Risk factor analysis of postoperative complications after adjunctive pulmonary resection in patients with multidrug-resistant tuberculosis: A multi-institutional study.

BACKGROUND AND OBJECTIVE: Multidrug-resistant tuberculosis (MDR-TB) requires extended treatment with regimens with multiple side effects, resulting in high treatment failure rates. Adjunctive lung resection combined with anti-tubercular agents improves outcomes. However, few studies have evaluated the potential harm from surgery and determined the optimal conditions for surgery. We aimed to analyze perioperative conditions to assess risk factors for postoperative complications in a multi-institutional setting. METHODS: This retrospective study included 44 patients with MDR-TB who underwent adjunctive lung resection at three management groups of the Taiwan MDR-TB consortium between January 2007 and December 2020. Demographic data, clinical characteristics, radiological findings, sputum culture status before surgery, primary or acquired drug resistance, surgical procedure, complications, and treatment outcomes were collected and analyzed. Multivariate logistic regression was used to identify risk factors for postoperative complications. RESULTS: Twenty-seven patients (61.4%) underwent lung resection using video-assisted thoracic surgery (VATS). The overall surgical complication rate was 20.5%, and the surgical mortality rate was 9.1%. Postsurgical hemothorax was the most common complication (11.4%). According to the univariate analysis, hilum involvement in images, positive preoperative sputum culture, and thoracotomy approach were unfavorable factors. VATS approach [adjusted OR, 0.088 (95% CI, 0.008-0.999)] was the only favorable factor identified by multivariate analysis. CONCLUSION: The minimally invasive approach is a growing trend, and lobectomies and sublobar resections were the main procedures for MDR-TB. The VATS approach significantly reduced the surgical complication rate. Postsurgical hemothorax was noteworthy, and meticulous hemostasis of the chest wall and residual lung surface is critical for successful resections.

Lobectomy Versus Sublobar Resection in Simultaneous Bilateral Thoracoscopic Lung Resection.

BACKGROUND: Simultaneous bilateral thoracoscopic lung resection (SBTLR) has been shown to be a feasible and efficacious approach for a wide range of pulmonary conditions. Our aim was to evaluate the impact of different procedures on surgical outcomes in patients receiving SBTLR. METHODS: Between 2012 and 2021, 207 patients with bilateral lung neoplasms who underwent SBTLR were retrospectively reviewed. Fifty-one patients received ipsilateral plus contralateral lobectomy or sublobectomy (lobar group), whilst 156 patients received bilateral sublobectomy (sublobar group). Propensity scores were calculated and matched. Perioperative and clinicopathologic outcomes were compared. RESULTS: The lobar group had a greater mean age (64.5 vs. 60.0 years, p = 0.008), longer operative time (254 vs. 205 min, p < 0.001), and more blood loss (74 vs. 46 ml, p < 0.001). The sublobar group had fewer complications (6.4 vs. 19.6%, p = 0.006), shorter hospital stay (4.8 vs. 7.4 days, p < 0.001), and lower hospital costs (p = 0.03). Among 50 pairs of matched groups, significant differences were found only in operative time, hospital stay, and costs. Maximum tumor size and pathological features differed significantly before and after matching (all p < 0.05), with the lobar group consistently demonstrating a larger main tumor (median, 2.5 cm) and a higher percentage of primary lung cancer (84%). Multivariate logistic regression analysis showed that a longer operative time was the factor associated with more complications (OR: 1.01; 95% CI 1.00-1.02, p = 0.002). CONCLUSIONS: With regard to SBTLR, our data suggests that sublobectomy may reduce the prolonged recovery, hospital costs, and complications incurred by lobectomy, without compromising oncological outcomes.

One-stage thoracoscopic resection of bilateral bronchiectasis.

