Lung Resection In Patients Research Articles

Perioperative Anti-Fibrotic Treatment Prevents Acute Exacerbation of Idiopathic Pulmonary Fibrosis After Lung Cancer Surgery.

The surgical treatment of concomitant lung cancer in patients with idiopathic pulmonary fibrosis is challenging due to the risk of life-threatening complications such as acute exacerbation development in the perioperative period. Few studies have investigated the role of anti-fibrotic drugs in this setting. The aim of this multicenter retrospective study was to evaluate the incidence of acute exacerbation, according to Collard, after lung resection in patients affected by concomitant idiopathic pulmonary fibrosis and lung cancer who were or were not on antifibrotic treatment. Secondary outcomes included: 30 and 90-day mortality and an estimation of overall and disease-free survival. The study population consisted of patients affected by idiopathic pulmonary fibrosis who received curative-intent lung surgery in three Italian academic centers between 2015 and 2022. Patients were divided into two groups based on whether they were on perioperative treatment with anti-fibrotic drugs (chronical or prophylactic use) or not. To define predictors of acute exacerbation, univariate and multivariable exact logistic regression analysis were performed. The Kaplan-Meier method with log-rank test was used to estimate survival. During the study period, n = 55 patients underwent lung resection for lung cancer, including 29 patients who were treated with antifibrotic agents. Although the sample size was small and few events were studied, the incidence of acute exacerbation was significantly lower among patient on anti-fibrotic therapy (3.4% vs. 23.1%, p = 0.044); in addition, anti-fibrotic treatment was the strong factor preventing acute exacerbation at the multivariable analysis (OR 0.089, p = 0.038). Post-operative 30- and 90-day mortality rates were not significantly lower in the anti-fibrotic treatment group (0% and 0% vs. 7.7% and 11.5%, p = 0.21 and p = 0.099, respectively). Overall and disease-free survival rates were similar. Considering the limitations of this retrospective study with a small sample size, anti-fibrotic perioperative treatment was associated with reduced incidence of acute exacerbation. Based on these real-world data, this pathway could be proposed as a prophylactic treatment in patients with concomitant idiopathic pulmonary fibrosis and cancer undergoing lung resection.

Feasibility of video-assisted thoracoscopic surgery as a redo chest approach for lung resection in patients with a history of surgical procedures on the same side.

Thoracic surgeons are increasingly facing situations for which patients are eligible for iterative thoracic surgery. With growing experience in minimally invasive thoracic surgery, the question of the safety and feasibility of minimally invasive redo procedure is rising. Our study aims to report the results of video-assisted thoracoscopic surgery (VATS) as surgical approach for reintervention after a previous ipsilateral intrathoracic surgery. This retrospective monocentric observational study required review of medical files of patients undergoing minimally invasive ipsilateral redo surgery between 2018 and 2023. Operative data, morbidity, and mortality were studied. Thirty-eight patients underwent redo-VATS for pulmonary resection. Of these, 22 (57.9%) were males, with a mean age of 66±12.2 years. Primary procedures included lung cancer resection (n=32, 84%) [lobectomy (n=8, 21.1%), segmentectomy (n=4, 10.5%), wedge resection (n=20, 52.6%)], lung transplantation (n=2, 5.3%), esophagectomy (n=1, 2.6%), thoracic aortic bypass (n=1, 2.6%), empyema (n=1, 2.6%), and chemical pleurodesis (n=1, 2.6%). The median duration between surgeries was 30 (range, 2-99) months. Redo-VATS resection included lobectomy (n=21, 55.3%), segmentectomy (n=3, 7.9%), and wedge resection (n=14, 36.8%). The median operating time was 153 (range, 30-287) min. Intraoperative blood loss was less than 200 mL in 34 (89.5%) cases. The conversion rate was 13.2% secondary to pulmonary artery injuries (n=2) and difficulties in dissection and exposure (n=3). Thirty-day mortality was 0%. Median chest drainage time was 3 (range, 1-37) days, median hospital stay was 5 (range, 3-24) days. redo-VATS lung tumor resection has been demonstrated as a safe and feasible approach with an acceptable conversion risk and morbidity. These encouraging results should question the indication for a systematic open surgical approach in this situation.

