Japanese Association For Chest Surgery Research Articles

Investigation of the Current Surgical Practice in Patients with Thymic Epithelial Tumors Among Board-certified Surgeons of the Japanese Association for Chest Surgery: Does a Discrepancy Exist Between Clinical Practice Guidelines and Clinical Practice?

Investigation of the Current Surgical Practice in Patients with Thymic Epithelial Tumors Among Board-certified Surgeons of the Japanese Association for Chest Surgery: Does a Discrepancy Exist Between Clinical Practice Guidelines and Clinical Practice?

The efficacy of thoracoscopic surgery for descending necrotizing mediastinitis.

Thoracotomy is a reliable approach for descending necrotizing mediastinitis (DNM), and the use of video-assisted thoracic surgery (VATS), a minimally invasive procedure, has been increasing. However, which approach is more effective for DNM treatment is controversial. We analysed patients who underwent mediastinal drainage via VATS or thoracotomy, using a database with DNM from 2012 to 2016 in Japan, which was constructed by the Japanese Association for Chest Surgery and the Japan Broncho-esophagological Society. The primary outcome was 90-day mortality, and the adjusted risk difference between the VATS and thoracotomy groups using a regression model, which incorporated the propensity score, was estimated. VATS was performed on 83 patients and thoracotomy on 58 patients. Patients with a poor performance status commonly underwent VATS. Meanwhile, patients with infection extending to both the anterior and posterior lower mediastinum frequently underwent thoracotomy. Although the postoperative 90-day mortality was different between the VATS and thoracotomy groups (4.8% vs 8.6%), the adjusted risk difference was almost the same, -0.0077 with 95% confidence interval of -0.0959 to 0.0805 (P = 0.8649). Moreover, we could not find any clinical and statistical differences between the 2 groups in terms of postoperative 30-day and 1-year mortality. Although patients who underwent VATS had higher postoperative complication (53.0% vs 24.1%) and reoperation (37.9% vs 15.5%) rates than those who underwent thoracotomy, the complications were not serious and most could be treated with reoperation and intensive care. The outcome of DNM treatment does not depend on thoracotomy or VATS.

The C-reactive protein to albumin ratio is a prognostic factor for stage I non-small cell lung cancer in elderly patients: JACS1303.

To establish the prognostic significance of C-reactive protein (CRP) and albumin in octogenarians with non-small cell lung cancer (NSCLC) based on the study of the Japanese Association for Chest Surgery (JACS 1303). A total of 618 octogenarians with pathological stage I NSCLC, who underwent pulmonary resection, were included in the analysis. We conducted multivariable Cox regression analysis to evaluate the CRP to albumin ratio (CAR) as a potential prognostic factor. Other clinicopathological factors were also evaluated. The median age was 82years. Operations included lobectomy (n = 388; 62.8%) segmentectomy (n = 95; 15%), and wedge resection (n = 135; 22%). Pathological stage IA was diagnosed in 380 (61.5%) patients. The 3-year (OS) and cancer-specific survival (CS) rates were 86.7% and 94.6%, respectively. OS was significantly higher for patients with low CAR (< 0.106) than for those with high CAR (≥ 0.106) (hazard ratio = 3.13, 95% confidence interval: 1.99-4.93, p < 0.0001). Univariate analysis identified sex, poor performance status, smoking status, comorbidity, solid tumor, histology, high Glasgow prognostic scale, and high CAR as significant prognostic factors. Multivariate analysis identified only the CAR as a significant prognostic factor for both OS and CS. Our analysis of the nationwide data demonstrated that the CAR is a useful prognostic factor for elderly patients with stage I NSCLC.

MA17.02 Visualization of Patterns of Lymph Node Metastases in Non-Small Cell Lung Cancer Using Network Graph Analysis

We visualized complicated patterns of lymph node metastases in surgically resected non-small cell lung cancer. Preliminary results will be presented in Japanese at the 38th Annual Meeting of the Japanese Association for Chest Surgery on May 2021 and in English at this conference.

