Uniportal versus multiportal thoracoscopic sleeve lobectomy for the surgical treatment of centrally located lung cancer: a single institution experience

BackgroundUniportal thoracoscopic sleeve lobectomy is rarely reported owing to its high degree of difficulty. We conducted a comparative study on the safety and efficacy of uniportal versus multiportal thoracoscopic sleeve lobectomy for the treatment of centrally located lung cancer.MethodsFrom January 2016 to December 2018, 30 thoracoscopic sleeve lobectomies (12 by the uniportal approach and 20 by the multiportal approach) for centrally located lung cancer at our institution were retrospectively analyzed.ResultsThe uniportal approach resulted in a significantly shorter chest drainage duration (5.3±1.9 vs. 7.1±2.8 days, P=0.028) and a smaller chest drainage volume (796.7±582.9 vs. 1,667.8±1,154.9 mL, P=0.004) than the multiportal approach. The two groups showed no significant differences in the dissection of lymph nodes, operation time, estimated blood loss, conversion rate, length of postoperative hospital stay and the proportion of patients with postoperative complications. The short-term overall survival (OS) and disease-free survival (DFS) between uniportal and multiportal groups were similar (3-year OS, 100.0% vs. 82.5%, P=0.222; 3-year DFS, 75.8% vs. 84.4%, P=0.641). For the eight cases of the uniportal approach conducted by the same surgeon, the cumulative sum (CUSUM) curve showed its inflection at patient number 4 and divided the series into phase I (learning phase) and phase II (experienced phase). A significant reduction in estimated blood loss (42.5±8.7 vs. 177.5±121.2 mL, P=0.037), chest drainage volume (280.0±155.8 vs. 972.5±464.5 mL, P=0.043) and chest drainage duration (3.8±1.0 vs. 6.8±2.2 days, P=0.027) was also noted in the phase II patients compared with the phase I patients.ConclusionsUniportal thoracoscopic sleeve lobectomy is technically feasible and safe for the treatment of centrally located lung cancer and may achieve superior surgical outcomes compared with the multiportal approach.     

Impact of FGFR2 gene fusions on survival of patients with intrahepatic cholangiocarcinoma following curative intent resection

BackgroundIntrahepatic Cholangiocarcinoma (iCCA) is an aggressive cancer with diverse mutational profiles. An important molecular subtype is fibroblast growth factor receptor 2 (FGFR2) fusion. The effect of FGFR2 fusions on prognosis is unknown. Our aim was to assess the outcomes in resected CCA patients in relation to FGFR2 status.MethodsSurgically treated CCA patients from a single institution were retrospectively reviewed between 2008 and 2014. FGFR rearrangements were detected by fluorescence in situ hybridization (FISH). Data included patient demographics, tumor pathology, disease-free survival (DFS) and overall survival (OS).ResultsNinety-five patients underwent surgical resection for iCCA. Twelve (13%) of these were found to have FGFR2 fusion, none of which were treated with FGFR targeted therapy. Patients with FGFR2 fusions were found to have a longer 5-year (83 vs. 32%, p = 0.01) and 10-year (46 vs. 22%, p = 0.04) OS. Five and 10-year DFS was also increased (68 vs. 33% p = 0.04) and (68 vs. 25 %, p = 0.02,). FGFR2 fusion status was the strongest independent factor associated with improved OS (HR 0.23, 0.09–0.62, p=0.003) and DFS (HR 0.18, 0.05–0.67, p=0.01).ConclusionPatients with CCA FGFR2 fusion have improved OS and DFS following surgical resection.     

Comparison of outcomes in DeBakey type I versus DeBakey type II aortic dissection: a 17-year single center experience

