Thoracoscopic Pulmonary Resection Research Articles

Preoperative non-invasive visual localization of synchronous multiple lung cancers using three-dimensional computed tomography lung reconstruction

BackgroundSynchronous multiple primary lung cancers are becoming more common with increasing use of computed tomography for screening. Intraoperative localization and resection of ill-defined pulmonary ground-glass opacities during thoracoscopic resection is challenging. This study aimed to determine the clinical feasibility of non-invasive visual localization of these nodules by three-dimensional computed tomography lung reconstruction before sublobar resection.MethodsForty-four patients with synchronous multiple primary lung cancers underwent thoracoscopic pulmonary resection at our institution between June 2017 and August 2019. Preadmission computed tomography images were downloaded and reconstructed into a three-dimensional model. Small nodules (< 15 mm) were localized non-invasively by three-dimensional computed tomography lung reconstruction before surgery. Patient demographics, nodule characteristics, procedural details, pathological data, and outcomes were obtained from the medical records.ResultsOne hundred and twenty-one pulmonary nodules from the 44 patients were scheduled for video-assisted thoracic surgery; 54 (44.6%) were pure ground-glass opacities and 57 (47.1%) were mixed ground-glass opacities. One hundred and seventeen nodules were localized preoperatively. The mean nodule diameter was 7.67 ± 3.87 mm. The mean distance from the nodule to the pleura was 14.84 ± 14.43 mm. All nodules were removed successfully by wedge resection (27 patients), lobectomy (26 patients), or segmentectomy (25 patients). Most lesions (85.1%) were malignant. Paraffin pathology revealed 12 cases of atypical adenomatous hyperplasia (9.92%), 13 of adenocarcinoma in situ (10.74%), 16 of minimally invasive adenocarcinoma (13.22%), and 73 of invasive adenocarcinoma (60.33%).ConclusionsThree-dimensional computed tomography lung reconstruction is a feasible and alternative method of visual localization for small lung nodules before sublobar resection in some suitable patients.

Clinical Application of Three-Dimensional Reconstruction Technique in Thoracoscopic Pneumonectomy

Objective. To investigate the clinical value of 3D computed tomography bronchoangiography (3D CTBA) in thoracoscopic anatomical lung segment resection or combined lung segment resection. Methods. The clinical data of 25 patients with non-small-cell lung cancer who underwent thoracoscopic radical lobectomy and pulmonary segmentectomy with pulmonary nodules were retrospectively analyzed. All patients underwent preoperative thin-slice CT scan, and the bronchus, pulmonary artery, and pulmonary vein were reconstructed by DeepInsight software. Meanwhile, pulmonary nodules, tumors, or enlarged lymph nodes were reconstructed. Accurate preoperative planning was carried out through preoperative reconstruction of three-dimensional images, especially the variation of pulmonary bronchus and blood vessels, the relationship between tumors and enlarged lymph nodes and pulmonary blood vessels, and the precise positioning of pulmonary nodules in pulmonary segments. Compared with preoperative three-dimensional reconstruction, intraoperative real-time navigation can achieve accurate operation. The intraoperative conversion to thoracotomy, operative time, intraoperative bleeding and postoperative hospitalization time, drainage tube removal time and total drainage volume, and the incidence of perioperative complications were recorded. Results. The anatomical structure and variation of bronchus and pulmonary vessels were clearly reconstructed in all patients, and the reconstruction of the relationship between central tumor and enlarged lymph nodes and blood vessels was satisfactory. The location of pulmonary nodules in pulmonary segments was clearly defined, and preoperative planning was performed accurately. All patients underwent real-time intraoperative navigation, and precise surgery was performed according to the preoperative planning. The operation was successfully completed without any transfer to thoracotomy or intraoperative accidental bleeding. The operative time was (147.60 ± 37.77) min, the intraoperative blood loss was (33.82 ± 22.17) mL, the postoperative hospital stay was (7.02 ± 1.78) d, drainage tube removal time was (4.68 ± 1.60) d, and postoperative total drainage volume was (221.00 ± 135.03) mL; there were no severe complications and no death during perioperative period. Conclusion. The application of three-dimensional reconstruction technique for preoperative evaluation and subsequent thoracoscopic pulmonary segmental resection can achieve accurate, safe, and effective pulmonary segmental resection, reduce the difficulty of thoracoscopic pulmonary segmental resection, reduce the risk of surgery, and improve the surgical effect.

