Duration Of Chest Drainage Research Articles

Neoadjuvant Therapy in Robotic Lung Surgery: Elevating Surgical Complexity Without Compromising Outcomes

Background: Neoadjuvant therapy, particularly the combination of chemotherapy and immunotherapy, has become standard in treating locally advanced non-small cell lung cancer (NSCLC). While this approach improves pathologic responses, its effect on postoperative outcomes following robotic-assisted thoracic surgery (RATS) is not fully characterized. Objective: This study aimed to evaluate the impact of neoadjuvant therapy on postoperative outcomes in patients undergoing RATS for NSCLC, focusing on operative time, conversion rates to open surgery, and postoperative complications. Methods: A retrospective cohort analysis was performed on patients who underwent RATS for NSCLC between February 2019 and August 2024. Propensity score matching was utilized to balance preoperative characteristics between the groups. The primary outcomes compared were operative time, conversion rates to open surgery, and postoperative complications, with statistical significance defined as p < 0.05. Results: A total of 253 patients were included in the analysis, of whom 23 received neoadjuvant therapy (either chemotherapy or chemoimmunotherapy) and 230 did not. The neoadjuvant group had significantly longer operative times (250 min vs. 221 min, p = 0.001) but there were no significant differences in conversion rates to open surgery (8.7% vs. 3.9%, p = 0.5). However, the neoadjuvant group showed a higher incidence of prolonged air leaks (>5 days) (39.13% vs. 35.21%, p < 0.001). Other parameters, such as hospital stay and chest drainage duration, showed no statistically significant differences between the groups (p = 0.860 and p = 0.760, respectively). Conclusions: These findings support the feasibility of robotic-assisted thoracic surgery following neoadjuvant therapy in NSCLC, suggesting that this approach may be safely integrated into clinical practice for selected patients. Further studies are needed to define patient selection criteria and optimize postoperative management, potentially guiding personalized treatment strategies in complex cases.

Chest drainage outcomes by water seal versus low suction on digital drainage systems after lung resection: retrospective study.

Despite advances in chest drainage technology, such as the use of digital drainage systems (DDS), there is still no consensus on the most effective method for reducing air leaks after lung resection. To evaluate the optimal drainage method, we compared traditional water seal with low suction pressure settings on DDS. We retrospectively analyzed the postoperative data of patients between August 2015 and April 2023 who underwent anatomical lung resection at our hospital and who had postoperative chest drains managed with either a water seal or DDS set to low suction pressure. We excluded cases without air leak on the first postoperative morning from the consideration in this study. We divided the patients into two groups according to the chest drainage method on the first postoperative morning and we compared air leak and chest drainage durations of both groups. We retrospectively analyzed 116 patients. The groups (water seal: 59 patients; low suction: 57 patients) were well balanced for baseline and degree of air leakage on the first operative morning. The water seal group showed significantly shorter air leak duration (2 vs. 3 days, P<0.001) and chest drainage duration (3 vs. 5 days, P<0.001) compared with the low suction group. Pleurodesis (P=0.002) and conversion (P=0.001) were higher in the low suction group, with no significant differences in drain reinsertion. Water seal management was suggested to be safe and comparably effective to low suction on DDS in reducing air leak and chest drainage durations after lung resection.

Initial experience with the da Vinci single-port system in patients with an anterior mediastinal mass.

The da Vinci single-port system is a novel robotic system that has gained popularity and demonstrated favourable outcomes in various surgical fields. Nevertheless, its application in thoracic surgery is relatively rare. In this study, we report our initial experiences with the da Vinci single-port system via a subxiphoid approach in patients with an anterior mediastinal mass. We retrospectively reviewed patients with an anterior mediastinal mass who underwent surgery using the da Vinci single-port system via a subxiphoid approach between October 2020 and April 2024. Clinicopathological, intraoperative, and postoperative data were retrospectively collected. A total of 14 patients were included in this study. The median age was 55 years (interquartile range 48-62 years), with 4 (28.6%) patients being male. All patients underwent complete resection without conversion to multiport or open surgery. The median operation time was 135 min (interquartile range 113-155 min). Nine (64.3%) patients were diagnosed with thymoma, and 2 (14.3%) patients had myasthenia gravis. The median pathologic size of the mass was 32.5 mm (interquartile range 25.3-38.0 mm), and the median peak Numerical Rating Scale score was 3 (interquartile range 2-4). The median duration of chest drainage and hospital stay were 2 (interquartile range 1-3) and 3 (interquartile range 2-3) days, respectively. No complications were reported following surgery. The da Vinci single-port system for anterior mediastinal mass was deemed safe and feasible. To expand indications in thoracic surgery, further accumulation of experience and additional technological advancements are necessary.

