Recent advances in video‐assisted thoracoscopic surgery for lung cancer

As a result of increased use of CT in both screening and daily practice, the number of early lung cancers has increased enormously. Surgeons pursue both curativity and reduced invasiveness in treating patients with early stage lung cancer; therefore, minimally invasive operations, such as video‐assisted thoracoscopic surgery (VATS) lobectomy are now being routinely performed. Most previous reports have shown that there is no difference in mortality and local recurrence between open surgery and VATS in stage I patients. However, surgeons' improved technical experience and patients' demands could soon make VATS lobectomy the operative method of choice for early stage lung cancer. Moreover, the indications for VATS are expanding to encompass complex procedures such as segmentectomy or sleeve resection. Training and dissemination of the technique and the monitoring of outcomes are necessary.     

Video-assisted thoracic surgery for lung cancer in hemodialysis patients

Introduction: In recent years, the number of hemodialysis patients has been continuously increasing. At the same time, the use of video‐assisted thoracic surgery (VATS) for lung cancer has also increased. However, reports of the outcome of VATS in hemodialysis patients are still quite rare. Methods: From 1995 to 2011, 14 patients with non‐small cell lung cancer who were also receiving hemodialysis underwent lung resection by open thoracotomy or VATS at our institution. These patients were divided into two groups as follows: open (five men and four women, mean age: 68.7 years) and (2) VATS (three men and two women, mean age: 64.0 years). We compared the clinical outcomes of these two groups. Results: Lobectomy was performed in eight patients in the open group, including one patient who also underwent a pneumonectomy, and in four patients in the VATS group, including one who also underwent a wedge resection. There were no significant difference between the groups' operation times, intraoperative blood loss, length of postoperative chest drainage, and length of postoperative hospitalization. There were no hospital deaths in either group. The 5‐year survival rate was 42.9% in the open group and 37.5% in the VATS group. This difference was not significant (P=0.73). Conclusion: VATS lung resection for lung cancer patients on hemodialysis is considered an acceptable treatment modality, though the long‐term survival rate of such patients is relatively low, which can be attributed to the diseases underlying the need for hemodialysis.     

Comparison of video‐assisted minithoracotomy and standard open thoracotomy for the treatment of non‐small cell lung cancer

This study represents a retrospective comparison of video‐assisted thoracic surgery (VATS) lobectomy with standard open lobectomy for non‐small cell lung cancer (NSCLC). The endpoints of this study include surgical stress as measured by interleukin 6 concentration and patient survival. A retrospective review was performed of 240 consecutive patients with clinical stage IA or IB NSCLC who underwent either VATS lobectomy (n?=?67) or conventional open lobectomy (n?=?173). The amount of blood loss was significantly less in the VATS group (110±75?ml) as compared to 165±90?ml for the open lobectomy group (P<0.05). A significantly lower incidence of postthoracotomy pain occurred in the VATS group (6.2±4.1 times/3days) than in the open lobectomy group (13.5±5.8 times/3 days, P<0.0001). The postoperative interleukin (IL)‐6 serum concentration of was significantly lower in the VATS group (112±43?pg/ml) than that in the open lobectomy group (351±133?pg/ml, P<0.001). There was no statistically significant difference in survival between the VATS and open lobectomy groups. The median follow‐up was 42 months in both groups. VATS lobectomy for NSCLC is a reasonable treatment option for selected patients with stage I NSCLC.     

Video-assisted thoracoscopic surgery for the treatment of lung cancer

A growing proportion of lung resections is being performed by video-assisted thoracoscopic surgery (VATS). VATS lobectomy is indicated for clinical stage I suspected lung cancer with pulmonary function sufficient to tolerate resection. Retrospective and matched analyses suggest less morbidity with fewer postoperative complications with VATS compared with open lobectomy. Five-year survival for VATS lobectomy in stage I non-small lung cancer patients approaches 80%. A potential oncologic benefit of VATS lobectomy (over thoracotomy) has been proposed through attenuation of postoperative cytokine release. Regardless of whether VATS or an open approach is utilized, thorough lymphadenectomy is important and may confer an additional survival benefit.     