Descending necrotizing mediastinitis and the proposal of a new classification

ObjectiveWe aimed to clarify the clinical features and surgical outcomes of descending necrotizing mediastinitis (DNM) to provide a guide for its surgical treatment, focusing on the type of extension and the deployed procedures. MethodsAs a joint study of the Japan Broncho-esophagological Society and the Japanese Association for Chest Surgery (JBES1703/JACS1806 study), the clinical data of consecutive patients with DNM who underwent surgical drainage between 2012 and 2016 were collected from 131 participating institutions. The infection limited to the area superior to the carina level was defined as type I; while spreading to the lower mediastinum (LM) as type II. The LM infection limited to the anterior LM, that spread to both the anterior and posterior LM and that limited the posterior LM (type IIC) were further categorized as type IIA, IIB, and IIC, respectively. ResultsA total of 225 patients were ultimately eligible. One hundred patients (44.4%) were categorized as type I, whereas 125 patients were type II (56.6%); The number of type IIA, IIB, and IIC cases was 20 (16%), 62 (49.6%) and 43 (34.4%), respectively. Patients with type I and IIC infections more commonly underwent cervical drainage than patients with type IIA and IIB infections (34.3% and 13.4%, respectively). A total of 8 patients died within 30 days (3.6%, type I/II: 1/7). The 5-year overall survival rate was 68.6%. Type II infection was associated with the 90-day mortality (odds ratio, 5.18; P = .045). ConclusionsThis study demonstrated a previously unclassified group of lower mediastinal extent that is localized within the posterior mediastinum (type IIC). We proposed a new DNM classification including type IIC mediastinitis.

System for thymic disease research and clinical practice in Japan.

Japanese Association for Research of the Thymus (JART) established by emeritus professor Akira Masaoka is a cross-sectional association of physicians and researchers and have worked in clinical and basic research on thymic neoplasms and thymus-related diseases in collaboration with The Japanese Surgical Society (JSS), Japanese Association for Chest Surgery (JACS), Japanese Association for Thoracic Surgery (JATS), Japan Lung Cancer Society (JLCS), Japanese Respiratory Society (JRS) and Japanese Association for Respiratory Endoscopy (JARE). JART has performed several clinical trials, and the most important establishment of JART in recent days is the project of the nation-wide retrospective database of thymic epithelial tumors, which contributed to UICC TNM staging. Currently, JART is building the prospective database in collaboration with the Japanese Joint Committee for Lung Cancer Registry (JJCLCR).

Presidential address for 36th Annual Conference of Japanese Association for Chest Surgery (JACS)

Presidential address for 36th Annual Conference of Japanese Association for Chest Surgery (JACS)

Presidential Lecture of the Japanese Association for Chest Surgery in 2019

The Japanese Association for Chest Surgery, JACS, was established in 1984. The Japanese Association for Thoracic Surgery, JATS, was founded in 1964 by thoracic surgeons, but cardiovascular surgeon came to occupy a large number, and it was necessary to establish a society exclusively for thoracic surgeon. And we use the name “Chest” instead of “Thoracic” for the academic society, because abdominal surgeons do esophageal surgery in Japan. In this meaning, thoracic surgery usually means chest surgery in Japan. Both cardiovascular surgeons and thoracic surgeons are members of the Japan Surgery Society, JSS. JSS has about 40,000 members, and JACS accounts for about 8% of the JSS membership.

How to identify and divide an intersegmental plane in uniportal VATS segmentectomy

The number of patients with non-small cell lung cancer (NSCLC) underwent pulmonary segmentectomy is increasing worldwide because minimally invasive surgery is recently preferable in order to maintain quality of life, especially for preserving postoperative pulmonary function, in patients although lobectomy is the gold standard for the treatment of NSCLC (1,2). In patients’ prognosis, large retrospective study from Japanese Association for Chest Surgery (JACS) revealed favorable results of the 5-year overall (94%) and cancer free survival rates (93.7%) for patients with clinical stage IA undergoing sublobar resections (3). Moreover, in the prospective randomized trial, Suzuki and colleagues described the patients undergoing pulmonary segmentectomy had the equivalent results of postoperative complications with the patients undergoing lobectomy except for more frequency of prolonged air leakage (4). The report finally concluded that segmentectomy will be a standard treatment if the superior pulmonary function and noninferiority in overall survival are confirmed.

Summary of 36th Annual Conference of Japanese Association for Chest Surgery (JACS)

The 36 th annual conference of the Japanese Association for Chest Surgery (JACS) was held on May 16 th and 17 th at Osaka International Convention Center, Osaka City, Japan. I am honored to be given this opportunity report a summary of the conference in the current issue of Journal of Visualized Surgery .

Venous thromboembolism prophylaxis in thoracic surgery patients: an international survey.