Electromagnetic navigation bronchoscopy localization of lung nodules for thoracoscopic resection.

BackgroundThoracoscopic localization of small peripheral pulmonary nodules is a concern. Failure can lead to larger parenchymal resection or conversion to thoracotomy. This study evaluates our experience in preoperative electromagnetic navigation bronchoscopy-guided localization of small peripheral lung lesions.MethodsFrom January 2017 to March 2020 clinical, radiographic, surgical, and pathological data of patients who underwent electromagnetic navigation bronchoscopy (ENB)-guided methylene blue pleural marking of highly suspected pulmonary lesions before a full thoracoscopic resection were evaluated. Localization was performed for solid or mixed subpleural nodules measuring <10 mm, solid nodules measuring <20 mm located at more than 1 cm from the pleura and any pure ground glass opacity. Successful localization was defined as successful identification and thoracoscopic resection of target lesions.ResultsForty-eight patients were included: 30 solid nodules (63%), 12 pure GGO (25%) and 6 mixed (13%). The median largest diameter at CT-scan was 11 mm (IQR, 9–14 mm) while the median distance from the pleural surface was 12 mm (IQR, 6–16 mm). The median ENB length was 25 min (19–33 min). Localization procedure was successful in 45 cases (94%). No procedural-related complications were reported.ConclusionsENB is a safe and accurate preoperative procedure to localize small lung peripheral lesions. The high successful rate, the absence of related complications, the possibility of performing the procedure in the same operating room with a single general anesthesia, make ENB-guided dye marking an advantageous tool for thoracoscopic pulmonary resection.

Risk factors for postoperative nausea and vomiting after thoracoscopic pulmonary wedge resection: pitfalls of an increased fentanyl dose.

BackgroundThoracoscopic pulmonary wedge resection (TPWR) is a surgical procedure that can maintain lung function and is less physically invasive to a patient. However, the risk factors for postoperative nausea and vomiting (PONV) following TPWR remain unknown. We aimed to evaluate multiple risk factors of PONV after TPWR and the impact of PONV on postoperative outcomes.MethodsWe retrospectively reviewed consecutive patients who underwent TPWR for malignant pulmonary tumors at our institution between October 2017 and March 2020. We assessed the differences in the clinical and perioperative parameters between the PONV and non-PONV groups.ResultsWe reviewed 160 patients, of whom 27 (16.9%) had PONV. Sixteen (59.3%) patients with PONV required postoperative antiemetics. Failed mobilization was associated with PONV requiring postoperative antiemetics (P=0.048). In the multivariate analysis, increased fentanyl dose was an independent risk factor for PONV (P=0.022). Using the receiver operating characteristic curve, the optimal cut-off value for PONV was 3.58 µg/kg/hr (area under the curve =0.665; sensitivity =85.2%; specificity =53.4%; 95% confidence interval: 0.562–0.768; P=0.007). For example, in a case of a 50-kg patient who underwent a 70-min operation (our median operative time), the total dose of fentanyl within 208 µg was the cut-off value for preventing PONV.ConclusionsAn increased dose of fentanyl/kg/h was the strongest risk factor for PONV during TPWR. The optimal cut-off value for PONV was 3.58 µg/kg/hr. It is important to avoid the inadvertent administration of intraoperative fentanyl.

Prevalence and Predictors of Bacterial Contamination in Excisional Lymph Node Biopsies: Implications for Diagnosis and Management.