OBJECTIVE: To evaluate the results of one-stage thoracoscopic resection of bilateral bronchiectasis. METHODS: Between June 2009 and December 2020, there were 23 patients selected for one-stage thoracoscopic resection of bilateral bronchiectasis. Their average age was 58.5 (36-73). Female patients were more common, accounting for 17 (74%). Preoperatively, 17 (74%) patients mainly presented with hemoptysis and the other 6 (26%) patients with purulent sputum. RESULTS: In these 23 patients, a total of 121 segments were resected, with an average of 5.26 segments, ranging from 3 to 9 segments. Five of 17 patients with massive hemoptysis underwent ligation of bronchial arteries in addition to lung resections. The average operating time was 271 min, ranging from 145 to 500 min. The average blood loss was 108 ml, ranging from 20 to 600 ml. The average postoperative hospital stay was 8 days, ranging from 3 to 20 days. There was no surgical morbidity or surgical death. Hemoptysis and purulent sputum of all patients was almost controlled after surgery. CONCLUSION: One-stage thoracoscopic resections of bilateral localized bronchiectasis could be well-tolerated and safe for these selected patients. The one-stage operation could shorten the course of treatment.

Innominate Arterial Barrier Blocked a 25-Year Substernal Neoesophagus.

A 67-year-old woman underwent esophagogastroduodenectomy, partial jejunectomy, pancreaticojejunostomy, cervical esophagostomy, and feeding jejunostomy at the age of 42 for corrosive necrosis. She underwent esophageal reconstruction using the ileocolon through the substernal route 4 months later. Twenty-five years after esophageal reconstruction, the proximal part of the neoesophagus was obstructed by the innominate artery barrier. She could eat regular diets after revision surgery.

From one incision to one port: The surgical technique and the evolution of segmentectomy in patients with pulmonary tuberculosis.

OBJECTIVES: We retrospectively reviewed the evolution of segmentectomy for pulmonary tuberculosis (TB) and the feasibility of multi- and single-incision video-assisted thoracoscopic segmentectomy. METHODS: Of 348 patients undergoing surgery for TB, the medical records of 121 patients undergoing segmentectomy between January 1996 and November 2015 were reviewed. Clinical information and computed tomography (CT) image characteristics were investigated and analyzed. RESULTS: Eighteen patients underwent direct or intended thoracotomy. Sixty-four underwent video-assisted thoracoscopic segmentectomy (VATS), including 53 multi-incision thoracoscopic segmentectomy (MITS), and 11 single-incision thoracoscopic segmentectomy (SITS). Thirty-nine were converted to thoracotomy. The intended thoracotomy group had more operative blood loss (p = 0.005) and hospital stay (p = 0.001) than the VATS group although the VATS group had higher grade of cavity (p = 0.007). The intended thoracotomy group did not differ from converted thoracotomy in operative time, blood loss, or hospital stay, and the grade of pleural thickening was higher in the converted thoracotomy group (p = 0.001). The converted thoracotomy group had more operative blood loss, hospital stay, and complication rate than the MITS group (p = 0.001, p<0.001, and p = 0.009, respectively). The MITS group had lower pleural thickening, peribronchial lymph node calcification, cavity, and tuberculoma grading than the converted thoracotomy group (p<0.001, p = 0.001, 0.001, and 0.017, respectively). The SITS group had lower grading in pleural thickening, peribronchial lymph node calcification, and aspergilloma grading than the converted thoracotomy group (p = 0.002, 0.010, and 0.031, respectively). Four patients in the intended thoracotomy group and seven in the converted thoracotomy group had complications compared with three patients in the MITS and two in the SITS group. Risk factors of conversion were pleural thickening and peribronchial lymph node calcification. CONCLUSION: Although segmentectomy is technically challenging in patients with pulmonary TB, it could be safely performed using MITS or SITS and should be attempted in selected patients. Its efficacy for medical treatment failure needs investigation.

Pleural drainage using drainage bag for thoracoscopic lobectomy.