Features and outcomes of bilateral anatomical lung resections in patients with lung cancer

The aim of this study was to evaluate the feasibility and safety of sequential bilateral anatomical lung resections performed via video-assisted thoracic surgery (VATS) or thoracotomy approaches in lung cancer patients, as well as to identify factors affecting the postoperative period. Material and Methods. Of 534 NSCLC patients undergoing anatomical lung resection in Center for Intensive Pulmonology and Thoracic Surgery from 2014 to 2022, 14 patients with consecutive bilateral anatomical lung resections were included in the retrospective study. The patients were divided into two groups depending on a surgical approach used during the first surgery: group I – 5 patients underwent thoracotomy and group II – 9 patients underwent videoassisted thoracic surgery (VATS). The groups were matched for gender, age, smoking, Charlson Comorbidity Index, lung resection, functional status and stage of the disease. Surgical treatment included anatomical lung resection and ipsilateral systematic lymph dissection. Results. There were significant differences in intraoperative blood loss between the groups. Postoperative complications after surgery on the contralateral lung were observed more often in group 1 patients than in group II patents. The overall 5-year survival rates in patients of groups 1 and 2 were 60 % and 86 %, respectively. Respiratory function indicators three months after surgery corresponded to preoperative prognosis, and their decrease did not depend on the surgical approach used. In comparison with patients who underwent standard unilateral lung resection, bilateral anatomical lung resection was not associated with increased number of “major” complications, however, an increase in the frequency of prolonged air discharge was noted (26 % vs 6 %; p<0.05). Conclusion. Sequential bilateral anatomical lung resections are feasible and safe after thorough preoperative assessment of the functional reserves of the cardio-respiratory system. Mini-invasive technologies make it possible to reduce the frequency of complications in the early postoperative period. The use of the VATS approach makes it possible to safely perform anatomical resection of the contralateral lung.

Walking or breathing: comparing the 6-minute walking distance test to the pulmonary function test for lung resection candidates.

Given the limited use of the 6-minute walking distance (6MWD) test as a replacement for standard tests in thoracic surgery, insufficient research exists on the prognostic value of this test, and further studies are necessary. This study aimed to investigate the correlation between pulmonary function tests (PFT) and the 6MWD test in lung resection patients. This cross-sectional study, conducted in 2021-2022, involved lung resection candidates referred to the thoracic surgery clinic. Demographic data, including age, sex, and body mass index (BMI), were collected, and pulmonary function tests and 6MWD tests were conducted for all patients. The sample size of the study was 31, and all patients received routine treatment during hospitalization. Of the 31 subjects included in the study, 16 were male (51.6%) and 15 (48.4%) were female. The mean age of the patients was 33.45±13.78 years. The median forced expiratory volume in one second (FEV1) and the mean ratio of FEV1/forced vital capacity (FVC) were 2.16 (1.49-2.85) liters and 81.80±7.34%, respectively. No significant correlation was found between the results of 6MWD and PFT, including FVC, FEV1, and FEV1/FVC ratio (P>0.05). The 6MWD test is a more economical and easily accessible test than PFT. However, this study found no correlation between the 6MWD test and spirometry parameters. Therefore, we suggest that surgeons should not rely on the 6MWD test as a predictive value for assessing respiratory function in lung resection candidates. The study's findings have important implications for clinical practice.

Risk factors and prognostic analysis of right ventricular dysfunction after lung resection for NSCLC.