电视胸腔镜辅助肺叶切除在Ⅰ／Ⅱ期肺癌根治术中的应用

【目的】探讨电视胸腔镜辅助肺叶切除术在Ⅰ／Ⅱ期肺癌根治术中的临床应用价值。【方法】选择2005年3月至2008年3月本院30例Ⅰ、Ⅱ期非小细胞肺癌患者施行电视胸腔镜辅助小切口肺叶切除术并清扫纵隔肺门淋巴结,同时与30例常规开胸肺叶切除术及淋巴结清扫的同期患者进行比较研究。【结果】胸腔镜组患者术中出血量和术后引流量少,术后镇痛时间和住院时间较对照组短,差异有显著性（P〈0．05）,淋巴结清扫与对照组比较差异无显著性（P〉0．05）。【结论】小切口电视胸腔镜辅助肺叶切除术适合于早中期肺癌,疗效确切,可以作为非小细胞型肺癌的一种常规的治疗手段。     

Comparison of video-assisted minithoracotomy and standard open thoracotomy for the treatment of non-small cell lung cancer.

This study represents a retrospective comparison of video-assisted thoracic surgery (VATS) lobectomy with standard open lobectomy for non-small cell lung cancer (NSCLC). The endpoints of this study include surgical stress as measured by interleukin 6 concentration and patient survival. A retrospective review was performed of 240 consecutive patients with clinical stage IA or IB NSCLC who underwent either VATS lobectomy (n=67) or conventional open lobectomy (n=173). The amount of blood loss was significantly less in the VATS group (110+/-75 ml) as compared to 165+/-90 ml for the open lobectomy group (P<0.05). A significantly lower incidence of post-thoracotomy pain occurred in the VATS group (6.2+/-4.1 times/3 days) than in the open lobectomy group (13.5+/-5.8 times/3 days, P<0.0001). The postoperative interleukin (IL)-6 serum concentration of was significantly lower in the VATS group (112+/-43 pg/ml) than that in the open lobectomy group (351+/-133 pg/ml, P<0.001). There was no statistically significant difference in survival between the VATS and open lobectomy groups. The median follow-up was 42 months in both groups. VATS lobectomy for NSCLC is a reasonable treatment option for selected patients with stage I NSCLC.     

原发性非小细胞性肺癌胸腔镜微创治疗效果及影响因素分析

目的探讨原发性非小细胞性肺癌(NSCLC)行电视胸腔镜(VATS)微创切除术的临床疗效以及影响疗效的相关因素。方法将2011年1月至2013年1月间收治的90例原发性非小细胞性肺癌患者,采用随机分组对照方法分为观察组(胸腔镜辅助下小切口肺叶切除术)45例,对照组(传统的开胸肺叶切除术)45例。两组间采取KaplanMeier法及Log-rank检验估计各组生存时间的生存率以及中位生存时间,胸腔镜微创治疗效果的影响因素分析采用Cox比例风险回归模型进行多因素分析。结果全组患者中位生存期为27个月。观察组的中位生存期为29个月,1、3、5年生存率分别为77.8%、51.1%以及37.8%;对照组中位生存期为22个月,1、3、5年生存率分别为80.0%、46.7%以及33.3%,两组患者生存率差异无统计学意义(P=0.294);单因素分析显示病灶长度、肿瘤分期、组织分化、支气管切缘情况、清扫的淋巴结数目以及术后是否辅助化疗对NSCLC预后有影响,Cox比例风险回归模型分析显示清扫的淋巴结个数与肿瘤分期是NSCLC的独立影响因素。结论胸腔镜下微创外科治疗NSCLC与传统开胸手术疗效相当;清扫的淋巴结个数和肿瘤分期是预后的独立影响因素。     

全电视胸腔镜与传统开胸手术行肺叶切除的比较研究

【目的】对比全胸腔镜下肺叶切除术与传统肺叶切除术患者的相关临床指标,探讨胸腔镜手术治疗可行性及应用价值。【方法】分析实行全胸腔镜下及传统肺叶切除术的肺癌患者共为176例,施行全胸腔镜下肺叶切除术95例,传统肺叶切除术81例,对比两组的手术时间、术中出血量、淋巴结清扫枚数、术后疼痛、胸腔引流时间、住院时间、手术费用、术后并发症、术后肿瘤转移复发等有无差异。【结果】VATS组手术时间、胸管引流时间较传统组差异无统计学意义（P〉0．05）;与传统组相比,VATS组术后疼痛明显减轻、住院时间减少、出血量明显减少;两组均无死亡。【结论】VATS行肺癌根治术具有微创、安全、恢复快、并发症少等优点,可以作为早期肺癌外科治疗的一种方案。’     