BackgroundIt is controversial if the type or the size of aortic dissection is associated with the mortality in patients with acute aortic dissection (AAD) type I or type II according to DeBakey. Due to the pronounced aortic pathology in DeBakey type I compared to DeBakey type II, it is to be expected, that the DeBakey type I is associated with a significant higher morbidity and mortality. But we hypothesize that the current advances in surgical techniques, circulatory management, and postoperative care improve the clinical outcome of patients with DeBakey type I and II. The purpose of this study was to evaluate retrospectively the effect of these parameters on surgical outcome in patients with DeBakey type I and type II in a large cohort study.MethodsFrom 2001 to 2019, 395 consecutive patients (34.2% female) underwent surgical aortic repair at our institution. Patients were retrospectively classified into 2 groups: patients with type 1 dissection (group 1: n=309, median age of 62.0 years) and patients with type 2 dissection (group 2: n=86, 67.5 years). Survival was estimated by Kaplan-Meier estimator. Risk factors were analyzed by logistic regression analysis.ResultsThe patients in group 1 suffered significantly more often from coronary heart disease [43 (13.9%) vs. 20 (23.3%), P=0.036]. Otherwise, there were no significant differences between both groups concerning preoperative risk factors. The median surgical duration (279 vs. 263 min, P=0.026) and the circulatory arrest time (35 vs. 27 min, P<0.001) in group 1 were significantly higher. In a significantly higher number of patients in group 1, the aortic arch was completely replaced (18.4% vs. 1.2%, P<0.001) and a simultaneous coronary artery bypass grafting [18 (5.8%) vs. 11 (12.8%), P=0.028] was performed. The rate of re-thoracotomy [62 (20.1%) vs. 9 (10.5%), P=0.040], of postoperative delirium [66 (21.4%) vs. 9 (10.6%), P=0.024], and of tracheotomy [85 (27.5%) vs. 14 (16.3%), P=0.034] were significantly higher in group 1. Thirty-day mortality was 15.7% and did not differ significantly between both groups (P=0.867), as well as the long-term survival rates (P=0.956).ConclusionsDue to the pronounced aortic pathology in type I compared to type II, it is to be expected, that the type I is associated with a significant higher morbidity and mortality. DeBakey type I was an independent predictor for 30-day mortality in our study, however, based on our 17-year single center experience there was no difference between the long-term survival in both groups.     

Earlier surgery is associated to reduced postoperative morbidity in ileocaecal Crohn's disease: Results from SURGICROHN – LATAM study

BackgroundEarly surgical resection is an emerging concept for patients with ileocaecal Crohn's disease (CD). The aim of this study was to compare postoperative outcomes after ileocaecal resections between patients with luminal and complicated CD.MethodsA retrospective analysis of patients operated for ileocaecal CD during an 8-year period in ten tertiary referral academic centres from Latin America was performed. Patients were allocated into 2 groups: those operated for early (luminal) disease (Early Crohn's Disease -ECD-) and for complications of CD (Complicated Crohn's disease -CCD-). A comparative analysis was performed regarding short-term outcomes of surgery, considering overall postoperative complications as main outcome.Results337 patients were included in the analysis, 60 (17.80%) in the ECD group. Smoking and exposure to perioperative biologic drugs were more prevalent in CCD group. CCD patients had increased requirement of urgent surgery (26.71 vs. 15%, p = 0.056), longer operative time (164.25 vs. 90.53 min, p< 0.01), lower rates of primary anastomosis (90.23 vs. 100%, p = 0.012), increased rate of overall postoperative complications (33.21 vs. 16.67%, p = 0.013), more reoperations (13.36 vs. 3.33%, p = 0.026), and higher rates of major anastomotic fistulas and hospital stay. On multivariable analysis, smoking (p = 0.001,95%CI: 2.59–32.11), operative time (p = 0.022,95%CI:1–1.02), associated procedures (p = 0.036,95%CI:1.09–15.72) and intraoperative complications (p = 0.021,95%CI:1.45–92.31) were independently related to presenting postoperative complications.ConclusionEarly (luminal) ileocaecal resections were associated to lower rates of overall postoperative complications. Proper timing for surgery, avoiding delays in surgical indication can impact postoperative outcomes.     

From conventional two-stage hepatectomy to ALPPS: Fifteen years of experience in a hepatobiliary surgery unit

BackgroundHepatectomy in patients with large tumor load may result in postoperative liver failure and associated complications due to excessive liver parenchyma removal. Conventional two-stage hepatectomy (TSH) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique are possible solutions to this problem. Colorectal liver metastases (CRLM) is the most frequent indication, and there is a need to assess outcomes for both techniques to improve surgical and long-term oncological outcomes in these patients.MethodsA single-center retrospective study was designed to compare TSH with ALPPS in patients with initially unresectable bilateral liver tumors between January 2005 and January 2020. ALPPS was performed from January 2012 onwards as the technique of choice. Long-term overall survival (OS) and disease-free survival (DFS) were evaluated as primary outcome in CRLM patients. Postoperative morbidity, mortality and liver growth in all patients were also evaluated.ResultsA total of 38 staged hepatectomies were performed: 17 TSH and 21 ALPPS. Complete resection rate was 76.5% (n = 13) in the TSH group and 85.7% (n = 18) in the ALPPS group (P = 0.426). Overall major morbidity (Clavien-Dindo ≥ 3a) (stage 1 + stage 2) was 41.2% (n = 7) in TSH and 33.3% (n = 7) in ALPPS patients (P = 0.389), and perioperative 90-day mortalities were 11.8% (n = 2) vs. 19.0% (n = 4) in each group, respectively (P = 0.654). Intention-to-treat OS rates at 1 and 5 years in CRLM patients for TSH (n = 15) were 80% and 33%, and for ALPPS (n = 17) 76% and 35%, respectively. DFS rates at 1 and 5 years were 36% and 27% in the TSH group vs. 33% and 27% in the ALPPS group, respectively.ConclusionsALPPS is an effective alternative to TSH in bilateral affecting liver tumors, allowing higher resection rate, but patients must be carefully selected. In CRLM patients similar long-term OS and DFS can be achieved with both techniques.     