Lung cancer is the leading cause of cancer death, and 80-85% of all lung cancer cases are non-small cell lung cancer (NSCLC). Surgical resection is the standard treatment for early-stage NSCLC. However, lung resection, a surgical procedure, can result in complications and increased mortality. Recent studies have shown a significant correlation between complications after lung resection and right ventricular dysfunction. Transthoracic echocardiography-derived right ventricular-pulmonary artery coupling (RV-PAC) was utilized to assess right ventricular function in these patients. Multivariate logistic regression analysis was also conducted to assess risk factors independently associated with RV-PA uncoupling. The 3- and 5-year cumulative survival rates were estimated with Kaplan-Meier curves, and differences between groups were analyzed using the Mantel-Cox log-rank test. RV-PA uncoupling was defined as a TAPSE/PASP value < 0.67 mm/mm Hg according to spline analysis. The results of multivariable logistic regression analysis indicated that diabetes is an independent risk factor for right ventricular dysfunction after lung resection in patients with NSCLC. Kaplan-Meier analysis revealed a significant decrease in the survival rate of patients with RV-PA uncoupling at both the 3-year follow-up (73% vs 40%, p < 0.001) and 5-year follow-up (64% vs 37%, p < 0.001). After lung resection for NSCLC, the patient's right ventricular function predicts prognosis. Patients with right ventricular dysfunction, particularly those with diabetes mellitus, have a worse prognosis. It is crucial to actively prevent and correct risk factors to reduce the mortality rate in these patients.

Predictive significance of systemic immune-inflammation index combined with prealbumin for postoperative pneumonia following lung resection surgery

BackgroundWe aimed to determine whether systemic immune-inflammation index (SII) combined with prealbumin can provide better predictive power for postoperative pneumonia in patients undergoing lung resection surgery.MethodsWe identified eligible patients undergoing lung resection surgery at the Affiliated Hospital of Nantong University from March 2021 to March 2022. Demographic characteristics, clinical data, and laboratory information were collected and reviewed from the electronic medical records of the patients. To test the effect of the combined detection of SII and prealbumin, we made an equation using logistic regression analysis. The receiver operating characteristic curve (ROC) was plotted to evaluate the predictive powers, sensitivity, and specificity of prealbumin, SII, and SII combined with prealbumin. Decision curve analysis (DCA) was used to determine the clinical validity and net benefit of different methods of detection.ResultsTotally 386 eligible patients were included with a median age of 62.0 years (IQR: 55.0, 68.0), and 57 (14.8%) patients presented with postoperative pneumonia within 7 days after surgery. The multivariate regression analysis showed that preoperative SII as continuous variable was associated with an increased risk of postoperative pneumonia (OR: 1.38, 95% CI: 1.19–2.83, P = 0.011), whereas the prealbumin as continuous variable remained as an independent protective predictor of postoperative pneumonia in the adjusted analysis (OR: 0.80, 95% CI: 0.37–0.89, P = 0.023). Compared to SII or prealbumin, the combined detection of preoperative SII and prealbumin showed a higher predictive power with area under curve of 0.79 (95% CI: 0.71–0.86, P < 0.05 for all). Additionally, DCA indicated that the combined detection was superior over preoperative SII or prealbumin alone in clinical validity and net benefit.ConclusionBoth preoperative SII and prealbumin are independent influencing factors for postoperative pneumonia after lung resection surgery. The combined detection of preoperative SII and prealbumin can significantly improve prediction capability to identify potential postoperative pneumonia-susceptible patients, facilitating early interventions to improve postoperative quality of life for surgical lung resection patients.

Robotic-Assisted Bronchoscopy for the Diagnosis of Lung Lesions: Experience With the Use of Frozen Sections as an Aid to Confirm the Localization of Lesions During the Procedure.

Robotic-assisted navigation bronchoscopy (R-ANB) is used to target peripheral pulmonary nodules that are difficult to biopsy using conventional approaches. Frozen sections are requested to confirm these lesions have been localized and/or to diagnose neoplasms that can be immediately resected. To estimate diagnostic concordance between frozen section diagnosis (FSD) and formalin-fixed tissue diagnosis (FFTD) in biopsies obtained with R-ANB, calculate the sensitivity and specificity of FSD and FFTD for a diagnosis of malignancy, and evaluate whether the residual tissue that can be fixed in formalin after frozen section still has sufficient material for molecular studies. The results of consecutive FSD rendered on biopsies performed with R-ANB during a 30-month period were used to calculate the metrics listed above. FFTD and/or the diagnoses rendered on computed tomography-guided core biopsy subsequently performed in patients with negative R-ANB and/or lung resections in patients with malignancies were used as true-positive results. The overall concordance between FSD and FFTD in 226 lesions from 203 patients was 72%. Frozen section diagnosed 76 of 123 malignancies with 100% specificity and 68% sensitivity. Adequate material was available in 92% of biopsies where next-generation sequencing and other molecular studies were requested. Intraoperative consultations are helpful to diagnose a variety of lung lesions and help surgeons confirm that targets have been accurately reached by R-ANB. Malignancies can be diagnosed with 100% specificity but only 68% sensitivity. The performance of frozen section did not interfere with the subsequent analysis of tissue with molecular studies in most cases.

