left-sided pneumonectomy. Histological analysis revealed a pathological complete response. Conclusions: The case demonstrates that the combination of neoadjuvant chemo-, radio- and immunotherapy in advanced NSCLC may lead to a relevant down-staging and may enable a R0-resection of a borderline resectable tumor. However, the combination of four different treatment modalities requires resilience and a good performance status. A triple induction treatment may be a promising option for selected patients with locally advanced NSCLC and good performance status. [ABSTRACT FROM AUTHOR]

Background: Analysis of patient-reported outcomes (PROs) offers valuable insights into distinguishing the effects of closely related medical procedures from the patient's perspective. In this study we compared symptom burden in patients undergoing uniportal thoracoscopic segmentectomy and wedge resection for peripheral small-sized non-small cell lung cancer (NSCLC). Methods: This study included patients with peripheral NSCLC from an ongoing longitudinal prospective cohort study (CN-PRO-Lung 3) who underwent segmentectomy or wedge resection with tumor diameter ≤ 2 cm and consolidation tumor ratio (CTR) ≤ 0.5. PROs data were collected using the Perioperative Symptom Assessment for Lung Surgery questionnaire pre-operatively, daily post-surgery up to the fourth hospitalization day, and weekly post-discharge up to the fourth week. Propensity score matching and a generalized estimation equation model were employed to compare symptom severity. In addition, short-term clinical outcomes were compared. Results: In total, data of 286 patients (82.4%) undergoing segmentectomy and 61 patients (17.6%) undergoing wedge resection were extracted from the cohort. No statistically significant differences were found in the proportion of moderate-to-severe symptoms and mean scores for pain, cough, shortness of breath, disturbed sleep, fatigue, drowsiness, and distress during the 4-day postoperative hospitalization or the 4-week post-discharge period before or after matching (all p > 0.05). Compared with segmentectomy, wedge resection showed better short-term clinical outcomes, including shorter operative time (p = 0.001), less intraoperative bleeding (p = 0.046), and lower total hospital costs (p = 0.002). Conclusions: The study findings indicate that uniportal thoracoscopic segmentectomy and wedge resection exert similar early postoperative symptom burden in patients with peripheral NSCLC (tumor diameter ≤ 2 cm and CTR ≤ 0.5). Clinical trial registration: Not applicable. [ABSTRACT FROM AUTHOR]

Background: Understanding cancer treatment–related cardiovascular (CV) events is important for cancer care; however, comprehensive evaluation of CV events in patients with lung cancer is limited. This study aimed to assess the cumulative incidence and associated risks of various CV event types in patients with non–small cell lung cancer (NSCLC). Methods: A total of 7868 individuals aged 40 years and older, recently diagnosed with NSCLC (2007–2018), were assessed with data obtained from the National Cancer Center, Korea. This study included nine types of CV events. A 2‐year cumulative incidence function (CIF) of CV events was estimated, with death as a competing event. The associated risks were assessed by subdistribution hazard ratio (sHR) in the Fine–Gray competing risks model. Results: CV events were observed in 7.8% of patients with NSCLC, with the most frequently observed types being atrial fibrillation and flutter (AF) (2.7%), venous thromboembolic disease (2.0%), and cerebrovascular disease (CeVD) (1.5%). Overall, all CV events were highest in the group treated with systemic therapy (CIF, 10.6%; 95% confidence interval [CI], 9.5%–11.8%), followed by those treated with surgery (CIF, 10.0%; 95% CI, 8.6%–11.6%); the incidence of AF (CIF, 5.7%; 95% CI, 4.6%–7.0%) was highest in patients treated with surgery. Individuals treated with systemic therapy were found to exhibit a higher CeVD risk than those treated with surgery (sHR, 4.12; 95% CI, 1.66–10.23). Among the patients who underwent surgery, those with lobectomy and pneumonectomy had a higher AF risk (vs. wedge resection/segmentectomy; sHR, 7.79; 95% CI, 1.87–32.42; sHR, 8.10; 95% CI, 1.60–40.89). Conclusions: These findings revealed treatment‐related CV event risks in patients with NSCLC, which suggests that the risk of AF in surgery and CeVD in systemic therapy should be paid more attention to achieve a better prognosis and improve cancer survivorship outcomes. Plain Language Summary: Atrial fibrillation and flutter (AF) is the most common cardiovascular event, particularly at a high risk in patients with non–small cell lung cancer (NSCLC) undergoing surgery.Patients receiving surgery with poor performance status, diagnosed with regional stage, and undergoing lobectomy or pneumonectomy are at a high risk of AF.Systemic/radiotherapy is associated with cerebrovascular and ischemic heart disease in patients with NSCLC. This study revealed that cardiovascular events occurred in approximately 8% of patients with non–small cell lung cancer during 2‐year treatment periods, with atrial fibrillation and flutter, venous thromboembolic disease, and cerebrovascular disease being the most common types. The findings further emphasize the importance of monitoring atrial fibrillation in patients receiving surgery and cerebrovascular disease in those treated with systemic therapy to enhance cancer care and survivorship outcomes. [ABSTRACT FROM AUTHOR]