Objective This study was designed to compare the effectiveness and convenience of a drainage bag and a chest bottle following thoracoscopic lobectomy. Methods We conducted a test to ensure that the drainage bag was characterized by easy drainage and an antireflux effect. Thereafter, the drainage bag was used in all thoracic operations in our service. To understand the usefulness of the drainage bag, a retrospective cohort study enrolled 30 patients who had a drainage bag after thoracoscopic lobectomy and compared them with 30 similar patients operated on previously who had chest bottles. Variables studied included total drainage volume, duration of drainage, complications, and satisfaction of the care providers. Results There was no significant difference between the chest bottle and drainage bag groups respectively in terms of total drainage (697.5 ± 89.7 vs. 614.1 ± 76.6 mL, p = 0.483) or duration of drainage (4.23 ± 0.38 vs. 4.43 ± 0.38 days, p = 0.713). No device-related complication was observed. After our experience with the drainage bag, we abandoned use of the chest bottle. The drainage bag was more convenient for patients and promoted early ambulation as well improving cost effectiveness. Most care providers preferred to use the drainage bag (p = 0.000). Conclusion The drainage bag is superior to the chest bottle for postoperative drainage.

From biportal to uniportal video-assisted thoracoscopic anatomical lung resection: A single-institute experience.

Our study sought to review our experience from biportal to uniportal video-assisted thoracoscopic surgery (VATS) major lung resection. Lessons we learned from the evolution regarding technical aspects were also discussed.We retrospectively reviewed patients who underwent VATS lobectomy or segmentectomies in Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi, Taiwan, during January 2012 and December 2014. Patient clinical profiles, surgical indications and procedures, postoperative course, and oncological parameters were analyzed and compared between the biportal and uniportal groups.A total of 121 patients were enrolled in this study with median follow-up of 19.5 ±â€Š11.6 months for all patients and 22.5 ±â€Š11.5 months for primary lung cancer patients. Operation time (146.1 ±â€Š31.9-158.7 ±â€Š40.5 minutes; P = 0.077), chest drainage time (3.8 ±â€Š3.3-4.4 ±â€Š2.4 days; P = 0.309), conversion to thoracotomy rate (2.2%-2.6%; P = 0.889), and complication rate (15.6%-19.7%; P = 0.564) were equal between the groups, whereas blood loss (96.7 ±â€Š193.2-263.6 ±â€Š367; P = 0.006) was lower in the uniportal group. For lung cancer cases, there were no statistical differences in the histology, cancer staging, mediastinal lymph node dissection stations, numbers of dissected N1, N2, and overall lymph nodes between uniportal and biportal groups.Our preliminary data showed that uniportal VATS anatomical lung resection is as feasible, equally safe, and of comparative oncological clearance efficacy to biportal VATS.

The Role of Video-Assisted Thoracoscopic Therapeutic Resection for Medically Failed Pulmonary Tuberculosis.

There are few reports regarding video-assisted thoracoscopic therapeutic resection for medically failed pulmonary tuberculosis (TB). We reviewed our surgical results of video-assisted thoracoscopic surgery (VATS) therapeutic resection for pulmonary TB with medical failure, and its correlation with image characteristics on chest computed tomography (CT) scan.Between January 2007 and December 2012, among the 203 patients who had surgery for TB, the medical records of 89 patients undergoing therapeutic resection for medically failed pulmonary TB were reviewed. Clinical information and the image characteristics of CT scan were investigated and analyzed.Forty-six of the 89 patients undergoing successful VATS therapeutic resection had significantly lower grading in pleural thickening (P < 0.001), peribronchial lymph node calcification (P < 0.001), tuberculoma (P = 0.015), cavity (P = 0.006), and aspergilloma (P = 0.038); they had less operative blood loss (171.0 ±â€Š218.7 vs 542.8 ±â€Š622.8 mL; P < 0.001) and shorter hospital stay (5.2 ±â€Š2.2 vs 15.6 ±â€Š15.6 days; P < 0.001). They also had a lower percentage of anatomic resection (73.9% vs 93.0%; P = 0.016), a higher percentage of sublobar resection (56.5% vs 32.6%; P = 0.023), and a lower disease relapse rate (4.3% vs 23.3%; P = 0.009). Eighteen of the 38 patients with multi-drug resistant pulmonary tuberculosis (MDRTB) who successfully underwent VATS had significantly lower grading in pleural thickening (P = 0.001), peribronchial lymph node calcification (P = 0.019), and cavity (P = 0.017). They were preoperatively medicated for a shorter period of time (221.6 ±â€Š90.8 vs 596.1 ±â€Š432.5 days; P = 0.001), and had more sublobar resection (44.4% vs 10%), less blood loss (165.3 ±â€Š148.3 vs 468.0 ±â€Š439.9 mL; P = 0.009), and shorter hospital stay (5.4 ±â€Š2.6 vs 11.8 ±â€Š6.9 days; P = 0.001).Without multiple cavities, peribronchial lymph node calcification, and extensive pleural thickening, VATS therapeutic resection could be safely performed in selected patients with medically failed pulmonary TB as an effective adjunct with satisfactory results.