Mediastinal lymphadenectomy fulfilling NCCN criteria may improve the outcome of clinical N0–1 and pathological N2 non-small cell lung cancer

Background

This retrospective study investigated whether mediastinal lymphadenectomy compliant with the National Comprehensive Cancer Network (NCCN) criteria will improve the oncological outcomes of clinical early-stage lung cancer.

Methods

From 2003–2010, 712 consecutive cases of clinical N0/1 were included for retrospective analysis, including 152 confirmed cases of pN2 and 560 of pN0–1 disease following surgery. Group A was defined as the cases fulfilling NCCN lymphadenectomy criteria (≥ three stations of N2 nodes dissection) and group B included all other cases. The groups were stratified according to pN status and the outcomes were assessed.

Results

Five-year overall survival (OS) and 5-year disease-free survival (DFS) were significantly different between group A versus B [72%±2% vs. 63%±4% (OS), P=0.014; 58.0%±2% vs. 49%±4% (DFS), P=0.038] in the whole cohort. After stratification by pN status, this difference was remained in pN2 subgroup [50%±5% vs. 25%±9% (OS), P=0.006; 31.0%±4% vs. 13%±7% (DFS), P=0.014], but not in pN0–1 subgroups. Cox regression analysis showed that performing a lymphadenectomy fulfilling NCCN criteria was a significant prognostic factor for OS either in the whole cohort [P=0.003, hazard ratio (HR): 0.598, 95% confidence interval (CI): 0.425–0.841] or in patients of pN2 status (P=0.038, HR: 0.559, 95% CI: 0.323–0.968). Cases with ≥4 N2 stations dissected did not achieve better survival benefit compared to those harvesting 3 stations in cN0/1–pN2 group (P=0.152).

Conclusions

Mediastinal lymphadenectomy fulfilling NCCN criteria appears to improve the survival of unexpected N2 group (cN0/1-pN2) among early-stage lung cancer patients. More extended N2 node dissection may not further improve the outcome in this group.     

The impact of marginal lung function on outcomes in the era of minimally invasive thoracic surgery

BackgroundThe effect of marginal lung function on outcomes after lung resection has traditionally been studied in the context of open thoracic surgery. Its impact on postoperative outcomes in the era of minimally invasive lung resection is unclear.MethodsIn this retrospective cohort study, we included adult patients who underwent minimally invasive lung resection at our institution between January 2017 and May 2020 for known malignancy or lung nodule. Marginal lung function was defined as pre-operative forced expiratory volume in 1 second (FEV1) and/or diffusion lung capacity of carbon monoxide <60% of predicted. Our outcomes included a composite outcome of pulmonary morbidity and/or 30- and 90-day mortality, and hospital length of stay. We used multivariable logistic and Poisson regression models to identify associations with outcomes, and Kaplan-Meier and Cox models to estimate survival.ResultsOf 300 patients, 88 (29%) had marginal lung function. Patients in the marginal group were more likely to be female (69% vs. 56%; P=0.028), and more likely to have: hypertension (HTN) (83% vs. 71%; P=0.028), chronic obstructive pulmonary disease (COPD) (38% vs. 12%; P<0.001), interstitial lung disease (ILD) (9% vs. 3%; P<0.019), and ischemic heart disease (28% vs. 18%; P=0.033). Patients were similar in terms of age (68±8 vs. 68±10 years; P=0.932), and other comorbidities. Anatomic lung resection comprised 56.8% of the marginal group vs. 74% in the non-marginal group (P=0.003). The most common complication was prolonged air leak (18.2% vs. 11.8%; P=0.479). Marginal lung function had a trend toward increased composite respiratory complications (22.7% vs. 15.1%; P=0.112) and 90-day mortality (5.7% vs. 4.2%; P=0.591), although they did not reach statistical significance. There was a statistically significant 1-day average increase in length of stay in the marginal lung function cohort (4.6 vs. 3.4 days; P<0.015) with a stronger association with diffusion lung capacity of carbon monoxide than FEV1. Survival was similar (marginal function HR =1.0; P=0.994).ConclusionsIn the era of minimally invasive thoracic surgery, lung resection in patients with marginal lung function may be considered in select patients. These findings aid in the selection consideration and counseling of this patient population.     