肺癌术后行肺动脉灌注化疗的探讨

目的:通过前瞻性对照研究,比较肺动脉灌注化疗与外周静脉化疗对中晚期肺癌行肺叶切除术后的治疗效果。方法:病人分为2组(每组45例),PAI 组于肺叶切除后行选择性肺动脉置管于手术侧剩余肺叶间动脉内,灌注化疗。Ⅵ组则于术后用外周静脉给药途径化疗。结果:PAI组共化疗215疗程,平均4.7疗程,Ⅵ组化疗195疗程,平均4.3疗程。PAI组根治手术病例1、3、5年生存率94％、84.6％、52.9％,Ⅵ组1、3、5年生存率为87.5％、60％、22.2％,其中3、5年生存率有显著性差异 P<0.05。Ⅵ组行姑息手术病例 1年生存率 45％,无 3年生存率。PAI 组姑息手术病例 1、3年生存率为50％、33.3％优于Ⅵ组,但无统计学差异。PAI组根治手术病例3年局部复发率为12.8％,Ⅵ组为35％,有显著性差异,P<0.05。PAI组 1、3、5年血行转移复发率为 17.8％、20％、26.3％,Ⅵ组为15.5％、35％、51.3％,其中3、5年血行转移率减少有显著性差异P<0.05。结论:选择性肺动脉灌注化疗作为一种新的化疗方式,用于肺叶切除术后的肺癌患者,具有提高局部化疗药物浓度、增强化疗效果的作用,能够杀灭和抑制局部微转移灶,减少局部复发和远期血行转移的发生率,改善长期生存率。     

电视胸腔镜下与传统开胸下行肺叶切除术治疗非小细胞肺癌临床疗效对比的Meta分析

目的对电视胸腔镜(VATS)与传统开胸(OPEN)两种术式对非小细胞肺癌(综合分期Ⅰ、Ⅱ期)行肺叶切除术的综合临床效益进行系统评价。方法按照Cochrane系统评价制作方法,计算机检索PubMed、EMBASE、Medline、同方数据库相关文献,结合手工检索收集相关文献,采用Cochrane协作网提供的RevMan5.0软件对相关研究数据进行Meta分析,以获得非小细胞肺癌(综合分期Ⅰ、Ⅱ期)在VATS下行肺叶切除术的临床疗效与OPEN下相比有无优势的相关证据。结果经过全面检索及筛查后,共纳入17篇回顾性临床对照研究,共计1586例患者,Meta分析表明:针对非小细胞肺癌(综合分期Ⅰ、Ⅱ期),与OPEN术相比,VATS能减低术后全身[P=0.03,优势比(OR)=0.57,95%可信区间(CI)0.34～0.96]和肺部(P=0.001,OR=0.34,95%CI0.17～0.66)并发症的发生率、减少五年死亡率(P=0.0005,OR=0.43,95%CI0.27～0.69)、至研究终点总死亡率(P=0.0004,OR=0.46,95%CI0.30～0.70)和肿瘤复发率(P=0.02,OR=0.63,95%CI0.42～0.94)。结论针对非小细胞肺癌(综合分期Ⅰ、Ⅱ期),与OPEN术相比,VATS能明显减少术后全身尤其是肺部并发症的发生率、减少五年死亡率、总死亡率和肿瘤复发率。     

The advanced lung cancer inflammation index predicts outcomes of patients with non-small cell lung cancer following video-assisted thoracic surgery