Routine tissue handling exposes lymph node specimens to microbial contamination that can confound microbiological culture results and interfere with diagnosis. The scope and impact of this problem remain poorly understood. We combined over 13 years of lymph node pathology, culture data, and patient records to define the prevalence, predisposing factors, microbiology, and clinical management of false-positive lymph node cultures at a large academic medical center. Nearly one third (31.9%) of 216 cultured lymph nodes yielded bacterial growth. Approximately 90% of positive bacterial cultures grew 1 of 2 common skin-resident taxa-coagulase-negative Staphylococcus and Cutibacterium acnes-with well-documented predispositions for contamination in other clinical settings. Lymph nodes excised from axillary, cervical, and inguinal regions yielded higher positive culture rates than nodes excised from the mediastinum, suggesting proximity to the skin surface may increase contamination risk. Accordingly, cultures from thoracoscopic pulmonary resections displayed contamination rates over 5-fold lower than those from percutaneously accessed lymph nodes. Lymph nodal tissue allocated for culture in the operating room yielded unexpectedly high contamination rates, significantly higher than cultures sent from the frozen section processing area. A significant minority of contamination events were noted in the clinical record and prompted antibiotic therapy on multiple occasions. Collectively, our results illuminate the risk factors contributing to bacterial contamination and argue that routine lymph node bacterial cultures provide minimal clinical benefit for adult patients. This widespread bacterial contamination also warrants cautious implementation of increasingly sensitive molecular microbiology tools for excised tissues.

Variations in the branching patterns of pulmonary artery during thoracoscopic pulmonary resection.

The knowledge of variations in the branching patterns of pulmonary artery may have important clinical implications in the field of thoracic surgery. At the Department of Thoracic Surgery of Monaldi Hospital in Naples, between January 2017 and December 2019, 569 anatomic pulmonary resections via video-assisted thoracic surgery, including lobectomy and segmentectomy, were performed. Among the 569 thoracoscopic pulmonary resections, 24 variations in the branching patterns of pulmonary artery were identified and documented. Anatomic variations on the left were more frequent than on the right. This paper, providing a summary of vascular anomalies identified during major lung resections, could help surgeons avoid intraoperative complications, especially during minimally invasive procedures where the visual field is more restricted than open surgery.

A retrospective comparative study of thulium laser and mechanical stapler in pulmonary wedge resection under thoracoscopy.

This retrospective study aimed to evaluate the safety and efficacy of thulium laser pulmonary wedge resection under thoracoscopy. Sixty cases of thoracoscopic pulmonary wedge resection by thulium laser and sixty cases with mechanical stapler from February 2015 to September 2018 were selected. The operation time, intraoperative hemorrhage, postoperative hospital stay, severe air leaks, drainage time, and complications (including postoperative hemorrhage, hemoptysis, atelectasis, and pulmonary infection) were compared between groups. The thulium laser group showed a lower incidence of intraoperative hemorrhage (10.0 [5.0-20.0] ml vs. 15.0 [10.0-50.0] ml, P = 0.010) and a shorter postoperative hospital stay (3.9 ± 2.5 days vs. 4.9 ± 2.0 days, P = 0.031).There was no significant difference between groups in the operation time, postoperative drainage time, the occurrence of severe air leaks, or complication rate (P > 0.05). No patients were lost during follow?up (median follow?up time: 28.4 months, range: 18.0-36.0 months). No statistically significant difference in overall survival was found (P = 0.547). pulmonary wedge resection with thulium laser under thoracoscopy had better safety, less damage, and higher accuracy compared with the control group.