Mild hypothermic circulatory arrest with selective cerebral perfusion in open arch surgery

BackgroundThis study aimed to evaluate whether the use of mild hypothermic circulatory arrest (HCA) with selective cerebral perfusion (SCP) in open arch procedure provides comparable perioperative results to moderate HCA for patients with dissected or degenerative arch pathologies.MethodsBetween January 2017 and September 2020, a total of 88 consecutive patients (mean age 47±11 years, 71 males) underwent open arch repair under a single surgeon at our institution with mild or moderate systemic hypothermia assisted by unilateral or bilateral SCP. Patients were divided into groups according to the nasopharyngeal temperature at the beginning of HCA: a moderate HCA group (n=47, 53.4%) and a mild HCA group (n=41, 46.6%). The postoperative mortality, morbidity, and visceral organ functions between these groups were analyzed retrospectively.ResultsCompared to the moderate HCA group, the mild HCA group had a significantly higher core temperature (nasopharynx: 24.4±0.8 vs. 28.5±2, P<0.001; bladder 25.9±0.9 vs. 30±1.2, P<0.001), and the incidence of major adverse events (MAE) in this group was markedly lower (21.3% vs. 4.9%, P=0.031). No differences were identified between the two groups refer to in-hospital mortality, permanent neurological deficit (PND), temporary neurological deficit (TND), and paraplegia (8.5% vs. 2.4%, P=0.366; 8.5% vs. 0, P=0.120; 6.4% vs. 7.3%, P=1.0; 4.3% vs. 2.4%, P=1.0, respectively). In the moderate HCA group, 6 patients (12.8%) developed acute renal failure needing replacement therapy, which did not occur in the mild HCA group (P=0.028). The duration of ventilator support and intensive care unit stay was shorter in the mild HCA group, as well as a decreased volume of drainage during the first 24 h and reduced platelet transfusion.ConclusionsThe preliminary results of the mild HCA group with SCP applied in open arch repair, mainly in total arch replacement (TAR) and stented elephant trunk (SET) implantation for aortic dissection, were satisfactory. Furthermore, comparable inferior outcomes were obtained with mild HCA compared with that of the conventional moderate HCA strategy. These encouraging surgical and postoperative results favor this more aggressive hypothermia strategy in open arch repair.     

The Association of Digital Health Application Use With Heart Failure Care and Outcomes: Insights From CONNECT-HF

BackgroundIt is unknown whether digital applications can improve guideline-directed medical therapy (GDMT) and outcomes in heart failure with reduced ejection fraction (HFrEF).Methods and ResultsCare Optimization Through Patient and Hospital Engagement Clinical Trial for Heart Failure trial (CONNECT-HF) included an optional, prospective ancillary study of a mobile health application among patients hospitalized due to HFrEF. Digital users were matched to nonusers from the usual-care group. Coprimary outcomes included change in opportunity-based composite HF quality scores and HF rehospitalization or all-cause mortality. Among 2431 patients offered digital applications across the United States, 1526 (63%) had limited digital access or insufficient data, 425 (17%) were digital users, and 480 (20%) declined use. Digital users were similar in age to those who declined use (mean 58 vs 60 years; P = 0.031). Digital users (n = 368) vs matched nonusers (n = 368) had improved composite HF quality scores (48.0% vs 43.6%; + 4.76% [3.27–6.24]; P = 0.001) and composite clinical outcomes (33.0% vs 39.6%; HR 0.76 [0.59–0.97]; P = 0.027).ConclusionsAmong participants in the CONNECT-HF trial, use of digital applications was modest but was associated with higher HF quality-of-care scores, including use of GDMT and better clinical outcomes. Although cause and effect cannot be determined from this study, the application of technology to guide GDMT use and dosing among patients with HFrEF warrants further investigation.     