ObjectiveThe advanced lung cancer inflammation index (ALI) predicts overall survival (OS) in patients with advanced lung cancer. However, few studies have tested ALI’s prognostic effect in patients with non-small cell lung cancer (NSCLC) following video-assisted thoracic surgery (VATS), especially patients at stage III. This study investigated the relationship between ALI and outcomes of patients with NSCLC following VATS.MethodsWe retrospectively examined 339 patients with NSCLC who underwent VATS at Hebei General Hospital, China. Preoperative clinical and laboratory parameters were collected and analyzed. Optimal cutoff values of potential prognostic factors, including ALI, were determined. Kaplan–Meier and Cox regression analyses were used to determine each factor’s prognostic value.ResultsThe median OS was 31 months. The optimal cutoff value for ALI was 41.20. Patients with high ALI (≥41.20) displayed increased OS (33.87 vs. 30.24 months), higher survival rates, and milder clinical characteristics. Univariate and multivariate analyses showed a significant correlation between ALI and the prognosis of patients with NSCLC, including those at stage IIIA, who underwent VATS.ConclusionsLow ALI correlated with poor outcomes in patients with NSCLC following VATS. Preoperative ALI might be a potential prognostic biomarker for patients with NSCLC following VATS, including patients at stage IIIA.     

电视辅助胸腔镜与传统开胸肺叶切除术治疗肺癌的效果比较

目的：评价电视辅助胸腔镜手术（VATS）肺叶切除治疗肺癌患者的近期和远期疗效。方法：2002-2006年203例可手术的非小细胞肺癌患者按手术方法分为传统开胸术组（100例）和VATS组（103例）,两组分别行传统开胸肺叶切除术和VATS肺叶切除,比较两组患者术后近期及远期效果。结果：VATS组手术切口长度、术中出血量、术后当日引流量及住院时间均小于传统开胸术组（P〈0.01）,两组手术时间比较差异无统计学意义（P〉0.05）。随访3年,两组术后1年及3年的生存率比较差异均无统计学意义（P均〉0.05）。结论：VATS肺叶切除治疗肺癌安全、可行,既可以减少开胸探查率,又可以达到传统开胸术的远期疗效,可作为肺癌的常规治疗手段。     

Long‐term follow‐up of patients with portal vein thrombosis and myeloproliferative neoplasms

Summary. Background: Myeloproliferative neoplasms (MPNs) are frequently identified as an underlying cause in patients with non‐cirrhotic portal vein thrombosis (PVT). The aim of this study was to describe the long‐term outcome of patients with PVT and MPN. Methods: A cohort study was performed including all adult patients referred to our hospital between 1980 and 2008 with non‐cirrhotic, non‐malignant PVT and confirmed MPN. Results: A total of 44 patients (70% female) were included, with a median age at PVT‐diagnosis of 48 years (range 18–79). In 31 patients (70%) PVT was the first manifestation of an MPN. Additional risk factors for thrombosis were present in 20 patients (45%). Median follow‐up was 5.8 years (range 0.4–21). Twenty‐three patients (52%) were treated with oral anticoagulants after diagnosis of PVT, of whom 15 (34%) received long‐term therapy. During follow‐up, 17 patients (39%) experienced at least one episode of gastrointestinal bleeding. Additional thrombotic events occurred in 12 patients (27%). Twelve patients (27%) had progression of the underlying MPN. Seventeen patients (39%) died at a median age of 64 years (range 30–88). Death was directly related to end‐stage MPN in eight patients (47%) and to a new thrombotic event in three patients (18%). No patients died from gastrointestinal bleeding. Conclusions: PVT is often the presenting symptom of an underlying MPN, highlighting the need for thorough screening for this disease. Recurrent thrombosis is a common and severe complication in patients with PVT and MPN. Mortality is primarily related to the underlying MPN and not to complications of portal hypertension.     