Association Between Intercostal Nerve Block and Postoperative Glycemic Control in Patients With Diabetes Undergoing Video-Assisted Thoracoscopic Pulmonary Resection: A Retrospective Study

The present study was performed to investigate the possible association between intercostal nerve block (INB) and postoperative glycemic control in patients with diabetes undergoing video-assisted thoracoscopic pulmonary resection. A retrospective study. Single-center tertiary academic hospital. Patients with diabetes, ages 18 to 79 years, who had undergone elective video-assisted thoracoscopic pulmonary resection (segmentectomy or lobectomy) from January 1, 2015, to December 31, 2018. Postoperative blood glucose levels and insulin dosage were extracted from the record. Patients with diabetes who received INB before closure of surgical incisions were compared with those who did not receive INB. The primary outcome was the daily blood glucose (BG) level. Univariate analyses and multivariate regression analysis were performed to explore risk factors of hyperglycemia within 48 hours after the surgery. Baseline characteristics were comparable between the two groups. Patients who received INB had a lower maximum BG level and amplitude of glycemic excursion from zero-to-24 hours after surgery (p = 0.007 and p = 0.041, respectively) and lower maximum and minimum BG levels from 24-to-48 hours after surgery (p = 0.023 and p = 0.006, respectively). Meanwhile, the daily insulin dose increment during zero-to-24 hours and 24-to-48 hours after surgery decreased (p = 0.010 and p = 0.003, respectively), the white blood cell counts within 48 hours after surgery were lower (p = 0.021), and the length of postoperative stay decreased in the INB group (p = 0.044). Multivariate regression analysis further confirmed that INB was an independent protective factor of postoperative hyperglycemia (Nagelkerke R2 value 0.229; odds ratio 0.298; 95% confidence interval 0.099-0.901; p = 0.032). INB, performed before closure of surgical incisions, was associated with improved glycemic control in patients with diabetes within 48 hours after video-assisted thoracoscopic pulmonary resection.

Intrathoracic use of a small ultrasonic probe for localizing small lung tumors in thoracoscopic surgery: Empirical results and comparison with preoperative CT images.

To evaluate the use of a small mobile ultrasound probe to localize small lung tumors during thoracoscopic surgery under thoracic CO2 insufflation. We prospectively enrolled 20 patients (26 tumors) scheduled to undergo thoracoscopic pulmonary wedge resection between April 2016 and October 2018. Ultrasonographic tumor detection was performed with an ARIETTA 850 and L51K probe (Hitachi, Tokyo, Japan). Ultrasonography was repeated after achieving adequate lung collapse under a positive intrathoracic pressure of 8-15mmHg. The appearance on preoperative CT versus the ultrasonographic localization was compared for each tumor. The receiver operating characteristic curves were compared for the tumor dimension of the lung window, consolidation dimension of the lung window, tumor dimension of the mediastinal window (MD), and tumor depth from the lung surface. The average age was 62years (range 42-79years), average pathological tumor size was 9mm (range 3-22mm), and average tumor depth was 6mm (range 1-25mm). Although no tumors could be visualized before lung collapse, 22 tumors (85%) were detectable with ultrasonography after lung collapse. Of these 22 tumors, 16 were well-depicted, while six were poorly delineated. MD showed the largest area under the receiver operating characteristic curve (0.81), and tumors with a MD of ≤ 6mm had a high risk of difficult localization using ultrasonography. This ultrasonographic method obtained high tumor detection rates, especially for tumors with a MD > 6mm. Tumors with a MD ≤ 6mm may require another localization method. University Hospital Medical Information Network Clinical Trials Registry (UMIN000036921).

Magnetic Anchor Technique Assisting with Video-Assisted Thoracoscopic Pulmonary Wedge Resection: A Clinical Study from China

Yan, Xiaopeng MD, PhD; Li, Yixing MD; Zhang, Yong MD, PhD; Lyu, Yi FACS, MD, PhD Author Information

Predictive factors of cough after uniportal video-assisted thoracoscopic pulmonary resection.