Venous thromboembolic events (VTE) after thoracic surgery (TS) can be prevented with mechanical and chemical prophylaxis. Unlike other surgical specialties, TS lacks evidence-based guidelines. In the process of developing these guidelines, an understanding of the current prophylaxis methods practiced internationally is necessary and is described in this article. A 26-item survey was distributed to members of the European Society of Thoracic Surgeons (ESTS), American Association of Thoracic Surgery (AATS), Japanese Association for Chest Surgery (JACS) and Chinese Society for Thoracic and Cardiovascular Surgery (CSTCS) electronically or in person. Participants were asked to report their current prophylaxis selection, timing of initiation and duration of prophylaxis, perceived risk factors and the presence and adherence to institutional VTE guidelines for patients undergoing TS for malignancies. In total, 1613 surgeons anonymously completed the survey with an overall 36% response rate. Respondents were senior surgeons working in large academic hospitals (≥70%, respectively). More than 83.5% of ESTS, AATS and JACS respondents report formal TS thromboprophylaxis protocols in their institutions, but 53% of CSTCS members report not having such a protocol. The regions varied in the approaches utilized for VTE prophylaxis, the timing of initiation perioperatively and the use and type of extended prophylaxis. Respondents reported that multiple risk factors and sources of information impact their VTE prophylaxis decision-making processes, and these factors vastly diverge regionally. There is little agreement internationally on the optimal approach to thromboprophylaxis in the TS population, and guidelines will be helpful and vastly welcomed.

STS, ESTS and JACS survey on surveillance practices after surgical resection of lung cancer.

A 1995 survey of Society of Thoracic Surgeons (STS) members revealed wide variation in postresection lung cancer surveillance practices and pessimism regarding any survival benefit. We sought to compare contemporary practice patterns and attitudes among members of STS, European Society of Thoracic Surgeons (ESTS) and the Japanese Association for Chest Surgery (JACS). A survey identical to the one conducted in 1995 was administered via mail or electronically. χ2 tests for associations were used to compare profiles of respondents and attitudes towards testing between groups. All the statistical tests were two-sided and P-values of 0.05 or less were considered statistically significant. A total of 2978 STS members (response rate 7.8%, n = 234), 1450 ESTS members (response rate 8.4%, n = 122) and 272 JACS (response rate 40.8%, n = 111) members were surveyed. Rate of guideline-recommended surveillance computed tomography was reported highest among ESTS respondents for stage I patients (22% ESTS, 3% STS and 6% JACS members, P < 0.001). However, both JACS and ESTS respondents reported higher rates of use of non-guidelines-recommended tests compared to STS respondents, which persisted on adjusted analyses. Regarding attitudes towards surveillance, more JACS and ESTS members either 'agree' or 'strongly agree' that routine testing for non-small-cell lung cancer recurrence results in potentially curative treatment (ESTS: 86%, STS: 70%, JACS: 90%, P < 0.001). Similarly, JACS and ESTS respondents believe that the current literature documents definitive survival benefits from routine follow-up testing (ESTS: 57%, STS: 30%, JACS: 62%, P < 0.001). The Japanese attitude towards surveillance is similar to that of ESTS members potentially highlighting significant differences between European and Asian surgeons compared to STS members. These differences clearly highlight the need for better prospective studies and joint recommendations to globally standardize practice.

The maximum dimension of the inferior vena cava is a significant predictor of postoperative mortality in lung cancer patients with idiopathic interstitial pneumonia.

Several vascular measurements in computed tomography (CT) were reported to be indicators of pulmonary hypertension in chronic obstructive pulmonary disease (COPD) patients. We evaluated the usefulness of these parameters as predictors of postoperative mortality in lung cancer patients with IIP. This retrospective study was performed on 1888 patients. The following CT findings were evaluated: diameter of the main pulmonary artery, ascending aorta, and the short axis of the inferior vena cava (IVC). Univariate and multivariate analyses were conducted to determine predictors of surgical mortality. In the IIP patients, the 90-day mortality was 0.8%, and the 2-year mortality was 5.8%. Regarding the 90-day mortality in patients with IIP, a multivariate analysis revealed a short axis of IVC > 21mm [odds ratio (OR) 6.4, p < 0.01) and the risk score reported by Japanese Association for Chest Surgery (JACS) (OR 1.4, p = 0.01) as independent predictors. Regarding the 2-year mortality in patients with IIP, a multivariate analysis revealed IVC > 21mm (OR 2.3, p < 0.04), %VC < 80% (OR 2.4, p = 0.02), and pathological cancer stages II and III vs. I (OR 7.2, p < 0.001) as independent predictors. Enlargement of the IVC as measured by CT was a significant predictor of mortality after surgery for lung cancer with IIP patients.