原发中叶肺癌的外科治疗

目的探讨原发中叶肺癌的临床特点、诊断及外科治疗特点。方法对1987年1月～2006年12月经外科手术治疗的43例原发中叶肺癌的临床资料进行回顾性分析。结果本组原发中叶肺癌43例,占同期肺癌手术病例的3.7%,年龄≥50岁的占79.1%,男性多见。手术方式:单纯中叶切除16例,姑息切除10例,中上叶切除或中下叶切除术6例,剖胸探查4例,楔形切除3例,根治术4例。全组病例中除1例术后发生纵隔气肿再次剖胸修补肺断面漏气外,其余均无并发症,均痊愈出院。术后1年生存率67.44%,3年生存率25.58%,5年生存率9.3%。1年内死亡病例均为姑息切除和剖胸探查的患者。结论本组病例发现时多已是中晚期,病变常侵及心包、胸壁及膈肌,累及上叶或下叶,中叶支气管旁及纵隔淋巴结转移常见,手术效果欠理想。临床医生应提高对中叶肺癌的认识,提高早期确诊率,避免错过手术时机。术前掌握患者的肺功能及远处转移情况,制定合适的手术方案,尽可能行根治性切除,单纯中叶切除适合于肿瘤局限,无扩散或转移的病例。如肿瘤跨叶,可行双肺叶切除、袖式肺叶切除或全肺切除。如肿瘤已扩散或转移,可行局部姑息切除,但复发率高,远期效果差。     

Metachronous solitary mediastinal lymph node metastases of hepatocellular carcinoma treated by video‐assisted thoracic surgery twice: Report of a case

Solitary mediastinal lymph node metastasis of hepatocellular carcinoma (HCC) is rare. We report a case of metachronically solitary mediastinal metastases of HCC treated by video‐assisted thoracic surgery (VATS) twice. A 66‐year‐old man underwent repeated laparoscopic radiofrequency ablation or trans‐arterial catheter chemo‐embolization against HCC for more than 10 years. The level of alpha fetoprotein protein was elevated, and radiological modalities including FDG‐PET revealed solitary mediastinal tumor metachronically. VATS was performed bilaterally twice. The postoperative course was uneventful and there had no recurrence of extra‐hepatic metastases and tumor markers are within normal limits at 18 months after second VATS. VATS is a minimally invasive and useful procedure for solitary mediastinal lymph node metastasis of HCC. If primary HCC was controlled and lymph node metastasis was solitary, mediastinum lymphadenectomy using VATS might give good short and long term results.     

Surgical specialization and training – its relation to clinical outcome for colorectal cancer surgery

Rationale, aims and objectives Surgical sub‐specialization has been considered to be a major factor in improving cancer surgery‐related outcomes in terms of 5‐year survival and disease‐free intervals. In this article we have looked at the evidence supporting the improvement in colorectal cancer outcomes with ‘colorectal specialists’ performing colon and rectal surgery. Methods A literature review was carried out using search engines such as Pubmed, Ovid and Cochrane Databases. Only studies looking at colorectal cancer outcome related to surgery were included in our review. Results Specialist surgeons performing a high volume of colorectal cancer surgery demonstrated better 5‐year survival rates in patients, with less local recurrence. This was most evident in surgery for rectal cancer, where an association with increased sphincter saving surgery was also seen. Total mesorectal excision is now the accepted treatment for rectal cancer and has markedly improved survival rates and decreased local recurrence. Conclusion The outcomes in colorectal surgery continue to steadily improve. The training of specialized colorectal surgeons is a major contributing factor towards this improvement.     

Robotic assisted radical cystectomy: short to medium‐term oncologic and functional outcomes

Purpose: To report short‐ and medium‐term oncological and functional outcomes of the first robotic‐assisted laparoscopic radical cystectomy (RARC) series from the UK. Materials and methods: Thirty patients underwent RARC between 2004 and 2007 at our unit. We report oncological and functional outcomes of this procedure in 20 patients (17 ileal conduit and three Studer Pouches), who have completed at least 6 months of follow up. Results: There were 17 men and three women, median age 66 years (range 38–77 years). Median operating time was 330 min (range 295–510 min), and median blood loss 150 ml (range 100–1150 ml). There were two major complications (10%); a port site bleed and a rectal injury. The median follow up of this cohort is 23 months (range 7–44 months). One patient died of distant metastases at 8 months, and another developed a right ureteric tumour at 7 months. None of the patients had local pelvic or port site recurrence. The overall and disease‐free survival are 95% and 90% respectively. Functional complications included a neovesico‐urethral stricture at 3 months, a left upper ureteric stricture at 6 months and an incisional hernia at 12 months. Conclusion: Robotic‐assisted laparoscopic radical cystectomy is an emerging minimally invasive procedure which at short‐ to medium‐term follow up, in our experience, is oncologically and functionally equivalent to open radical cystectomy.     