Physical activity in patients with non-small cell lung cancer after lung resection

BackgroundLung resection is the standard of care for patients with clinical stage I/II non-small cell lung cancer. This surgery reduces both the duration and quality of patients' daily ambulatory activities 1 month after surgery. However, little is known about physical activity after lung resection in patients with lung cancer. To evaluate the recovery process of physical activity with pulmonary rehabilitation in patients after lung resection and examine whether physical activity is affected by age. MethodsIn this prospective, observational study, we measured and analysed participants' postoperative physical activity using a uniaxial accelerometer daily from postoperative day 1 to 30. FindingsWe analysed 99 patients who underwent thoracic surgery. The number of walking steps significantly increased until day 4 and then reached a plateau thereafter. The duration of exercise at <3 metabolic equivalents significantly increased until day 3, and no significant difference was observed thereafter. Exercise at >3 metabolic equivalents significantly increased until day 4 and reached a plateau thereafter. A significant correlation was observed between age and number of steps after day 4. Compared with video-assisted thoracoscopic surgery, thoracotomy significantly decreased the number of steps from day 3 to 4. InterpretationWe found that the level of physical activity varied by index in patients with non-small cell lung cancer who underwent lung resection. Age and surgical procedure affect different periods with the increase in post-operative walking steps.

Safety of lung resection surgery after severe acute respiratory syndrome coronavirus 2 infection in the post-vaccination era.

To investigate the postoperative outcomes of lung resection in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and determine the optimal timing of surgery. This retrospective, single-centre cohort study included patients who underwent lung resection between June 2021 and June 2022. Patients were divided into the coronavirus disease 2019 (COVID-19) and non-COVID-19 groups based on their preoperative SARS-CoV-2 infection history, and postoperative outcomes were compared. Logistic regression analysis was conducted to identify the risk factors of complications after lung resection surgery. In total, 1194 patients were enrolled, of whom, 79 had a history of SARS-CoV-2 infection. In the COVID-19 group, 66 patients (90.4%) had received at least 1 vaccination dose. The average interval between infection and surgery was 67 days, with no significant impact on postoperative outcomes. Regarding postoperative outcomes, there were no significant differences in major complication rate (6.3% vs 5.4%, P = 0.613), respiratory complication rate (19.0% vs 12.2%, P = 0.079) or length of stays (4.9 ± 3.4 vs 5.0 ± 5.6, P = 0.992) between the 2 groups. Multivariate logistic regression analysis revealed that age, male sex, poor pulmonary function test, open surgery and extensive lung resection were risk factors for postoperative complications, while preoperative COVID-19 infection status was not a statistically significant risk factor. In the post-vaccination era, lung resection surgery can be safely performed shortly after SARS-CoV-2 infection, even within 4 weeks of infection.

Time between imaging and surgery is not a risk factor for upstaging of clinical stage IA non-small-cell lung cancer.

The timing of preoperative imaging in patients with lung cancer is a debated topic, as there are limited data on cancer progression during the interval between clinical staging by imaging and pathological staging after resection. We quantified disease progression during this interval in patients with early stage non-small-cell lung cancer (NSCLC) to better understand if its length impacts upstaging. We retrospectively reviewed our institutional database to identify patients who underwent surgery for clinically staged T1N0M0 NSCLC from January 2015 through September 2022. Tumour upstaging between chest computed tomography (CT) and surgery were analysed as a function of time (<30, 30-59, ≥60 days) for different nodule subtypes. We analysed data across 3 timeframes using Pearson's chi-squared and analysis of variance tests. During the study period, 622 patients underwent surgery for clinically staged T1N0M0 NSCLC. CT-to-surgery interval was <30 days in 228 (36.7%), 30-59 days in 242 (38.9%) and ≥60 days in 152 (24.4%) with no differences in patient or nodule characteristics observed between these groups. T-stage increased in 346 patients (55.6%) between CT imaging and surgery. Among these patients, 126 (36.4%) had ground-glass nodules, 147 (42.5%) had part-solid nodules and 73 (21.1%) had solid nodules. CT-to-surgery interval length was not associated with upstaging of any nodule subtype (full-cohort, P = 0.903; ground-glass, P = 0.880; part-solid, P = 0.858; solid, P = 0.959). This single-centre experience suggests no significant association between tumour upstaging and time from imaging to lung resection in patients with clinical stage IA NSCLC. Further studies are needed to better understand the risk factors for upstaging.