Impact of the interval between neoadjuvant immunotherapy and surgery on prognosis in esophageal squamous cell carcinoma (ESCC): a real-world study

BackgroundThe time interval between neoadjuvant immunotherapy and surgery is 6 weeks for esophageal squamous cell carcinoma (ESCC), but whether delayed surgery affects prognosis remains unclear.MethodsClinical data of locally advanced ESCC who underwent neoadjuvant immunotherapy followed by esophagectomy from November 2019 to December 2022 were collected. The surgery outcomes and prognosis were compared between short-interval (time to surgery ≤ 6 weeks) and long-interval groups (time to surgery > 6 weeks).Results152 patients were enrolled totally, with a ratio of 91:61 between short-interval and long-interval groups. The rate of pathological complete response in the short-interval and long-interval groups were 34.1% and 24.6% (P = 0.257). Delayed surgery did not have a significantly impact on the number of lymph node dissections (P = 0.133), operative duration (P = 0.689), blood loss (P = 0.837), hospitalization duration (P = 0.293), chest drainage duration (P = 0.886) and postoperative complications (P > 0.050). The 3-year Overall survival (OS) rates were 85.10% in the short-interval group, and 82.07% in the long-interval group (P = 0.435). The 3-year disease-free survival (DFS) rates were 83.41% and 70.86% in the two groups (P = 0.037). Subgroup analysis revealed that patients with a favorable response to immunotherapy (tumor regression grade 0) exhibited inferior 3-year OS (long-interval vs. short-interval: 51.85% vs. 91.08%, P = 0.035) and DFS (long-interval vs. short-interval: 47.40% vs. 91.08%, P = 0.014) in the long-interval group.ConclusionsDelayed surgery after neoadjuvant immunotherapy does not further improve pathological response; instead, it resulted in a poorer DFS. Especially for patients with a favorable response to immunotherapy, delayed surgery increases the risk of mortality and recurrence.

Uniportal versus multiportal video-assisted thoracoscopic surgery for spontaneous pneumothorax

BackgroundMultiportal video-assisted thoracic surgery (mVATS) is the standard approach for the surgical treatment of spontaneous pneumothorax. However, uniportal VATS (uVATS) has emerged as an alternative aiming to minimize surgical morbidity. This study aims to strengthen the evidence on the safety and efficiency of uVATS compared to mVATS.MethodsFrom January 2004 to December 2020, records of patients who had undergone surgical treatment for primary or secondary spontaneous pneumothorax were evaluated for eligibility. Patients who had undergone pleurectomy combined with bullectomy or apical wedge resection via uVATS or mVATS were included. Surgical characteristics and postoperative data were compared between patients who had undergone surgery via uVATS or mVATS. Univariable and multivariable analyses were performed to determine whether the surgical approach was associated with any complication (primary outcome), major complications (i.e., Clavien-Dindo ≥ 3), recurrence, prolonged hospitalization or prolonged chest drainage duration (secondary outcomes).ResultsA total of 212 patients were enrolled. Patients treated via uVATS (n = 71) and mVATS (n = 141) were significantly different in pneumothorax type (secondary spontaneous; uVATS: 54 [76%], mVATS: 79 [56%]; p = 0.004). No significant differences were observed in (major) complications and recurrence rates between both groups. Multivariable analyses revealed that the surgical approach was no significant predictor for the primary or secondary outcomes.ConclusionsThis study indicates that uVATS is non-inferior to mVATS in the surgical treatment of spontaneous pneumothorax regarding safety and efficiency, and thus the uVATS approach has the potential for further improvements in the perioperative surgical care for spontaneous pneumothorax.