Thoracoscopic resection of congenital cystic adenomatoid malformation in an adolescent

Congenital cystic adenomatoid malformation (CCAM) in adolescents or adults is extremely rare. In this case study, a 17‐year‐old boy was admitted to our clinic for the treatment of a giant bulla in the lower lobe of the right lung. Preoperative imaging studies led to the diagnosis of cystic lung disease. The patient underwent wedge resection of the right lower lobe with VATS, and histological examination confirmed the presentation of type 1 CCAM. A thoracoscopic lobectomy was performed after the second surgery because of postoperative air leakage.Herein, we report a case of CCAM in an adolescent. VATS was a suitable procedure for the operation. Between the parenchyma‐saving resection and lobectomy for CCAM, we believe that the lobectomy is the better treatment option when the extent of the disease cannot be determined clearly or it is extremely large. Therefore, strategies for deciding between parenchyma‐saving resection and lobectomy for the treatment of CCAM should be developed.     

Cause‐specific mortality associated with leukoreduced,buffy coat–depleted,or no blood transfusion after elective surgery for colorectal cancer: a posttrial 15‐year follow‐up study

BACKGROUND: We previously reported that both leukoreduced (LR) and buffy coat–depleted (BCD) blood transfusions had a detrimental effect on long‐term overall survival in patients who underwent elective surgery for colorectal disease. This analysis investigates long‐term cause‐specific mortality in trial participants diagnosed with colorectal cancer (CRC). STUDY DESIGN AND METHODS: We used the Danish Civil Registration System to follow 448 trial participants with CRC, from their enrollment in 1992 to 1995 until January 2007. A total of 108 patients were transfused with BCD blood, 94 with LR blood, and 246 did not receive a transfusion (NT). We reviewed death certificates for study patients who died during follow‐up. Cause‐of‐death data were coded according to the International Classification of Diseases (ICD‐8 and ‐10). The Charlson Comorbidity Index was used for risk adjustment. RESULTS: A total of 43% of NT, 28% of BCD, and 27% of LR transfused patients were alive after 15 years of follow‐up (p = 0.001 for transfused vs. NT patients). For LR‐transfused versus NT patients the adjusted mortality ratio for death from rectal cancer was 1.81 (95% confidence interval [CI], 0.97‐3.38), and for death from cardiovascular disease 2.12 (95% CI, 1.23‐3.62). For BCD versus NT patients the adjusted mortality ratio for death from rectal cancer was 1.19 (95% CI, 0.61‐2.33) and for cardiovascular disease it was 1.68 (95% CI, 0.97‐2.91). CONCLUSION: LR transfusion is associated with decreased long‐term survival due to death from cardiovascular disease. A similar but weaker tendency was observed for BCD transfusion.     

Anti‐MDA‐5 antibody‐positive clinically amyopathic dermatomyositis with rapidly progressive interstitial lung disease treated with therapeutic plasma exchange: A case series

We present six cases of antimelanoma differentiation‐associated gene 5 antibody (anti‐MDA5‐Ab)‐positive clinically amyopathic dermatomyositis (CADM) with rapidly progressive interstitial lung disease (RP‐ILD), which is known to have a poor prognosis. The outcomes of these cases are described after treatment with therapeutic plasma exchange (TPE). Clinical and therapeutic data for patients with CADM with RP‐ILD were collected retrospectively from medical records. All six patients received early intensive care including high‐dose corticosteroids, intravenous cyclophosphamide, and a calcineurin inhibitor, but lung disease and hypoxia became more severe. TPE was performed over a median of 9.5 sessions (range 3‐14) per patient, and the median duration from admission to TPE was 23 days. Three patients received combined direct hemoperfusion using a polymyxin B‐immobilized fiber column (PMX‐DHP) therapy on successive days to manage acute respiratory failure. Four patients survived and two died due to respiratory failure. In the survival cases, ferritin decreased, and ferritin and KL‐6 were lower at diagnosis. The patients who died had a higher alveolar‐arterial oxygen difference and more severe lung lesions at the time of initiation of TPE. These findings indicate that a combination of conventional therapy and TPE may be useful for improvement of the prognosis of CADM with RP‐ILD at the early stage of onset.