Qualitative assessment of expectations on the content, form and way of delivery of a prehabilitation programme in patients with lung resection surgery - A Swiss tertiary centre experience.

To assess the interest in a prehabilitation programme of patients awaiting lung resection and to identify expectations from such a programme. At present, in Switzerland, there are no multimodal clinical prehabilitation programmes for lung resection patients awaiting surgery. Semi-structured face-to-face interviews were conducted with patients who have had or were awaiting lung resection at a Swiss tertiary centre. Thematic analysis was performed to identify common prespecified themes. Twenty-two patients (45.5% female, age 70.6 ± 16.6 years) were interviewed. Seventy-seven percent were interested in a prehabilitation programme. Sixty-two percent, 67% and 90% were interested in endurance, strength and respiratory training, respectively. Six patients (27%) were active smokers, of whom two (one-third) were interested in a smoking cessation programme. Seventy-six percent were interested in nutrition counselling and 90% in receiving education on risk factor management. Forty percent preferred centre-based training/counselling sessions, 20% preferred home-based training/counselling and 30% found both forms acceptable. Patients were willing to perform prehabilitation activities on 2.6 days/week for a total of 162 min/week. Participating in peer groups was desired by only 25%. Patients with lung resection were highly interested in participating in prehabilitation, albeit only for a mean time cost of 2.7 h per week. Offering a prehabilitation programme with a combination of in-hospital group sessions and home-based training seems feasible.

Lung resection after initial nonoperative treatment for non–small cell lung cancer

ObjectivesThe study objectives were to assess the outcomes of lung resection in patients with non–small cell lung cancer previously treated with nonoperative treatment and to identify prognostic factors associated with survival. MethodsPatients who underwent surgery (2010-2022) after initial nonoperative treatment at a single institution were identified from a prospectively maintained database. Exclusion criteria included metachronous cancer, planned neoadjuvant therapy, and surgery for diagnostic or palliative indications. Cox models were constructed for overall survival and event-free survival. Survival of patients with stage IV disease was compared with survival of a nonstudy cohort who did not undergo surgery. ResultsIn total, 120 patients met the inclusion criteria. Initial clinical stage was early stage in 16%, locoregionally advanced in 25%, and metastatic in 59% of patients. The indication for surgery was recurrence in 18%, local persistent disease in 23%, oligoprogression in 22%, and local control of oligometastatic disease in 38% of patients. Grade 3 or greater complications occurred in 5% of patients; 90-day mortality was 3%. Three-year event-free survival and overall survival were 39% and 73%, respectively. Male sex and lymphovascular invasion were associated with shorter event-free survival and overall survival; younger age and prior radiation therapy were associated with shorter overall survival. Patients with stage IV disease who received salvage lung resection had better overall survival than similar patients who received subsequent systemic therapy and no surgery. ConclusionsIn this selected, heterogeneous population, lung resection after initial nonoperative treatment for non–small cell lung cancer was safe. Surgery as local consolidative therapy was associated with encouraging outcomes and should be considered for these patients.

Effects of lung resection on heart structure and function: A tissue Doppler ultrasound survey of 43cases.