Is chest tube capnography effective in differentiating between true and false air leaks after minimally invasive thoracic surgery?

Air leak (AL) is the most frequent adverse event after thoracic surgery. When AL occurs, the concentration of the principal gas in the pleural space should be similar to that of air exhaled. Accordingly, we tried to develop a new method to identify AL by analyzing pCO2 levels in the air flow from the chest drainage using capnography. This is a prospective observational study of 104 patients who underwent VATS surgery between January 2020 and July 2021. Digital drainage systems were used to detect AL. Eighty-two patients (79%) had lung resection. Among them, 19 had post-operative day 1 air leaks (median 67ml/min). AL patients had higher intrapleural CO2 levels (median 24mmHg) (p < 0.001). Median chest drainage duration was 2days (range 1.0-3.0). Univariable logistic regression showed a linear and significant association between intrapleural CO2 levels and AL risk (OR 1.26, 95% CI 1.17-1.36, p < 0.001, C index: 0.94). The Univariable Gamma model demonstrated that an elevation in CO2 levels was linked to AL on POD1 (with an adjusted mean effect of 7.006, 95% CI 1.59-12.41, p = 0.011) and extended duration of drainage placement (p < 0.001). Intrapleural CO2 could be an effective tool to assess AL. The linear association between variables allows us to hypothesize the role of CO2 in the identification of AL. Further studies should be performed to identify a CO2 cutoff that will standardize the management of chest drainage.

Robotic Lobectomy Learning Curve Has Better Clinical Outcomes than Videothoracoscopic Lobectomy.

Introduction: The robotic-assisted (RATS) lobectomy learning curve is usually measured compared to an established videothoracoscopic (VATS) surgery program. The objective of our study is to compare the learning curves of both techniques. Methods: We performed an intention-to-treat analysis comparing the RATS vs. VATS lobectomies. Surgical time, conversions, complications, number of lymph nodes (LNs) and lymph node stations harvested, chest drainage duration, length of stay, readmissions, and 90-day mortality were compared between both groups. The learning curve was assessed using the CUSUM method. Results: RATS cases (30) and VATS cases (35) displayed no significant differences. The RATS learning curve was completed after 23 procedures while the VATS curve required 28 interventions. Complications appeared in four RATS procedures and in eight VATS patients. No differences in the number of LNs and harvested LN stations were reported. Four patients were readmitted in the RATS group, and eight in the VATS group. No 90-day postoperative mortality was observed in either group. The RATS group reported fewer chest tube days (3 (2-5) vs. 5 (4-5.8), p = 0.005) and hospital days (4 (3-6) vs. 5 (4-6), p = 0.023). Conclusions: The RATS curve appears shorter than the VATS curve. RATS lobectomies resulted in reduced chest tube duration and length of stay during the learning time period.

Zero-leak prediction during major lung resection aiming for minimal chest drainage duration: a retrospective analysis

BackgroundEarly chest tube removal should be considered to enhance recovery after surgery. The current study aimed to provide a predictive algorithm for air leak episodes (ALE) and to create a knowledge base for early chest tube removal.MethodsThis retrospective study enrolled patients who underwent thoracoscopic anatomical pulmonary resections in our unit. We defined ALE as any airflow ≥ 10 mL/min recorded in the follow-up charts based on the digital thoracic drainage device. Multivariate regression analysis was used to control for preoperative and intraoperative confounding factors. The ALE prediction algorithm was constructed by combining an additive ALE risk-scoring system using the coefficients of the significant predictive factors with the intraoperative water-sealing test.ResultsIn 485 consecutive thoracoscopic major pulmonary resections, ALE developed in 209 (43%) patients. Statistically significant ALE-associated preoperative factors included male sex, lower body mass index, radiologically evident emphysema, lobectomy, and upper lobe surgery. Significant ALE-associated intraoperative factors were incomplete fissure and pleural adhesion. The ALE risk scoring demonstrated an average area under the receiver operating characteristic curve of 0.72 in the fivefold cross-validation test. The ALE prediction algorithm correctly predicted ALE-absent patients at a negative predictive value of 80%.ConclusionsThe algorithm may promote the optimization of the chest tube-dwelling duration by identifying potential ALE-absent patients for accelerated tube removal.