The “No-touch” technique improves the survival of patients with advanced hepatocellular carcinomas treated by liver transplantation: A single-center prospective randomized controlled trial

Background: Liver transplantation(LT) is the best treatment for patients with hepatocellular carcinoma(HCC). However, the surgical technique needs to be improved. The present study aimed to evaluate the “no-touch” technique in LT. Methods: From January 2018 to December 2019, we performed a prospective randomized controlled trial on HCC patients who underwent LT. The patients were randomized into two groups: a no-touch technique LT group(NT group, n = 38) and a conventional LT technique group(CT ...     

Surgical septal myectomy outcome for obstructive hypertrophic cardiomyopathy after alcohol septal ablation

BackgroundAlthough surgical treatment of residual obstruction after alcohol septal ablation (ASA) is often challenging in patients with obstructive hypertrophic cardiomyopathy (OHCM) there are very few relevant clinical reports. Thus, outcomes of surgical septal myectomy (SSM) in this subgroup of patients remain to be determined. Therefore, this study aimed to determine the surgical and follow-up outcomes in patients with OHCM exhibiting residual obstruction after ASA.MethodsWe collected case data for 62 patients with OHCM and residual obstruction after ASA who underwent SSM at Fuwai Hospital between January 2002 and June 2019. Propensity score matching with patients having had a myectomy as the only invasive procedure—was conducted in a 1:2 ratio. Echocardiography parameters, surgery results, and follow-up outcomes were compared between the groups.ResultsThe prior ASA group had a higher incidence of complete atrioventricular block (AVB) and subsequently postoperative permanent pacemaker (PPM) implantation than the primary myectomy group (9.7% vs. 1.6%, P=0.01). Two patients died within 30 days after surgery in the prior ASA group, and one patient died in the primary myectomy group, with an operative mortality rate of 3.2% and 0.8%, respectively (P=0.2). The 5-year event-free survival rate was 86.0% in the prior ASA group (median follow-up period: 3.2 years; mean: 3.9±2.6 years; maximum, 10.6 years) and 88.5% in the primary myectomy group (median follow-up period: 2.4 years; mean 2.8±1.7 years; maximum, 9.1 years) (P=0.2). During follow-up, four of 62 (6.5%) patients in the prior ASA group and one of 124 (0.8%) patients in the primary myectomy group progressed to advanced heart failure (P=0.025).ConclusionsPatients with OHCM following ASA are at an increased risk of developing AVB after SSM. Their surgical outcomes, and long-term survival rate were satisfactory and, osimilar to those for patients having had a myectomy as the only invasive procedure. In addition, they had an increased risk of advanced heart failure after SSM in the present study.     

Reappraisal of mechanical tricuspid valve replacement in the current era: a single center retrospective study

BackgroundThis study aimed to investigate the early and late outcomes of mechanical tricuspid valve replacement (mTVR).MethodsWe evaluated 113 patients (82 women; median age, 53 years) who underwent mTVR between 1995 and 2017. Based on a history of cardiac surgery, patients were divided into primary (n=42) and reoperative mTVR (n=71) groups. The median follow-up duration was 12.7 years in primary and 9.3 years in reoperative mTVR, respectively (P=0.045).ResultsPatients in the reoperative group were older (54 vs. 46 years; P=0.007) and showed higher central venous pressure (16±6 vs. 13±6 mmHg; P=0.002) than the primary group. Early mortality occurred in 2 patients in the reoperative group (2 vs. 0; P=0.529). There was no significant difference in overall survival between the primary and reoperation groups (15-year survival rate: 86% vs. 78%; P=0.215). The independent risk factors of overall survival were age [P<0.001; hazard ratio (HR), 1.11; 95% confidential interval (CI), 1.05–1.18], left ventricular ejection fraction of less than 40% (P=0.001; HR, 5.1; 95% CI, 2.21–28.2), and central venous pressure over 20 mmHg (P=0.016; HR, 3.7; 95% CI, 1.28–10.7). Overall survival did not differ between the age groups (<60 vs. 60–70 years) in the reoperative group (P=0.772). Tricuspid valve thrombosis occurred in 8 patients (7 primary, 1 reoperative; P=0.004).ConclusionsThe incidence of tricuspid valve thrombosis was significantly higher in the primary mTVR group compared with the reoperative mTVR group. The patients who underwent mTVR at a relatively young age showed good early and late outcomes in both groups.     