Background: Pericardial defect that occurs after intrapericardial pneumonectomy can cause many fatal complications, and closing the defect with mesh is a widely used surgical method to prevent these complications. Methods: Data of patients who underwent intrapericardial pneumonectomy and pericardial resection in our clinic between October 2010 and June 2022 were retrospectively reviewed. Patients were divided into two groups, those who had prolene mesh used to close the pericardial defect and those who underwent the "Rug Weave" technique we proposed as an alternative, and the results were compared. Results: The study included 23 patients, one of whom was female. All patients underwent surgery due to malignancy. The vast majority of the patients had a diagnosis of squamous cell lung carcinoma (86.9%). Atrium was added to three patients and rib resection was added to one patient during intrapericardial pneumonectomy and pericardial resection. There was no significant difference between the two groups in terms of average age, gender, and length of hospital stay. There was no significant difference between the two groups in terms of complications, including atrial fibrillation, which is commonly seen in these patients (p = 0.795). The Rug Weave group had an average defect width of 23.96 cm2 and was found to be advantageous in terms of overall survival compared to the mesh group (p = 0.017). Conclusions: The "Rug Weave" technique we proposed for closing pericardial defects after pneumonectomy can be used as a cheaper method safely and effectively that reduces complications as much as the traditional method of using mesh. [ABSTRACT FROM AUTHOR]

Background: Despite the implementation of Enhanced Recovery After Surgery (ERAS) programs, surgical stress continues to influence postoperative rehabilitation, including the period after discharge. However, there is a lack of data available beyond the point of discharge following video-assisted thoracoscopic surgery (VATS) wedge resection. Therefore, the objective of this study is to investigate incidence and risk factors for readmissions after ERAS VATS wedge resection. Methods: A retrospective analysis was performed on data from prospectively collected consecutive VATS wedge resections from June 2019 to June 2022. We evaluated main reasons related to wedge resection leading to 90-day readmission, early (occurring within 0–30 days postoperatively) and late readmission (occurring within 31–90 days postoperatively). To identify predictors for these readmissions, we utilized a logistic regression model for both univariable and multivariable analyses. Results: A total of 850 patients (non-small cell lung cancer 21.5%, metastasis 44.7%, benign 31.9%, and other lung cancers 1.9%) were included for the final analysis. Median length of stay was 1 day (IQR 1–2). During the postoperative 90 days, 86 patients (10.1%) were readmitted mostly due to pneumonia and pneumothorax. Among the cohort, 66 patients (7.8%) had early readmissions primarily due to pneumothorax and pneumonia, while 27 patients (3.2%) experienced late readmissions mainly due to pneumonia, with 7 (0.8%) patients experiencing both early and late readmissions. Multivariable analysis demonstrated that male gender, pulmonary complications, and neurological complications were associated with readmission. Conclusions: Readmission after VATS wedge resection remains significant despite an optimal ERAS program, with pneumonia and pneumothorax as the dominant reasons. Early readmission was primarily associated with pneumothorax and pneumonia, while late readmission correlated mainly with pneumonia. [ABSTRACT FROM AUTHOR]

Simple Summary: The key to successful segmentectomy lies in precisely identifying the tumor and intersegmental planes to ensure adequate resection margins. This study is the first to use intravenous indocyanine green injections at different time points and doses to simultaneously detect lung cancer and intersegmental planes. Additionally, we aimed to assess the clinical feasibility of the method through a combination of preclinical and clinical studies. This approach not only simplifies the treatment process for patients by avoiding complex procedures but also accurately defines the resection margins for lung cancer while addressing the complications arising from preoperative CT-guided positioning. This technique has the potential to improve patient outcomes and improve the quality of life for patients with lung cancer. Segmentectomy is a targeted surgical approach tailored for patients with compromised health and early-stage lung cancer. The key to successful segmentectomy lies in precisely identifying the tumor and intersegmental planes to ensure adequate resection margins. In this study, we aimed to enhance this process by simultaneously visualizing the tumor and intersegmental planes through the intravenous injection of indocyanine green (ICG) at different time points and doses. Lung tumors were detected by intravenous injection of ICG at a dose of 2 mg/kg 12 h before surgery in a rabbit model. Following the dissection of the pulmonary artery, vein, and bronchi of the target segment, 0.6 mg/kg of ICG was injected intravenously to detect the intersegmental plan. Fluorescent images of the lung tumors and segments were acquired, and the fluorescent signal was quantified using the signal-to-background ratio (SBR). Finally, a pilot study of this method was conducted in three patients with lung cancer. In a preclinical study, the SBR of the tumor (4.4 ± 0.1) and nontargeted segments (10.5 ± 0.8) were significantly higher than that of the targeted segment (1.6 ± 0.2) (targeted segment vs. nontarget segment, p < 0.0001; target segment vs. tumor, p < 0.01). Consistent with preclinical results, lung tumors and the intersegmental plane were successfully detected in patients with lung cancer. Consequently, adequate resection margins were identified during the surgery, and segmentectomy was successfully performed in patients with lung cancer. This study is the first to use intravenous ICG injections at different time points and doses to simultaneously detect lung cancer and intersegmental planes, thereby achieving segmentectomy for lung cancer. [ABSTRACT FROM AUTHOR]