Reduction in drain-related adverse events using the barbed suture method for chest tube wound closure.

A chest tube is usually placed in patients undergoing general thoracic surgery. Although the barbed suture method has been introduced for chest tube wound closure, its superiority to the conventional suture methods for drain management remains unclear. The study aimed to determine whether the barbed suture method could reduce drain-related adverse events compared to the conventional method. We retrospectively reviewed the medical records of patients who underwent general thoracic surgery between January 2021 and December 2022, 1year before and after the introduction of the barbed suture method at our institution. Patients who underwent the barbed suture or conventional method were included. Univariate and multivariate analyses of drain-related adverse events were performed. Of the 250 participants, 110 and 140 underwent the barbed suture method and conventional suture method, respectively. The univariate analysis showed that a higher body mass index, preoperative malignant diagnosis, lobectomy, longer operative time, larger tube size, longer chest drainage duration, surgical complications, and conventional method were risk factors for drain-related adverse events. The multivariate analysis showed that the barbed suture method was a protective factor against drain-related adverse events (odds ratio 0.267; 95% confidence interval 0.103-0.691; P = 0.007). The barbed suture method could reduce drain-related adverse events compared to the conventional method. Therefore, it might be a potential standard method for chest tube wound closure in patients undergoing general thoracic surgery.

Utility of 4K three-dimensional endoscopic system in performing video-assisted thoracoscopic surgery lobectomy: initial results of the first year after installation.

With the evolution of technology in the field of thoracoscopy, three-dimensional (3D) endoscopic systems with 4K resolution have recently come into use. This study aimed to determine perioperative outcomes of video-assisted thoracoscopic surgery (VATS) lobectomy performed a year after the 4K three-dimensional (3D) endoscopic system installation and compare them with those of the high-definition (HD) 3D endoscopic system. We included patients who underwent complete VATS (cVATS) lobectomy for primary lung cancer using an HD3D endoscopic system (HD3D group, June 2015-September 2021, n = 251) or 4K3D endoscopic system (4K3D group, October 2021-September 2022, n = 47). The perioperative outcomes were compared between the two groups. The operation time was significantly shorter in the 4K3D group (mean, 189.5min) than in the HD3D group (208.5min; p = 0.021), and the 4K3D group did not require conversion to thoracotomy or transfusion. The 4K3D group had less blood loss volume (4K3D group: mean, 24.0mL vs. HD3D group: 43.3mL; p = 0.105) and shorter chest drainage duration (4K3D group: mean, 2.3days vs. HD3D group: 3.1days; p = 0.115) and hospitalization period (4K3D group: mean, 7.9days vs. HD3D group:10.0days; p = 0.226) than the HD3D group, with no significant difference. No difference was observed in the incidence of ≥ Grade IIIa complications (p = 0.634). The 4K3D endoscopic system significantly shortened the duration of cVATS lobectomy. It is useful for lung resection and may replace other endoscopy systems.

The relation of body adiposity to the outcomes of thoracoscopic lobectomy for lung cancer - a single-center cohort study.