Femoral artery cannulation as a safe alternative for aortic dissection arch repair in the era of axillary artery cannulation

BackgroundTo evaluate the safety and efficacy of femoral artery cannulation as an alternative to axillary artery cannulation, we retrospectively compared outcomes between patients with axillary or femoral artery cannulation during open aortic arch repair for type A aortic dissection (TAAD).MethodsBetween January 2014 and January 2019, 646 patients underwent open aortic arch repair with circulatory arrest for TAAD using antegrade selective cerebral perfusion (SACP) and were divided into two groups according to the site of arterial cannulation: an axillary artery group (axillary group, n=558) or a femoral artery group (femoral group, n=88). The axillary artery was considered as the primary cannulation site, and the femoral artery was used as an alternative when axillary artery cannulation was deemed unsuitable or had failed. Propensity score matching was performed to correct baseline differences.ResultsAfter propensity score matching, the patients’ characteristics were comparable between groups (n=85 in each). The incidence of in-hospital mortality (10.6% vs. 14.1%; P=0.642) and stroke (3.5% vs. 5.9%; P=0.720) were comparable between the axillary and femoral groups. The incidence of newly required dialysis was lower in the femoral group, but the difference was not statistically significant (34.1% vs. 20.0%; P=0.050). Other outcomes and major adverse events were comparable.ConclusionsFemoral artery cannulation produced similar perioperative outcomes to axillary cannulation after open arch repair for TAAD. The femoral artery can be used as a safe and effective alternative to the axillary artery for arterial cannulation in TAAD patients undergoing open arch repair.     

Impact of Right Ventricle-Pulmonary Artery Coupling on Clinical Outcomes in the PARTNER 3 Trial

BackgroundPhysiologic right ventricle–pulmonary artery (RV-PA) coupling may be impaired in patients with aortic stenosis (AS).ObjectivesThis study aimed to assess the incidence and prognostic significance of impaired RV-PA coupling in low-risk patients with symptomatic severe AS undergoing transcatheter aortic valve replacement or surgical aortic valve replacement.MethodsRV-PA coupling was measured by transthoracic echocardiography as the ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) in patients in the PARTNER (Placement of Aortic Transcatheter Valve) 3 trial. The primary endpoint was the composite of all-cause mortality, stroke, and rehospitalization at the 2-year follow-up.ResultsAmong 570 low-risk patients included in the analysis, RV-PA uncoupling was defined by a TAPSE/PASP ratio ≤ 0.55 mm/mm Hg. At baseline, 222 of 570 (38.9%) patients had RV-PA uncoupling. At 2 years, patients with baseline RV-PA uncoupling had an increased incidence of the primary endpoint (19.1% vs 9.9%, P = 0.002), all-cause mortality (5.9% vs 0.6%, P < 0.001), cardiovascular mortality (4.1% vs 0.6%, P = 0.003), and rehospitalization (13.5% vs 7.3%, P = 0.018). On multivariable analysis, baseline RV-PA uncoupling remained an independent predictor of the primary endpoint at 2 years (HR: 1.92; 95% CI: 1.04-3.57; P = 0.038).ConclusionsIn patients with symptomatic severe AS at low surgical risk undergoing transcatheter aortic valve replacement or surgical aortic valve replacement, baseline RV-PA uncoupling defined by TAPSE/PASP ≤ 0.55 mm Hg was associated with adverse clinical outcomes at 2 years, including all-cause mortality, cardiovascular mortality, and rehospitalization.     

Radiofrequency ablation compared to resection in early‐stage hepatocellular carcinoma

ObjectivesThis study aimed to compare survival outcomes after hepatic resection (HR) and radiofrequency ablation (RFA) in early‐stage hepatocellular carcinoma (HCC) at a Western hepatobiliary centre.MethodsDemographic details, clinicopathologic tumour characteristics and survival outcomes were compared among non‐transplant candidate patients undergoing HR (n= 50) and RFA (n= 60) for early‐stage HCC during 2001–2011.ResultsPatients who underwent HR had larger tumours, a longer length of stay and a higher rate of postoperative complications. After a median follow‐up of 29 months, there were no significant differences between the treatment groups in 1‐, 3‐ and 5‐year overall survival (OS) [RFA group: 86%, 50%, 35%, respectively; HR group: 88%, 68%, 47%, respectively (P= 0.222)] or disease‐free survival (DFS) [RFA group: 68%, 42%, 28%, respectively; HR group: 66%, 42%, 34%, respectively (P= 0.823)]. The 58 patients who underwent RFA demonstrated ablation success on follow‐up computed tomography at 3 months. Of these, 96.5% of patients showed sustained ablation success over the entire follow‐up period. In a subgroup analysis of patients with tumours measuring 2–5 cm, no differences in OS or DFS emerged between the HR and RFA groups. Similarly, no significant differences in outcomes in patients with Child–Pugh class A cirrhosis were seen between the RFA and HR groups.conclusionsRadiofrequency ablation is comparable with HR in terms of OS and DFS. It is a reasonable alternative as a first‐line treatment for HCC in well‐selected patients who are not candidates for transplant.     