Thyroid carcinoma showing thymus-like differentiation with tracheal invasion.

We describe a case of thyroid carcinoma showing thymus-like differentiation with tracheal invasion. The malignant tumor was managed by refined spiral tracheoplasty after tangential resection of the trachea. At 8 months after the surgery, computed tomography and bronchoscopy showed no tumor recurrence or tracheal stenosis.

Perioperative Evaluation of Patient Outcomes after Severe Acid Corrosive Injury.

We reviewed 64 patients with perforation or full-thickness injury of the alimentary tract after acid ingestion. Based on our classification of laparotomy findings, there were class I (n = 15); class II (n = 13); class III (n = 16); and class IV (n = 20). Study parameters were preoperative laboratory data, gastric perforation, associated visceral injury, and extension of the injury. End points of the study were the patients' mortality and length of hospital stay. All these patients underwent esophagogastrectomy with (n = 16) or without (n = 24) concomitant resection, esophagogastroduodenojejunectomy with (n = 4) or without (n = 13) concomitant resection, and laparotomy only (n = 7). Concomitant resections were performed on the spleen (n = 10), colon (n = 2), pancreas (n = 1), gall bladder (n = 1), skipped areas of jejunum (n = 4), and the first portion of the duodenum (n = 4). The study demonstrates five preoperative risk factors, female gender, shock status, shock index, pH value, and base deficit, and four intraoperative risk factors, gastric perforation, associated visceral injury, injury beyond the pylorus, and continuous involvement of the jejunum over a length of 50 cm. The overall mortality rate was 45.3%, which increased significantly with advancing class of corrosive injury.

Apex-to-Cupola Distance Following VATS Predicts Recurrence in Patients With Primary Spontaneous Pneumothorax.

Our study sought to determine whether the size of the residual apical pleural space in young patients with primary spontaneous pneumothorax (PSP) following video-assisted thoracoscopic surgery is associated with the risk of recurrence. We retrospectively reviewed patients (≤30 years' old) with primary spontaneous pneumothorax following thoracoscopic surgery (2002-2010) in a university-affiliated hospital. The size of residual apical pleural space was estimated by measuring the apex-to-cupola distance on a postoperative chest radiograph at 2 time windows: first between postoperative day (POD) 0 and 3, and second between POD 4 and 14. A total of 149 patients were enrolled with a median follow-up of 11.2 months (interquartile range, 0.95-29.5 months), of whom 141 (94.6%) were male with a mean age of 20 years. The postoperative recurrence rate was 11.4%. Comparing the characteristics between the patients with and without recurrent pneumothorax, the patients with recurrence were younger (18.2 + 2.4 vs 20.7 + 3.7 years, P = 0.008), with a lower rate of pleurodesis (35% vs1 69%, P = 0.037), longer apex-to-cupola distance at POD 0 to 3 (22.41 ±â€Š19.56 vs 10.07 ±â€Š10.83 mm, P < 0.001) and POD 4 to 14 (11.82 ±â€Š9.75 vs 5.54 ±â€Š8.38 mm, P = 0.005) than the patients without recurrence. In a multivariate logistic regression model for recurrent pneumothorax, age <18 years (P = 0.026, odds ratio [OR]: 4.694), apex-to-cupola distance at POD 0 to 3 >10 mm (P = 0.027, OR: 5.319), and no pleurodesis during VATS (P = 0.022, OR: 5.042) were independent risk factors for recurrent pneumothorax. The recurrence rate was not low (11.4%) in young patients with PSP following VATS. Residual apical pleural space with apex-to-cupola distance of 10 mm or greater at POD 0 to 3, younger age, and no pleurodesis would increase postoperative recurrence of primary spontaneous pneumothorax.