The outcomes of lung cancer surgery depend on the patients' nutritional status. Body fat percentage (BF%) is one of the indicators of body composition and nutritional status. Direct measurement of BF% is complicated, requires significant resources and is rarely performed. The CUN-BAE (Clínica Universidad de Navarra - Body Adiposity Estimator) index has been shown to accurately predict BF% is several clinical settings, but its relation to the outcomes of lung surgery has not been reported so far. To determine the relation of the BF% to the outcomes of thoracoscopic lobectomy. This retrospective study included 1,183 patients who underwent thoracoscopic lobectomy for non-small cell lung cancer between June 1999, and September 2019 at one department. BF% was calculated according to the Clínica Universidad de Navarra - Body Adiposity Estimator equation. The primary endpoints were postoperative complications and long-term survival. Univariate analysis showed that higher BF% was related to lower incidence of complications (p = 0.001), including prolonged air leak (p < 0.001), atelectasis (p < 0.05), psychosis (p < 0.001), reoperations (p < 0.05), and shorter chest drainage (p = 0.001) and hospitalization duration (p < 0.001). Multivariate analysis showed that higher BF% was correlated with lower risk of complications (p = 0.005; OR = 0.964; 95% CI: 0.940 to 0.989), including prolonged air leak (p < 0.001; OR = 0.923; 95% CI: 0.886 to 0.962), and shorter duration of chest drainage (p < 0.001; B = -0.046; 95% CI: -0.069 to -0.023) and hospitalization (p < 0.001; B = -0.112; 95% CI: -0.176 to -0.048). Cox proportional hazards regression analysis showed that BF% was not related to long-term survival. Body fat percentage is a valuable tool that can help predict the short-term outcomes of minimally lobectomy for lung cancer.

PP94 Robotic-Assisted Thoracoscopic Surgery Versus Video-Assisted Thoracoscopic Surgery And Open Thoracotomy: A Systematic Review And Meta-Analysis

IntroductionRobot-assisted surgery is one of the minimally invasive surgical approaches that has been increasingly utilized across a wide range of surgeries. However, there is limited evidence of robotic-assisted thoracic surgery (RATS) for patients with lung cancer. This study aims to evaluate the safety and effectiveness of RATS in lung cancer patients compared with video-assisted thoracoscopic surgery (VATS) and open thoracotomy.MethodsA comprehensive search for studies that compared RATS versus VATS or open thoracotomy published until 12 April 2022, was conducted. Two review authors independently assessed studies for inclusion and risk of bias, and extracted data. We used results of reported perioperative outcomes, oncological outcomes, and survival outcomes. When more than two studies contributed data, meta-analyses were performed.ResultsFour randomized controlled trials (RCT) were included. Firstly, three RCTs comparing RATS with VATS were identified. Compared with the VATS group, the RATS group had significantly lower blood loss, more harvested lymph nodes and lymph node stations. However, there were no significant differences in operative time, transfusion rates, hospital stay, drainage duration, reoperation, readmission, postoperative pain, and postoperative complications. Survival outcomes were not reported. Secondly, one RCT comparing RATS with open thoracotomy was identified. Compared with open thoracotomy group, the RATS group had significantly lower blood loss, less postoperative pain, and shorter chest drainage duration. On the other hand, there were no significant differences in operative time, hospital stay, postoperative complications, number of harvested lymph nodes and lymph node stations, and survival outcomes (disease-free survival, overall survival).ConclusionsEvidence on the effectiveness and safety of RATS compared with VATS or open thoracotomy for lung cancer is of low certainty, but we suggest that RATS is a feasible and safe alternative to conventional thoracic surgeries for lung cancer patients on the basis of current data. Additionally, more and better studies are required to provide evidence on the benefits and cost-effectiveness of RATS.

A randomized controlled trial: Comparison of 14 and 24 French thoracic drainage after minimally invasive lobectomy – MZ 14-24 study

BackgroundThe optimal placement of a chest drain after video-assisted minimally invasive lobectomy should facilitate the aspiration of air and drainage of fluid. Typically, a conventional 24Ch polyvinyl chloride chest drain is used for this purpose. However, there is currently no scientific literature available on the impact of drain diameter on postoperative outcomes following anatomical lung resection. MethodsThis is a prospective, randomized, phase-1 trial that will include 40 patients, which will be randomly assigned into two groups. Group 1 will receive a 24 French chest drain according to current standards, while group 2 will receive a 14 French drain. Primary endpoint of the trial is the incidence of postoperative drainage-related complications, such as obstruction, dislocation, pleural effusion, and reintervention. Secondary endpoints are postoperative pain, chest drainage duration, incidence of complications, and hospital length of stay. The study aims to determine the number of subjects needed to achieve a sufficient test power of 0.8 for a non-inferiority study. DiscussionThoracic surgery is becoming more and more minimally invasive. One of the remaining unresolved problems is postoperative pain, with the intercostal drain being one of the main contributing factors. Previous data from other studies suggest that the use of small-bore drains can reduce pain and speed up recovery without an increase in drain-related complications. However, no studies have been conducted on patients undergoing anatomic lung resections to date. The initial step in transitioning from larger to smaller drains is to establish the safety of this approach, which is the primary objective of this trial.Trial registration: The study has been registered in the German Clinical Trials Register.Registration number: DRKS00029982.URL: https://drks.de/search/de/trial/DRKS00029982.