Modified risk scoring system for acute exacerbation of interstitial lung disease.

Lung cancer patients with interstitial lung disease often develop acute exacerbation of their interstitial lung disease after lung resection. Special care is needed in selection of the surgical procedure to reduce acute exacerbation and provide long-term survival. The Japanese Association for Chest Surgery devised a risk scoring system based on 7 risk factors to predict the probability of postoperative acute exacerbation. We excluded surgical procedures and used a modified system categorizing 4 groups: group A (risk score 0-6), group B (risk score 7-10), group C (risk score 11-14), and group D (risk score 15-18). We retrospectively examined 60 lung cancer patients with interstitial lung disease to determine whether the modified risk scoring system is useful for selecting the optimal surgical procedure in anticipation of curability and risk of postoperative acute exacerbation. Eight (13.3%) patients experienced postoperative acute exacerbation. In group A ( n = 20), there was no difference in the incidence of acute exacerbation between wedge (0%) and anatomic resection (6.3%, p = 0.800). In group B ( n = 40), the incidence was significantly higher after anatomic resection (5.0% vs. 30.0%, p = 0.046). Thus group A had high-quality outcomes with anatomic resection, and in group B, the incidence of postoperative acute exacerbation can be reduced if wedge resection is performed. Our modified risk scoring can be useful for selecting the optimal surgical procedure in anticipation of curability and the risk of acute exacerbation of interstitial lung disease after lung cancer surgery.

A proposal for a comprehensive risk scoring system for predicting postoperative complications in octogenarian patients with medically operable lung cancer: JACS1303.

Although some retrospective studies have reported clinicopathological scoring systems for predicting postoperative complications and survival outcomes for elderly lung cancer patients, optimized scoring systems remain controversial. The Japanese Association for Chest Surgery (JACS) conducted a nationwide multicentre prospective cohort and enrolled a total of 1019 octogenarians with medically operable lung cancer. Details of the clinical factors, comorbidities and comprehensive geriatric assessment were recorded for 895 patients to develop a comprehensive risk scoring (RS) system capable of predicting severe complications. Operative (30 days) and hospital mortality rates were 1.0% and 1.6%, respectively. Complications were observed in 308 (34%) patients, of whom 81 (8.4%) had Grade 3-4 severe complications. Pneumonia was the most common severe complication, observed in 27 (3.0%) patients. Five predictive factors, gender, comprehensive geriatric assessment75: memory and Simplified Comorbidity Score (SCS): diabetes mellitus, albumin and percentage vital capacity, were identified as independent predictive factors for severe postoperative complications (odds ratio = 2.73, 1.86, 1.54, 1.66 and 1.61, respectively) through univariate and multivariate analyses. A 5-fold cross-validation was performed as an internal validation to reconfirm these 5 predictive factors (average area under the curve 0.70). We developed a simplified RS system as follows: RS = 3 (gender: male) + 2 (comprehensive geriatric assessment 75: memory: yes) + 2 (albumin: <3.8 ng/ml) + 1 (percentage vital capacity: ≤90) + 1 (SCS: diabetes mellitus: yes). The current series shows that octogenarians can be successfully treated for lung cancer with surgical resection with an acceptable rate of severe complications and mortality. We propose a simplified RS system to predict severe complications in octogenarian patients with medically operative lung cancer. JACS1303 (UMIN000016756).

Perioperative management in myasthenia gravis: republication of a systematic review and a proposal by the guideline committee of the Japanese Association for Chest Surgery 2014.

Thymectomy is regarded as a useful therapeutic option for myasthenia gravis (MG), though perioperative management in MG patients is largely empirical. While evidence-based medicine is limited in the perioperative management of MG patients, treatment guidelines are required as a benchmark. We selected issues faced by physicians in clinical practice in the perioperative management of extended thymectomy for MG, and examined them with a review of the literature. The present guidelines have reached the stage of consensus within the Japanese Association for Chest Surgery.

Video-assisted thoracic surgery for lung cancer: republication of a systematic review and a proposal by the guidelines committee of the Japanese Association for Chest Surgery 2014.