BackgroundCough is one of the shared complications after lung surgery. In this study, a prospective analysis was conducted for exploring the risk factors of persistent cough after uniportal video-assisted thoracoscopic pulmonary resection.MethodsOne hundred thirty-five patients with pulmonary nodules who underwent surgical treatment in the same surgical group from November 2019 to January 2020 were enrolled in this prospective study. The severity of cough and its impact on patients’ quality of life before and after surgery were assessed by the Mandarin Chinese version of the Leicester cough questionnaire (LCQ-MC), and postoperative cough was tested by the cough visual analog scale (VAS) and cough symptom score (CSS). Risk factors of cough after pulmonary resection (CAP) were determined by univariate and multivariate logistic regression analysis.ResultsThe incidence of postoperative cough was 24.4% (33 of 135 patients). Univariate analysis showed that gender (female), the surgical site (upper right), the resection (lobectomy), subcarinal lymph node dissection, postoperative acid reflux, length of hospitalization contributed to the development of CAP resection. Multivariate logistic regression analysis showed that the resection (lobectomy) (OR 3.590, 95% CI: 0.637–20.300, P=0.017), subcarinal lymph node dissection (OR 4.420, 95% CI: 1.342–14.554, P=0.001), postoperative acid reflux (OR 13.55, 95% CI: 3.186–57.633, P<0.001) and duration of anesthesia (over 153 minutes, OR 0.987, 95% CI: 0.978–0.997, P=0.011) were independent risk factors for postoperative cough.ConclusionsThe application of uniportal video-assisted thoracoscopic techniques to several types of lung surgery are conducive to enhanced recovery after surgery (ERAS). Postoperative cough is related to an ocean of factors, the resection (lobectomy), subcarinal lymph node dissection, postoperative acid reflux, and duration of anesthesia (over 153 minutes) are independent high-risk factors for CAP resection.Trial registrationThis study was registered on ClinicalTrials.gov (NCT04204148).

Perioperative Outcomes of Thoracoscopic Reoperations for Clinical Recurrence of Pulmonary Malignancy

The utility of thoracoscopic lung surgery is well established, however, reoperation for pulmonary resections has not been thoroughly studied. We sought to evaluate patient perioperative outcomes following redo thoracoscopic pulmonary resections for malignancy by comparing first and second ipsilateral operations. We included patients undergoing redo thoracoscopic pulmonary resections for clinically recurrent disease following prior lung resection for malignancy from January 1, 2011 to May 31, 2019. Nonmalignant indications were excluded. We analyzed type of procedure, diagnosis, rate of conversion to open, estimated blood loss, operating time, margin status, length of stay and complications. Forty-one patients met our inclusion criteria. The median age was 68 years (range 13-84) and 20 were women. Redo operations had longer lengths of stay with a trend toward higher rate of conversion to thoracotomy, but other perioperative outcomes were similar. No difference in outcomes was seen when patients were grouped by indication for reoperation (recurrence, multiple primaries, and metastasis) or approach of first operation (VATS vs open). However, patients undergoing an anatomic resection after a prior anatomic resection had more complications, higher blood loss, higher rate of conversions to thoracotomy, significantly longer length of stay and longer operative times than nonanatomic resections. Thoracoscopic reoperation for recurrent, metachronous, or metastatic cancer to the lung is a reasonable approach. However, the surgeon must recognize and counsel patients that in patients undergoing a redo anatomic resection, thoracoscopic reoperations are more difficult with more adverse outcomes.