Changes in heart structure and function after lung resection in patients with lung cancer are challenging to manage. Therefore, a non-invasive and reliable measurement tool to gauge such changes is critical. The purpose of the present study was to compare cardiological changes before and after lung resection using tissue Doppler imaging (TDI). A total of 43 patients (19 men and 24 women) with primary non-small cell lung cancer (n=37) and metastatic cancer in the lungs (n=6) were enrolled in the study.nTDI was used to determine the thickness of the ascending aorta, the open size of the ascending valve, the anterior-oposterior diameters of the left atrium and left ventricle, and the thickness of the ventricular septum and right ventricle before and after lung resection. Left ventricular (LV) ejection fraction (EF), pulmonary valve flow rate, tricuspid annular or mitral leaflet tip early (E) peak/late (A) diastolic blood flow velocities, tricuspid regurgitation flow, the lateral mitral annulus early (e') diastolic velocity and mitral E/e' ratio were used to determine LV filling pressure. Results revealed no significant differences between male and female patients in terms of the open size of the ascending valve, the anterior-posterior diameter of the left ventricle and the mitral E/e' ratio. Significant differences were found in the width of the ascending aorta, anterior-posterior diameter of the left atrium, width of the LV septum and right ventricular (RV) diameter before and after lung resection. Finally, there were significantchanges in EF and tricuspid pressure. The results indicated that TDI was useful as a non-invasive method for assessing left and right heart function following lung resection. The LV and RV dimensions were affected, but LV filling pressure was preserved after lobectomy.

EP07.01-10 Risk assessment of severe pulmonary complications leading to death or oxygen therapy after lung resection in patients with primary lung cancer

EP07.01-10 Risk assessment of severe pulmonary complications leading to death or oxygen therapy after lung resection in patients with primary lung cancer

Hyperoxemia post thoracic surgery – Does it matter?

IntroductionPost-operative oxygen therapy is used to prevent hypoxemia and surgical site infection. However, with improvements of anesthesia techniques, post-operative hypoxemia incidence is declining and the benefits of oxygen on surgical site infection have been questioned. Moreover, hyperoxemia might have adverse effects on the pulmonary and cardiovascular systems. We hypothesized hyperoxemia post thoracic surgery is associated with post-operative pulmonary and cardiovascular complications. MethodsConsecutive lung resection patients were included in this post-hoc analysis. Post-operative pulmonary and cardiovascular complications were prospectively assessed during the first 30 post-operative days, or hospital stay. Arterial blood gases were analyzed at 1, 6 and 12 h after surgery. Hyperoxemia was defined as arterial partial pressure of oxygen (PaO2)>100 mmHg. Patients with hyperoxemia duration in at least two adjacent time points were considered as hyperoxemic. Student t-test, Mann-Whitney U test and two-tailed Fisher exact test were used for group comparison. P values < 0.05 were considered statistically significant. ResultsThree hundred sixty-three consecutive patients were included in this post-hoc analysis. Two hundred five patients (57%), were considered hyperoxemic and included in the hyperoxemia group. Patients in the hyperoxemia group had significantly higher PaO2 at 1, 6 and 12 h after surgery (p < 0.05). Otherwise, there was no significant difference in age, sex, comorbidities, pulmonary function tests parameters, lung surgery procedure, incidence of post-operative pulmonary and cardiovascular complications, intensive care unit and hospital length of stay and 30-day mortality. ConclusionHyperoxemia after lung resection surgery is common and not associated with post-operative complications or 30-day mortality.

Video-assisted thoracic surgery is associated with faster delivery to adjuvant chemotherapy after lung resection in patients with lung cancer

BackgroundRapid recovery after surgery is especially important for patients who are scheduled for adjuvant therapy.This study aimed to investigate the effect of video-assisted thoracic surgery (VATS) on chemotherapy referral time and chemotherapy tolerance in patients who underwent lung resection for non-small cell lung cancer.MethodsThe data of 612 patients who underwent lung resection with the diagnosis of non-small cell lung cancer in our clinic between January 2014 and December 2021 were reviewed. Patients who underwent lobectomy or bilobectomy with systematic mediastinal lymph node dissection and who received at least one cycle of adjuvant chemotherapy were included in the study. The characteristics of the patients, pathological data, postoperative follow-up findings, and the time between the operation and adjuvant chemotherapy were recorded.ResultsA total of 144 patients who met the criteria were included in the study. The mean age was 61.6 ± 7.9 years. The mean visual analogue scale scores were found to be lower, and the length of hospital stay was found to be shorter in the VATS group compared to thoracotomy.The mean time (days) to initiate chemotherapy after surgery was statistically shorter in the VATS group (48.9 ± 17.6 vs 58.1 ± 27.6, p = 0.049). However, there weren't seen any statistical differences between VATS and thoracotomy groups in terms of mean cycle completed, percentage of planned regimen received, and grade ≥ 3 toxicity rates (p = 0.16, p = 0.18, and p = 0.22, respectively).ConclusionsVATS provides faster recovery compared to open surgery and shortens the time for patients to refer to adjuvant chemotherapy.