Glomus tumor of the trachea managed by spiral tracheoplasty.

BACKGROUND: Glomus tumors are usually found over the dermis of the extremities, particularly over the subungual region of the fingers, and occurrence in the trachea is an extremely rare event. To date, only 29 cases of tracheal and 2 main bronchus glomus tumors have been reported in the English literature. Our patient is the first ever reported case in Taiwan that was managed by spiral tracheoplasty. CASE REPORT: A 58-year-old woman was admitted to our hospital because of hemoptysis. Computed tomographic (CT) scan revealed a mass over the posterior wall of the trachea. Surgical resection with spiral tracheoplasty was performed due to uncontrolled bleeding and airway compromise. Histopathology and immunostaining confirmed a glomus tumor. Postoperative course was unremarkable and she was discharged in improved condition after 9 days of hospital stay. CONCLUSIONS: Although chronic symptom presentation is the rule for tracheal glomus tumors, airway obstruction and bleeding are life-threatening presentations. Histopathological examination and staining are important to differentiate it from hemangiopericytoma or carcinoid tumors. Spiral tracheoplasty after tangential resection may be tried, as this preserves more tracheal tissue, decreases tension, and prevents postoperative leakage at the anastomotic site.

Factors predicting recurrence and postrecurrence survival in completely resected thymic carcinoma.

BACKGROUND: There are few data on factors predicting recurrence of completely resected thymic carcinoma. This study analyzed prognosticators for recurrence and postrecurrence survival. METHODS: Eighty-two patients with surgically treated thymic carcinoma were reviewed between June 1988 and March 2013, and 54 who underwent complete resection were enrolled. Sex, age, myasthenia gravis, tumor histologic classification, Masaoka staging, characteristics of locoregional invasion and recurrence, and the treatment for recurrence were collected. Continuous variables between groups were compared using Student's t test, and categorical variables were compared using the χ2 test, Fisher's exact test, or Spearman rank correlation. Survival analysis was performed using the Kaplan-Meier and log-rank test. Statistical significance was set at a probability value of less than 0.05. RESULTS: A total of 54 patients underwent complete resection for thymic carcinoma, 21 of whom had recurrent diseases and 33 of whom remained disease-free. Patients without recurrent disease had a significantly better 5-year overall survival of 79% than 26% of those who had recurrent disease (p=0.000). Masaoka staging and tumor invasion of the superior vena cava were significantly associated with recurrence-free survival in the univariate analysis (p=0.047 and 0.019, respectively). In the multivariate analysis for survival, tumor invasion into the superior vena cava was the only prognostic variable for recurrence-free survival (p=0.047). Patients who underwent surgical intervention followed by chemotherapy for recurrent diseases had the best progression-free survival after recurrence (p=0.000). CONCLUSIONS: Superior vena cava invasion as well as Masaoka staging was significantly associated with recurrence-free survival in patients with completely resected thymic carcinoma. In patients with recurrent disease, surgical resection should be attempted for localized disease because it might provide some benefit for progression-free survival.

Incremental change in acute esophageal necrosis: report of two cases.

Acute esophageal necrosis, also called "black esophagus" because of its characteristic appearance on endoscopy, is a life-threatening disease; however, its temporal evolution on endoscopy is not well understood. We describe the serial changes in acute esophageal necrosis in two patients, who underwent four upper endoscopic examinations each. Serial endoscopy demonstrated progressive necrosis extending from the lower esophagus proximally to involve the middle or upper thoracic esophagus in both patients. The first patient was treated with transhiatal esophagectomy, followed by esophageal reconstruction, and medical control of repeated duodenal ulcer bleeding. The second patient died of esophageal perforation, as a complication of Sengstaken-Blakemore tube stent placement to control esophageal bleeding. We report these cases to demonstrate the importance of early detection and prompt surgical treatment of acute esophageal necrosis.

Simple pyloroplasty using a linear stapler in surgery for esophageal cancer.