Drug-eluting beads bronchial arterial chemoembolization plus intercostals arterial infusion chemotherapy is effective and well-tolerated in treating non-small cell lung cancer patients with refractory malignant pleural effusion

BackgroundThe study aimed to explore the efficacy and safety of drug-eluting beads bronchial arterial chemoembolization (DEB-BACE) plus intercostals arterial infusion chemotherapy in non-small cell lung cancer (NSCLC) patients with refractory malignant pleural effusion (MPE).Methods17 NSCLC patients with refractory MPE treated by DEB-BACE plus the intercostals arterial infusion chemotherapy (DEB-BACE group) were recruited. Their treatment response [complete remission (CR), partial remission (PR), overall efficacy, failure] for MPE was assessed at 1 month after therapy; adverse effects were recorded; MPE progression-free survival and overall survival (OS) were calculated. Moreover, 19 NSCLC patients with refractory MPE treated by conventional chemotherapy were reviewed as control (chemotherapy group), then their medical records were collected.ResultsWith respect to MPE response, DEB-BACE group exhibited increased CR (82.4% vs. 10.5%, P<0.001) and overall efficacy (100.0% vs. 52.6%, P=0.001), similar PR (17.6% vs. 42.1%, P=0.112) while less failure (0.0% vs. 47.4%, P=0.001) compared to chemotherapy group. Furthermore, OS was prolonged in DEB-BACE group (median: 13.4; 95% CI: 11.0–15.8 months) than chemotherapy group (median: 7.0; 95% CI: 4.4–9.6 months) (P=0.002). Further analyses displayed that in DEB-BACE group, CR was associated with improved ECOG score and longer MPE progression-free survival, and adverse events mainly included fever, chest distress/pain, gastrointestinal side effects, myelosuppression, rash and hemoptysis, which were all mild and tolerable.ConclusionsDEB-BACE plus intercostals arterial infusion chemotherapy could serve as a salvage treatment option for NSCLC patients with refractory MPE.     

Invasive IPMN relapse later and more often in lungs in comparison to pancreatic ductal adenocarcinoma

BackgroundThe different oncological outcomes of invasive intraductal papillary mucinous neoplasm (I-IPMN) and pancreatic ductal adenocarcinoma (PDAC) are debated. This study aimed to compare disease recurrence patterns and histopathological characteristics in patients with resected I-IPMN and PDAC.MethodsConsecutive patients undergoing surgical resection for stage I-III I-IPMN or PDAC between 2010 and 2016 were retrospectively analyzed. Patients treated with neoadjuvant therapy or resected for Tis neoplasia were excluded. All surgical specimens were re-staged according to AJCC-8th-edition.ResultsA total of 330 patients were included, of whom 43 had I-IPMN and 287 had PDAC. Median follow-up time was 26.7 (1.3–92.3) months and estimated median disease-free survival (DFS) was 60.3 months (47.2–73.4) for I-IPMN and 23.8 (19.3–28.2) months for PDAC (p < 0.001). During follow-up, 32.6% of I-IPMN and 67.9% of PDAC patients experienced recurrence (p < 0.001). The sites of first recurrence were the lungs (38.5% vs 13.1%, p = 0.027), liver (28.6% vs 45.0%, p = 0.180) and local (15.4% vs 36.6%, p = 0.101) for I-IPMN and PDAC, respectively. At multivariate analysis, I-IPMN histology remained an independent predictive factor for longer DFS (OR 0.528, CI 95% 0.278–1.000, p = 0.050), regardless of stage or adjuvant chemotherapy. I-IPMN and PDAC differed in rates of neuroinvasion (51.2% vs 97.2%) and positive lymph node status (N+) (46.5% vs 82.7%), especially in patients with lower T status.ConclusionI-IPMN showed a different recurrence pattern compared to PDAC, with a higher lung tropism, and longer DFS. This different biological behavior is associated with lower rates of neuroinvasion and nodal involvement, especially in early-stage disease.     