Clinical Indicators of Effects of Yoga Breathing Exercises on Patients With Lung Cancer After Surgical Resection: A Randomized Controlled Trial.

Cancer itself and surgery pose a heavy burden on adults with lung cancer. Yoga breathing exercises have been proposed as a form of pulmonary rehabilitation exercises to improve these patients' perioperative outcomes. To investigate the impact of yoga breathing exercises based on a problem-solving model on dyspnea, exercise capacity, anxiety, depression, and postoperative indwelling time of thoracic drainage tube and compliance in adults with lung cancer undergoing surgery. One hundred eight lung cancer patients were randomly assigned to receive problem-solving model-based yoga breathing exercises, yoga breathing exercises, or usual care. Outcomes were collected at admission, the day before surgery, and at discharge. Patients in the combined intervention group showed a significantly greater improvement in dyspnea, exercise capacity, and anxiety compared with the control group. Yoga breathing training can significantly improve patients' dyspnea and anxiety. Significant difference favoring the combined group was observed in exercise capability and compliance between the 2 intervention groups. However, there was no significant difference in depression or indwelling time of thoracic drainage tube among the 3 groups at any time point. Findings indicate that yoga breathing exercises are effective in alleviating perioperative symptoms of lung resection patients. Compared with yoga breathing exercises, applying additional problem-solving model may achieve a better effect. Yoga breathing exercises can be considered as a promising pulmonary rehabilitation strategy for lung cancer patients with surgery. The problem-solving model could be integrated into yoga breathing exercises in clinical practice to enhance the rehabilitation effect.

N-Acetylcysteine and Postoperative Atrial Fibrillation: Reply.

We thank Dr. Kinoshita and Dr. Kawashima,1 and Dr. Wen, Dr. Huang, and Dr. Li2 for their comments and their interest in our work. In the comments from Kinoshita and Kawashima,1 they speculate that exposing our patients to a high fraction of inspired oxygen during one-lung ventilation negated the potential antioxidant effects of N-acetylcysteine during the 48 h after surgery. In our study, N-acetylcysteine was started only 1 to 2 h after the patient arrived at the postanesthesia care unit, where they had been receiving oxygen, by nasal cannula in most cases and occasionally by face mask, with varying degrees of inspired oxygen (typically in the range of 30 to 40%). In our practice, oxygen administration is usually titrated off as long as the patient is able to maintain an oxygen saturation measured by pulse oximetry greater than 94% on room air. Most lung-resection patients at our center are ambulating the day after surgery; among the patients in our study,3 some were discharged from the hospital upon completion of 48 h of N-acetylcysteine or placebo infusions. Although Dr. Kinoshita’s and Dr. Kawashima’s work in experimental animals is very interesting, it cannot be assumed that these findings apply to humans, nor is it warranted to speculate on which of the mechanisms that they identify apply to postoperative patients.Dr. Wen, Dr. Huang, and Dr. Li suggest the performance of a subgroup analysis by surgical modailty.2 However, because of the small number of patients within the groups and the lack of power to do so, we did not perform a secondary subgroup analysis of the incidence of atrial fibrillation by type of surgery, whether open or minimally invasive. We have previously shown that the extent of lung resection affects the incidence of atrial fibrillation, and it is for this reason that we included patients who underwent anatomical lung or esophageal resection.4 However, on the basis of our work—and the recommendations from the American Association for Thoracic Surgery task force on this topic—we disagree that the side of surgery affects the incidence of atrial fibrillation.5,6 We also disagree with the authors’ assertion that our finding of a lack of effect for N-acetylcysteine on inflammatory or oxidative stress markers is attributable to a lack of power. First, the number of patients in each of the randomized groups in our study was not small, and both groups were well balanced in terms of demographic and surgical characteristics. Second, all patients participated in an institutional enhanced recovery pathway and received similar intraoperative and postoperative opioid analgesics. Finally, the inflammatory and oxidative marker data were well distributed and did not require log transformation before statistical analysis. Considering that our use of N-acetylcysteine or placebo was intravenous over the course of 48 h and was started in the postanesthesia care unit long after intraoperative drugs, such as dexmedetomidine, were used, we do not believe that these pharmacologic agents influenced our findings.Support was provided solely from institutional and/or departmental sources.Dr. Jones serves as a consultant for AstraZeneca (Cambridge, United Kingdom) and on a Clinical Trial Steering Committee for Merck (Kenilworth, New Jersey). The other authors declare no competing interests.