A comparative study of robot-assisted thoracoscopic surgery and conventional approaches for short-term outcomes of anatomical segmentectomy

ObjectivesSince anatomical segmentectomy requires meticulous dissection of the segmental pulmonary vessels and bronchus, robot-assisted thoracoscopic surgery (RATS) has been widely adopted in recent years. We investigated the usefulness of RATS segmentectomy by comparing perioperative outcomes with conventional approaches including open thoracotomy or video-assisted thoracoscopic surgery (VATS). We compared perioperative outcomes of segmentectomy between RATS and conventional approaches including open thoracotomy or video-assisted thoracoscopic surgery (VATS).MethodsThis single-institutional retrospective study comprised 231 patients with primary lung cancer who underwent segmentectomy by RATS or conventional approaches between January 2011 and December 2022. Surgical outcomes and postoperative complications were analyzed among patients whose background factors were adjusted by propensity score matching (PSM).ResultsBefore PSM, there were significant differences in age, smoking status, and types of segmentectomy. After PSM, 126 patients (63 patients in each group) were included in this analysis. The RATS group had significantly shorter operative time (154 vs 210 min; p < 0.01), fewer bleeding amounts (10 vs 40 mL; p < 0.01), and shorter duration of chest drainage (2 vs 2 days; p = 0.04) than the conventional-approach group. There was no significant difference in the incidence of all complications; however, the incidence of postoperative pneumonia was significantly lower than in the conventional-approach group (p = 0.02).ConclusionsRATS segmentectomy is proposed to be useful. It was suggested that RATS segmentectomy may be useful with better perioperative results than the conventional approach. Further studies on oncological long-term outcomes and cost–benefit comparisons are needed.

Comparing Robotic-Assisted Thoracoscopic Surgery (RATS) vs Video-Assisted Thoracoscopic Surgery (VATS) Approaches for Non-Small Cell Lung Cancer (NSCLC): a Systematic Review and Meta-Analysis

Video-assisted thoracoscopic surgery (VATS) has demonstrated its efficacy and improved clinical outcomes as an option for early-stage non-small cell lung cancer. The development of robotic-assisted thoracoscopic surgery (RATS) has become the newest alternative to VATS. This study aims to compare VATS and RATS in terms of clinical outcomes. This Systematic Review research used the PRISMA method. RATS is proven to be an alternative with superior results compared to VATS on the Mortality in 30 days parameter (OR 0.59, 95% CI = 0.40, 0.86, I2 : 0%; p&lt;0.006) and transfusion rate (OR = 0.50; 95% CI: 0.27 - 0.92, I2: 6%; p = 0.34). There was no significant difference between the RATS vs VATS procedure in terms of duration of surgery (OR = 0.50; 95%CI: 0.27 - 0.92), and intraoperative complications (OR 1.98, 95%CI: 0.12 - 32.44) and postoperative complications (OR 1.05, 95%CI: 0.93 - 1.19). The parameters of length of stay and chest drain duration in most of the studies show that VATS requires longer treatment time and thoracic drainage time than RATS. RATS can be an alternative to minimally invasive surgery in early-stage lung cancer with a lower risk of death and transfusion requirements than VATS, but there is no difference in the duration of surgery, as well as intraoperative and postoperative complications.

Review of patients discharged post thoracic surgery with chest drain in situ and nurse-based follow-up clinic.