Patients with early-stage non-small cell lung cancer (NSCLC) are candidates for surgical intervention with curative intent. For these early-stage lung cancer surgeries, video-assisted thoracic surgery (VATS) is considered. The purpose of this article is to propose a recommendation for this according to the evidence and provide information for patients with operable early-stage lung cancer from the Japanese Association for Chest Surgery. The clinical question here is whether VATS lobectomy is recommended for patients with clinical stage I NSCLC. The Japanese Association for Chest Surgery guidelines committee reviewed and summarized the available literature and assessed the quality of the evidence. The available literature on VATS was examined using references from MEDLINE. The recommendations were provided according to the Medical Information Network Distribution Service in Japan (Minds). VATS lobectomy may be considered and applied to patients with clinical stage I NSCLC; however, well-established evidence is lacking. VATS showed better or at least equivalent outcomes regarding intra- or postoperative complications compared with thoracotomy, with less invasiveness. Additionally, long-term survival by VATS lobectomy was suggested to be at least equivalent, although there is a lack of evidence. VATS lobectomy by an experienced surgeon is associated with minimal invasiveness and an outcome equivalent to that of open lobectomy in stage I NSCLC. (Recommendation grade: Level C1).

Risk assessment of lung resection for lung cancer according to pulmonary function: republication of systematic review and proposals by guideline committee of the Japanese association for chest surgery 2014.

This manuscript provides preoperative physiologic assessments for patients considered for surgical resection of lung cancer. Medical studies of risk assessment of surgical resection for lung cancer according to pulmonary function were collected and a review article was written to present guidelines. Preoperative physiologic assessment should begin with a cardiovascular evaluation, and spirometry to measure FEV 1 and the diffusing capacity of carbon monoxide (DLCo). Predicted postoperative (ppo) lung functions should also be calculated. If both %ppo-FEV 1 and %ppo-DLCo values are ≥ 60%, the patient is considered to be at low risk for anatomic lung resection. If either of those are <60% of the predicted value, an exercise test should be performed for screening. If performance on the exercise test is acceptable, the patient is regarded to be at low risk for anatomic resection. These findings can be summarized as an algorithm. Careful preoperative physiologic assessment is useful for identifying patients at increased risk for standard lung cancer resection and enabling informed decisions by the patient about an appropriate therapeutic approach for their lung cancer.

Clinical relevance of decreased oxygen saturation during 6-min walk test in preoperative physiologic assessment for lung cancer surgery

The Japanese Association for Chest Surgery (JACS) has released guidelines on preoperative physiologic assessment for lung cancer surgery. However, cardiopulmonary exercise testing (CPET), which is recommended for patients with poor pulmonary function, is available only in limited institutions. We investigated the possibility of 6-min walk test (6MWT) as a substitute of maximum oxygen consumption test (VO(2)max) on preoperative physiologic assessment for lung cancer surgery. The relationship between VO(2)max and 6MWT was retrospectively analyzed in 51 subjects other than lung cancer patients. Following the preliminary analysis, we modified the risk assessment in the JACS guidelines by substituting 6MWT for VO(2)max, and patients who underwent lung cancer surgery were retrospectively assessed using the modified assessment. Analysis of the correlation between VO(2)max and 6MWT revealed VO(2)max to be significantly correlated to minimum SpO(2) (SpO(2)min) and maximum decrease in SpO(2) (ΔSpO(2)) during 6MWT. Receiver operating characteristic analysis revealed that SpO(2)min and ΔSpO(2) were predictable for a VO(2)max of 15 mL/kg/min, which is the borderline between the average- and increased-risk groups in the JACS guidelines. A total of 1,066 patients were assigned to the average- or increased-risk group according to the modified JACS guidelines using the criteria of SpO(2)min < 91 % and ΔSpO(2) > 4 %. The increased-risk group was significantly inferior to the average-risk group in Home Oxygen Therapy induction rate, cardiopulmonary-related 30- and 90-day mortality (p < 0.001). In clinical practice, decreased saturation during 6MWT may be simple and substitutive for CPET in risk assessment for lung cancer surgery using the JACS guidelines.

日本呼吸器外科学会総合診療対策委員会報告呼吸器外科領域の医療材料アンケート調査結果

日本呼吸器外科学会総合診療対策委員会報告呼吸器外科領域の医療材料アンケート調査結果