Surgical Management of Primary Spontaneous Pneumothorax Without Lung Bullae

IntroductionPrimary spontaneous pneumothorax (PSP) is a relatively common disease. Different studies have been published but lung resection, when no emphysema-like changes (ELC) are detected, is unclear. The aim of our study is to retrospectively investigate the role of lung resection of the apex of the lung in patients with no ELC. MethodsThis is a retrospective multicenter study of 516 patients who underwent surgical treatment of PSP with no ELC between January 2007 and December 2017. Patients were divided into two groups: pleurodesis alone group, only mechanical pleurodesis performed (53 patients), and apical resection group, apical resection of the lung and mechanical pleurodesis performed (463 patients). The following were the primary end points considered: recurrence rate and perioperative complications; the following were the secondary end points considered: length of stay, chest tube removal, residual pleural space, prolonged air leak, and reoperation rate. ResultsNo differences were found in the baseline and operative characteristics of the two groups. Both primary end points were statistically different: recurrence rate (15.1% versus 6.5%, P = 0.023) and perioperative complications (18.9% versus 7.3%, P = 0.004). Among secondary end points length of stay (6.94 versus 5.55, P = 0.033) and prolonged air leak (15.1% versus 4.3%, P = 0.001) were statistically different. On multivariate analysis, lung resection emerged as a protective factor for recurrence (hazard ratio 0.182, P < 0.001). ConclusionsIn our experience, apical lung resection in patients without ELC may reduce recurrence rate and perioperative complications when compared with pleurodesis alone.

Pulmonary vein stump thrombosis after lung resection for lung cancer: clinical features and outcome.

Pulmonary vein stump thrombosis (PVST) is uncommonly encountered postoperative in-situ thrombosis in the stump of pulmonary veins after lung resection. Data regarding the incidence and clinical behaviour of PVST are scarce. Thus, this study aims to investigate the incidence, clinical characteristics and outcome of PVST after lung resection in patients with lung cancer. Follow-up enhanced chest computed tomography (CT) scans acquired after the surgery were retrospectively reviewed to determine PVST presence for patients with lung cancer who underwent lung resection in two tertiary referral centres. Out of the 1885 patients with lung cancer who underwent lobectomy or more extensive lung resection, PVST was observed in 37 patients (2.0%) on their follow-up chest CT. Most stump thrombi were observed in the left superior pulmonary vein [35 (94.6%)] and in patients who underwent left upper lobectomy [34 (91.9%)]. At the last CT follow-up of each patient, 33 (89.2%) exhibited complete resolution, three partial resolution and one stabilization. Eleven (29.7%) patients received anticoagulant therapy after the diagnosis. The rate of complete PVST resolution did not differ significantly between the anticoagulation and nonanticoagulation groups. None of the PVST patients experienced systemic embolic events, regardless of anticoagulation. The PVST incidence diagnosed at routine chest CT follow-up following lung cancer surgery was 2%. PVST was characterized by a benign clinical course without progression and systemic embolization, regardless of anticoagulation. However, further studies are required to determine individualized therapeutic strategies, including anticoagulation.