Persistent air leaks and prolonged drainage are recognized complications of thoracic surgery, increasing hospital stay and costs. Patients can be discharged with a chest drain and followed up in a nurse-led clinic. We reviewed such patients and the rate of readmission after discharge to assess the effectiveness of the drain follow-up clinic. We conducted a retrospective review of our prospective database spanning 22 months, from March 2019 to January 2021. The analysis focused on the indication and duration of chest drainage, complications, and readmission for any reason. 62 patients (representing 5% of all thoracic surgery patients) were discharged with a chest drain. The median age was 67 years (range 22-85 years), with 24 females and 38 males. 52% underwent video-assisted thoracoscopic surgery, 27% had a thoracotomy, and 21% had bedside chest drain insertion. Following discharge, the median duration of chest drainage was 11 days [interquartile range (IQR) 7-18.75 days]. Patients had 106 review episodes in the ward-based nurse-led clinic. The indications were prolonged air leak (71%; 72 clinic reviews), persistent fluid drainage following empyema evacuation (16%; 24 clinic reviews), and persistent fluid drainage for simple effusion (13%; 10 clinic reviews). The median length of drain stay was 30 days (IQR 19.75-54 days) for empyema, 10 days (IQR 6-16 days) for air leak, and 8 days (IQR 6.5-12 days) for simple effusion. 9 patients required readmission (14.5%), and empyema had developed in 3 patients (4.8%). Patients discharged with a chest drain in place can be followed up in a dedicated ward-based nurse-led monitoring clinic for optimal quality of care.

Non-steroidal anti-inflammatory drugs reduce pleural adhesion in human: evidence from redo surgery

Non-steroidal anti-inflammatory drugs (NSAIDs) reduced pleural adhesion in animal studies, but its effect on human had not been studied. A retrospective study was carried out for patients with solitary pulmonary nodules without a pre-operative tissue diagnosis positive for malignancy. The impact of the use of NSAIDs after stage one wedge resection was assessed by the degree of pleural adhesions encountered during second-stage, redo completion lobectomy. From April 2016 to March 2022, 50 consecutive patients meeting the inclusion criteria were included, and 44 patients were selected for analysis after exclusion (Treatment group with NSAID: N = 27; Control group without NSAID: N = 17). The preoperative characteristics and the final tumor pathologies were similar between the groups. The use of NSAID was significantly associated with lower risk of severe pleural adhesions and complete pleural symphysis (risk difference = −29%, p = 0.03). After controlling the effect of tumor size and chest drain duration, only the use of NSAID was statistically associated with the lowered risk of severe pleural adhesions and complete pleural symphysis. No statistically significant effects of NSAID on operative time (p = 0.86), blood loss (p = 0.72), and post-operative length of stay (p = 0.72) were demonstrated. In human, NSAIDs attenuated the formation of pleural adhesions after pleural disruptions. Physicians and surgeons should avoid the use of NSAIDs when pleural adhesion formation is the intended treatment outcome.

Safety and feasibility of a novel chest tube placement in uniportal video-assisted thoracoscopic surgery for non-small cell lung cancer.

The type and placement of chest tube for patients undergoing uniportal video-assisted thoracoscopic lobectomy remains controversial. The aim of this study was to assess the efficacy and safety of a novel technique in which a pigtail catheter was used alone as the chest tube and placed near the incision for chest drainage after uniportal video-assisted thoracoscopic lobectomy and extended lymphadenectomy. A total of 217 patients undergoing uniportal video-assisted thoracoscopic lobectomy were retrospectively reviewed and divided into two groups. In group A, a 12-Fr pigtail catheter with several side ports was placed next to the uniportal wound. In group B, a conventional 20-Fr chest tube was placed through the uniportal wound itself. Postoperative complications related to chest tube placement and patients' subjective satisfaction were compared between the two groups. Postoperative pain management effect and other clinical outcomes such as duration of chest drainage and postoperative stay were also compared. There were 112 patients in group A and 105 patients in group B. A significantly lower incidence of wound complications was found in group A postoperatively (p = 0.034). The pain score on coughing in group A was significantly lower than that in group B on postoperative day two (POD2) (p = 0.021). There was no significant difference of other clinical outcomes such as duration of chest drainage and postoperative stay as well as major complications between the two groups. Placing a 12-Fr pigtail catheter alone next to the uniportal wound for chest drainage might be effective and safe after uniportal video-assisted thoracoscopic lobectomy and extended lymphadenectomy.