Feasibility of injecting Fluorescent Agent under the Guidance of Electromagnetic Navigation Bronchoscopy in Pulmonary Nodule Resection

背景与目的临床上肺内体积小，位置深且无实性成分的结节在电视辅助胸腔镜手术下切除给外科医生带来很多挑战。本研究的目前在于探讨经磁导航支气管镜（electromagnetic navigation bronchoscope, ENB）引导下肺部结节注入吲哚菁绿（indocyanine green, ICG）定位及在荧光腔镜下肺部小结节切除的可行性。方法2018年12月-2019年8月，我院连续16例共计30个肺周围病变患者接受了荧光胸腔镜下肺部结节切除术。术前均行磁导航引导注入ICG定位。结果所有患者均先行磁导航引导下肺结节定位术，染色完成后立即行手术切除。结节的平均大小为（11.12±3.65）mm。平均导航时间为（12.06±2.74）min，染料标记与肺部手术切除的平均间隔为（25.00±5.29）min。所有病灶均被完全切除，定位成功率100.00%，无出血及其他并发症发生，术后病理结果证实定位的准确性。结论经磁导航引导下注入荧光染剂是一种新颖且有效的方法，可以定位肺部微小不可触及的病灶。这种方法可帮助外科医生更快更方便的识别病灶，实用性强，值得推广。

Value of preoperative localization techniques for solitary pulmonary nodules in singleport thoracoscopic surgery

ObjectiveTo evaluate the value and clinical effect of different preoperative localization techniques for solitary pulmonary nodules (SPN) before single-port thoracoscopic surgery.MethodFrom January 2018 to June 2019, 54 patients diagnosed with solitary pulmonary nodules received single-port thoracoscopic surgery in Thoracic Department of General Hospital of Southern Theater Command of PLA. Based on the location methods of the nodules, the patients were divided into group A (34 cases) with preoperative CT-guided Hook-wire (a common positioning needle usually using in mammary gland) positioning and group B (20 cases) with preoperative CT-guided methylene blue location.ResultsThe success rate of localization in group A was 94.18% (32/34), significantly higher than that in group B [85% (17/20), P &lt; 0.05). No intraoperative conversion to thoracotomy occurred in group A, while the conversion rate was 10% (2/20) in group B (P &lt; 0.05). The average positioning cost was significantly higher in group A than in group B (1715±109 vs 1021±86 RMB yuan, P &lt; 0.05), but the total hospitalization cost was similar between the two groups (50 114±3788 vs 47871±5902 RMB yuan, P&gt;0.05). The length of hospital stay was significantly shorter in group A than in group B (6.71±1.23 vs 8.19±2.61 days, P &lt; 0.05).ConclusionCompared with the traditional methylene blue localization method, Hook-wire localization positioning can significantly increase the success rate of localization, and can be used as the standard preoperative localization method in patients undergoing single-port thoracoscopic pulmonary nodule resection, especially in those with deep nodule location from the visceral pleura.

Prognostic value of the advanced lung cancer inflammation index in early-stage non-small cell lung cancer patients undergoing video-assisted thoracoscopic pulmonary resection.

The aim of this study was to assess the prognostic value of the preoperative advanced lung cancer inflammation index (ALI) in early stage non-small lung cancer (NSCLC) patients who received videoassisted thoracoscopic surgery (VATS) pulmonary surgery as their only therapy. We retrospectively reviewed the medical records of patients who were diagnosed with earlystage NSCLC and received a VATS pulmonary resection from January 2014 to June 2016 in the Department of Thoracic Surgery, West China Hospital. A receiver operating characteristic (ROC) curve analysis was conducted to determine the optimal cut-off values, and patients were divided into low and high ALI groups. The Kaplan-Meier method and Cox proportional hazards model were used to evaluate potential predictors of overall survival (OS) and disease-free survival (DFS). A total of 292 patients were enrolled in our analysis. Then, 155 and 137 patients were assigned to the low ALI (ALI <50) and high (ALI >50) groups, respectively. The multivariate analyses revealed that preoperative ALI <50 was an independent prognostic factor for both OS [hazard ratio (HR) = 2.603, 95% confidence interval (95% CI): 1.128-6.006, P=0.025] and DFS (HR =2.372, 95% CI: 1.141-4.935, P=0.021), and patients with a low preoperative ALI had worse OS (P<0.001) and DFS (P<0.001) compared with those with a high preoperative ALI. A low preoperative ALI was significantly correlated with poor survival, and the ALI might serve as a promising marker of prognosis in early-stage NSCLC patients who received a VATS pulmonary resection as their only therapy.