This article describes a simple pyloroplasty procedure using a linear stapler in surgery for esophageal cancer. Simple pyloroplasty was carried out using a linear stapler in a total of 22 patients, whose stomachs were used as esophageal substitutes in the surgery for esophageal cancer. Endoscopy was performed and the pyloric diameter was measured perioperatively. A barium meal study was conducted 1 month after the surgery. Stapling enlarged the diameter of the pylorus by nearly 10 %. Endoscopy revealed a smooth inner surface of the pylorus, enlargement of pyloric channel, and fewer spasms of the pylorus at the 1-month follow-up. Postoperative barium meal studies showed good patency of all of the patients' gastric outlets. Simple pyloroplasty is a time-saving and non-soiling technique used to perform the drainage of the gastric conduit for resection of esophageal cancer.

The role of video-assisted thoracoscopic surgery in therapeutic lung resection for pulmonary tuberculosis.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has been considered an effective diagnostic modality for pulmonary tuberculosis. Its feasibility in therapeutic lung resection, however, has not been validated. METHODS: The medical records of patients who underwent VATS or a thoracotomy for therapeutic resection of pulmonary tuberculosis between January 2007 and March 2011 were reviewed for age, sex, indications for surgery, approach and procedures, preoperative sputum culture status, operative time, blood loss, hospital stay, and complications. RESULTS: One hundred twenty-three patients were enrolled. Sixty-three were successfully treated using VATS and 60 were converted to thoracotomy. The number of VATS wedge resections was significantly higher (p = 0.004). Patients who underwent VATS had significantly less blood loss, shorter hospital stays, and fewer complications (p = 0.031, 0.000, and 0.022, respectively). Lesions treated with a pneumonectomy or that required thoracoplasty failed to be done using VATS (p = 0.054 and 0.002, respectively). Patients who underwent VATS had slightly more isolated lobectomies and significantly (p = 0.005) shorter hospital stays than did thoracotomy patients. Concomitant and isolated segmentectomies were done using VATS, but there were significantly fewer than for thoracotomy patients (p = 0.033). CONCLUSIONS: Video-assisted thoracoscopic surgery is effective for therapeutic wedge resections, isolated lobectomies, and simple segmentectomies and lobectomies combined with wedge resections or segmentectomies for pulmonary tuberculosis. Tuberculosis lesions that require a pneumonectomy or thoracoplasty are still major challenges for VATS.

Image characteristics as predictors for thoracoscopic anatomic lung resection in patients with pulmonary tuberculosis.

BACKGROUND: A variety of complications occur in patients with pulmonary tuberculosis. The feasibility of a thoracoscopic approach to anatomic lung resection for the complications of mycobacterial infection has not been well evaluated. METHODS: We retrospectively analyzed chest computed tomography (CT) scans of patients who underwent anatomic lung resections without additional procedures for tuberculosis between January 2007 and September 2009. Image characteristics on chest CT scans were classified as bullae, pleural thickening, peribronchial lymph node calcification, tuberculoma, cavity, aspergilloma, atelectasis, and bronchiectasis, and graded according to the number of the lesions and degree of lobar involvement. Patients were divided into two groups, video-assisted thoracoscopic surgery (VATS) and thoracotomy for anatomic lung surgery, according to the eventual operative procedure. The variables between these two groups were compared using the Student t test; the image characteristics were compared using a χ2 test. RESULTS: Fifty patients were enrolled; 21 given VATS and 29 given a thoracotomy. The VATS group had significantly lower gradings in pleural thickening, peribronchial lymph node calcification, tuberculoma, cavity, and aspergilloma than did the thoracotomy group (p=0.000, 0.015, 0.001, 0.023, and 0.022, respectively). Mean operative time, blood loss, and complication rate were not significantly different, but the mean hospital stay was significantly shorter (10.00 days versus 14.96 days, p=0.048) in the VATS group. CONCLUSIONS: Multiple cavities, multiple aspergillomas, multilobar tuberculoma, extensive pleural thickening, and peribronchial lymph node calcification preclude VATS. It is reasonable to attempt a thoracoscopic approach in patients without these preoperative image characteristics.