Aggressive intraoperative warming and postoperative pulmonary complications in elderly patients recovering from esophageal cancer surgery: sub-analysis of a randomized trial.

Elderly patients having esophagectomies often become hypothermic which may promote complications. We tested the hypothesis that aggressive warming to a core temperature of 37°C reduces postoperative pulmonary complications (PPCs) in elderly patients having esophageal cancer resections. This study was a pre-defined sub-study of a multi-center, parallel group, superiority trial (PROTECT). Patients aged >65 years and having elective radical resection of esophageal cancer in a single center were randomly allocated into either aggressive warming group (target intraoperative core temperatures of 37°C) or routine thermal management group (target intraoperative core temperatures of 35.5°C). The primary endpoint was the incidence of PPCs. Secondary endpoints included duration of chest tube drainage and other postoperative complications. A total of 300 patients were included in the primary analysis. PPCs occurred in 27 (18%) of 150 patients in the aggressive warming group and 31 (21%) of 150 patients in the routine thermal management group. The relative risk (RR) of aggressive versus routine thermal management was 0.9 (95% CI: 0.5, 1.4; p = 0.56). The duration of chest drainage in patients assigned to aggressive warming was shorter than that assigned to routine thermal management: 4 (3, 5) days vs. 5 (4, 7) days; hazard ratio (HR) 1.4 [95% CI: 1.1, 1.7]; p = 0.001. Fewer aggressively warmed patients needed chest drainage for more than 5 days: 30/150 (20%) vs. 51/150 (34%); RR:0.6 (95% CI: 0.4, 0.9; p = 0.03). The incidence of other postoperative complications were similar between the two groups. Aggressive warming does not reduce the incidence of PPCs in elderly patients receiving esophagectomy. The duration of chest drainage was reduced by aggressive warming. But as a secondary analysis of a planned sub-group study, these results should be considered exploratory. https://www.chictr.org.cn/showproj.aspx?proj=37099, ChiCTR1900022257.

Robot-assisted thoracic surgery versus video-assisted thoracic surgery for mediastinal lesions.

Robot-assisted thoracic surgery (RATS) has become widely used for mediastinal procedures since 2018 when it was included in insurance coverage in Japan. Few studies have compared the surgical outcomes of RATS with the more established video-assisted thoracic surgery (VATS) approach to mediastinal surgery. We aimed to compare the perioperative outcomes of VATS and RATS to examine the advantages of the RATS approach in a single institutional cohort. A total of 144 patients who underwent VATS and 46 who underwent RATS mediastinal surgery between 2014 and 2022 were enrolled. We compared clinicopathological features such as age, sex, smoking history, respiratory function, surgical field, laterality, surgical procedure, board certification of the surgeon, and histology between the two groups. Perioperative outcomes including operation time, volume of blood lost, number of conversion cases to open surgery, duration of chest drainage, postoperative hospital stay, and postoperative complications were also reviewed. The comparison of patient characteristics between the groups showed significant differences in median age (VATS, 52.5 years; RATS, 67.0 years; P=0.001), combined resection of surrounding tissues of the tumor (VATS, 2.1%; RATS, 10.9%; P=0.02), board certification of the surgeon (VATS, 53.5%; RATS, 100.0%; P<0.001), and histology (RATS group had a higher percentage of thymic epithelial tumors, P=0.01). Regarding perioperative outcomes, the median operation time was 120 min in the VATS group and 88 min in the RATS group, showing a significant difference (P=0.03). There were no significant differences in the volume of blood lost, incidence of conversion to open chest surgery, duration of chest drainage, postoperative length of stay in hospital, and incidence of perioperative complications. In the perioperative outcomes of cases operated on by board-certified surgeons, the median operation time (VATS, 117 min; RATS, 88 min; P=0.02) and median postoperative length of stay in hospital (VATS, 7 days; RATS, 6 days; P=0.001) showed significant differences, while other postoperative outcomes were not significantly different. RATS for mediastinal surgery is as safe as the VATS approach and may result in a shorter operative time and postoperative hospital stay. Further analysis of RATS for mediastinal surgery in a larger cohort is warranted.