Morbi-mortalité de la résection pulmonaire pour cancer par chirurgie vidéo-assistée chez l’octogénaire

Due to an increase in life expectancy, onco-pulmonologists and thoracic surgeons are more frequently faced with octogenarian patients with lung cancer. In this age group, treatment modalities may need to be revised because of the increasing presence of comorbidities. Surgery remains the reference treatment for early stage disease, but mortality rates and postoperative complications are higher in this group of patients. One of the solutions to reduce the operative risk would be to develop videoassisted thoracoscopic pulmonary resection surgery. The aim of this study was to evaluate the results of this form of lung cancer surgery in octogenarians. All patients 80 years old or more who underwent videoassisted lung cancer surgery from 2014 to 2018 at Lyon University Hospital were included. Wedge resections and diagnostic procedures were excluded. Nineteen patients (13 men, 6 women) were included. The median age was 82 years old. All patients had undergone videoassisted lobectomy. Three patients required conversion to thoracotomy (15.8%). All patients underwent complete resection (R0). One patient had N1 lymph node involvement, all others were N0. The postoperative complication rate was 68.4%, the majority of which were grade II of the Clavien classification. Perioperative mortality was 5.3%. Videoassisted lung cancer resection in a selected population of octogenarians is associated with satisfactory short-term results. It is reasonable to favour minimally invasive techniques in this population, even if the proof of their superiority has not yet been firmly established.

A case of a primary pulmonary meningioma mimicking a metastasis from a papillary thyroid carcinoma due to a size reduction after radioactive iodine therapy

BackgroundPrimary pulmonary meningiomas (PPMs) are a rare mostly benign disease presenting as a solitary pulmonary nodule and are hardly distinguishable from a metastatic tumor because of a lack of specific radiological features. We described a case of a PPM initially diagnosed as a metastatic lung tumor from thyroid cancer with a size reduction after radioactive iodine therapy.Case presentationA 62-year-old woman who had undergone a total thyroidectomy for a papillary thyroid carcinoma 6 years prior presented with an enlarging pulmonary nodule. The nodule had decreased in size from 7.0 to 5.5 mm after adjuvant radioactive iodine therapy and enlarged to 8.7 mm over the next 5 years. Under a clinical diagnosis of a metastatic lung tumor, she underwent a thoracoscopic pulmonary wedge resection and was pathologically diagnosed with a PPM.ConclusionA surgical resection is required for histological diagnoses of PPMs especially in patients with a history of a malignancy.

Magnetic anchor technique and its clinical application

Magnetic anchor technique (MAT) is an important part of the magnetic surgery that utilizes the characteristics of the “field” interaction of magnets. By operating the anchoring magnets outsides the body, it draws the target magnets in the body and the instruments carried by them to the target position to assist expose the surgical field. At present, MAT has been applied in many fields, such as general surgery, thoracic surgery, gynecology and obstetrics, urinary surgery and endoscopic operation. In the reduction trocar or single incision laparoscopic surgery, it is difficult to establish triangulation. Besides, the main operating instrument, laparoscopic grasping forceps, laparoscopic camera system, etc. need to be accommodated in a narrow surgical entrance, they are easy to collide and interfere with each other, which increases the difficulty of operation and makes it difficult for operators to master. With the chest and abdominal wall coupling, MAT successfully reduces the trocar and pulling instruments, establishes effective triangulation, obtains a good surgical insight, and makes the surgery more minimally invasive and precision. MAT has been successfully used in laparoscopic cholecystectomy, appendectomy, total hysterectomy, hysteromyomectomy, adnexectomy, ovarian cyst resection, nephrectomy and radical prostatectomy, thoracoscopic pulmonary wedge resection and esophagectomy, endoscopic submucosal dissection. Besides, it also works well in radical mastectomy and preparation of donor liver in liver transplantation. In magnet-assisted single trocar (MAST) surgery, magnetic instruments provide sufficient retraction, good triangulation and surgical field exposure, improving the human mechanics of the surgeon during appendectomy and cholecystectomy. With the help of MAT, single incision laparoscopic surgery has been successfully completed appendectomies, cholecystectomies, Nissen fundoplications, gastrojejunostomies, splenectomies, ovarian tumor/cyst resections, retroperitoneal lymphangioma resection, adrenalectomy, total abdominal colectomy and pulmonary wedge resection. The traction generated by the combination of external magnets and internal magnets makes it possible to carry out NOTES surgery in patients with thick abdominal walls, and obtain a powerful traction/reverse traction without abdominal puncturing. With the deep cross and integration of magnetic materials, biomechanics and clinical diagnosis and treatment technique, MAT will expand the application in the future and promote the progress of surgical diagnosis and treatment technique and medical device industry.