The Effect of Psychosocial Risk Factors on Outcomes After Aortic Valve Replacement

BackgroundPsychosocial risk factors (PSRFs) have emerged as important nontraditional risk factors that are associated with worse surgical outcomes but have not been well-characterized in valvular disease.ObjectivesThis study evaluates the impact of PSRFs on 30-day outcomes following surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR).MethodsAll adult patients (≥18 years of age) who underwent isolated TAVR or SAVR in the Nationwide Readmissions Database from 2016 to 2018 were included. Patients were classified as having 0 PSRFs vs ≥1 PSRF. PSRFs included limited cognitive understanding, substance use, psychiatric disease, low socioeconomic status, or uninsured status. Primary outcomes included 30-day mortality, readmission, and composite morbidity (stroke, pulmonary embolus, pacemaker implantation, bleeding complications, acute kidney injury, myocardial infarction, or new atrial fibrillation).ResultsA nationally weighted total of 74,763 SAVR and 87,142 TAVR patients met inclusion criteria. For SAVR, patients with PSRFs had significantly higher 30-day mortality (4.2% vs 3.7%; P = 0.048) and readmissions (13.1% vs 11.3%; P < 0.001), but there was no difference in composite morbidity. For TAVR, patients with PSRFs had significantly higher 30-day readmission (11.7% vs 10.7%; P = 0.012) but no difference in 30-day mortality or composite morbidity. On risk-adjusted analysis, presence of PSRFs was a significant predictor of higher 30-day readmissions following SAVR (adjusted OR: 1.10; 95% CI: 1.02-1.19).ConclusionsThe presence of PSRFs is associated with worse short-term outcomes following SAVR and TAVR, with a more profound impact in SAVR. This study highlights the importance of identifying at-risk patients and suggests that TAVR may be beneficial in patients with less social support.     

Simultaneous bilateral thoracoscopic lobectomy for synchronous bilateral multiple primary lung cancer—single center experience

BackgroundThe 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.MethodsBetween 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.ResultsIn 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), FEV₁ <2 L (P=0.001), FEV₁% <80% (P=0.036), and the number of pulmonary segments resected ≥9 (P=0.014) were the risk factors to increased simultaneous resection postoperative complication. In addition, simultaneous resection could significantly reduce total cost compared to staged resection (10,854.6±1,998.8 vs. 16,241.4±2,972.8 USD, P<0.001). In long-time outcomes, the patients with simultaneous resection showed better disease-free survival (DFS) than patients with staged resection at 5 years (67.7% vs. 45.9%, P=0.039). In subgroup analysis, simultaneous resection also had a significantly better survival than staged resection in patients with bilateral pure solid lesions or the biggest tumor size >3 cm.ConclusionsBilateral 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.     

Hepatocellular Carcinoma in Non-cirrhotic Liver Arises with a More Advanced Tumoral Appearance: A Single-Center Cohort Study

BackgroundA small proportion of all hepatocellular carcinomas (HCCs) arise in a non-cirrhotic liver (NCL). However, our knowledge about the HCCs developing in a NCL is scarce. This study was undertaken to investigate the characteristics and survival course of this patient group.MethodsWe retrospectively analyzed the database of patients with HCC at a tertiary center during a 10-year period (2009-2019). All demographic, clinical, laboratory, and tumoral features with survival outcomes were compared between the HCC-CL and HCC-NCL groups.ResultsOut of 384 HCC cases, 11.2% (n = 43) had no cirrhosis. The dominant etiology in the HCC-NCL group was hepatitis B virus (n = 26, 60.5%), followed by non-alcoholic fatty liver disease (n = 10, 23.2%), and hepatitis C virus (n = 7, 16.3%). The maximum tumor diameter was approximately 2 times larger in the HCC-NCL group (HCC-NCL: 90 mm vs. HCC-CL: 46.5 mm, P < .001). The proportion of patients with vascular (HCC-NCL: 27.9% vs. HCC-CL: 8.6%, P < .001) and extrahepatic invasion (HCC-NCL: 14% vs. HCC-CL: 3%, P = .001) were prominently higher in the HCC-NCL group. Patients with HCC-NCL were less often detected in early-curable stages (BCLC 0-A) than those in the HCC-CL group (HCC-NCL: 16.3% vs. HCC-CL: 34.9%, P = .004). The overall survival was not different between the 2 groups (HCC-NCL: 19.4 ± 9.8 months vs. HCC-CL: 17.5 ± 2.3 months, P = .581).ConclusionHCC in NCL is diagnosed at more advanced tumoral stages with larger tumor size and more often with vascular and extrahepatic spread. Despite the preserved liver functions, the overall survival is not prolonged in HCCs without cirrhosis, due to the late recognition.