Efficacy of transcutaneous electrical acupoint stimulation combined with general anesthesia for sedation and postoperative analgesia in minimally invasive lung cancer surgery: A randomized, double-blind, placebo-controlled trial.

BackgroundMultimodal opioid‐sparing analgesia is a key component of an enhanced recovery pathway after surgery that aims to improve postoperative recovery. Transcutaneous electrical acupoint stimulation (TEAS) is assumed to alleviate pain and anxiety and to modify the autonomic nervous system. This study aimed to determine the efficacy of TEAS for sedation and postoperative analgesia in lung cancer patients undergoing thoracoscopic pulmonary resection.MethodsA total of 80 patients were randomized into two groups: the TEAS group and the sham TEAS combined with general anesthesia group. Postoperative pain levels at six, 24, 48 hours, and one month after surgery were measured using the visual analogue scale (VAS). Bispectral index (BIS) score during the TEAS prior to anesthetic induction, Observer's Assessment of Alertness/Sedation (OAAS) score, sufentanil consumption during postoperative patient‐controlled intravenous analgesia (PCIA), number of total and effective attempts of PCIA pump use, and incidence of postoperative nausea and vomiting were recorded and analyzed statistically.ResultsPatients in the TEAS group had significantly lower VAS scores at six, 24, and 48 hours after surgery (P < 0.01); lower BIS scores at 10, 20, and 30 minutes before induction (P < 0.01); lower levels of postoperative sufentanil consumption; lower number of PCIA attempts and effective rates (P < 0.01); lower incidences of nausea at 0, six, 24, and 48 hours; and lower incidence of vomiting at 24 hours after surgery (P < 0.05). The postoperative OAAS scores were similar between the groups.ConclusionsTEAS could be a feasible approach for sedation and postoperative analgesia in thoracoscopic pulmonary resection.

Malignant primary pulmonary meningioma with bone metastasis

Primary pulmonary meningioma is extremely rare and only <45 cases have been reported since its first report by Kemnitz and Heinrich (Meningioma of lung: first report with light and electronmicroscopic findings. Ultrastruct. Pathol. 1982;3:359–65). Among these cases, only five cases were malignant or atypical. A 67-year-old female with primary pulmonary meningioma underwent thoracoscopic pulmonary wedge resection of the left lower lobe a year before. She had been aware of left thigh pain for 9 months, then she was referred to our division. Positron emission tomography-computed tomography suspected multiple bone metastasis including frontal bone, mandible, left scapula, rib, vertebra, pubis, left femur and sternum. We performed a needle biopsy of the sternum. Histopathological diagnosis was metastasis of primary pulmonary meningioma, World Health Organization grade III. We treated her with denosumab and radiation therapy targeting the left femur. Two months after the treatment, the pain had decreased and she could walk with no cane. No case of malignant extracranial meningioma with bone metastasis have been reported.