Predictive factors of early autologous blood pleurodesis for postoperative air leak.

BACKGROUND: The usefulness of autologous blood pleurodesis for air leak after pulmonary resection is well known; however, factors predicting the therapeutic efficacy are poorly understood. Herein, we aimed to examine the predictors of early autologous blood pleurodesis for air leak following pulmonary resection. METHODS: Patients who underwent pulmonary resection and autologous blood pleurodesis with thrombin for postoperative air leak between January 2016 and October 2022 were retrospectively analyzed. Patients received 50-100 mL of autologous blood and 20,000 units of thrombin on postoperative days 1-4. If necessary, the same procedure or pleurodesis with other chemical agents was repeated until the air leak stopped. Patients were divided into single-dose and multiple-dose groups based on the number of times pleurodesis had occurred before the air leak stopped and were statistically analyzed. Logistic regression analysis was performed to identify predictors of treatment efficacy. RESULTS: Of the 922 patients who underwent pulmonary resection, 57 patients (6.2%) were included and divided into single-dose (n = 38) and multiple-dose (n = 19) groups. The amount of air leaks was identified as a significant predictor of multiple dosing, with a cutoff of 60 mL/min, in multivariate logistic regression analyses (odds ratio 1.13, 95% CI 1.03-1.24, p = 0.0065). The multiple-dose group showed a significantly higher recurrence of air leak (p = 0.0417). CONCLUSIONS: The amount of air leaks after pulmonary resection is the only significant factor predicting whether multiple autologous blood pleurodesis is required, and the recurrence rate of pneumothorax is significantly higher in such cases.

Prediction of visceral pleural invasion of clinical stage I lung adenocarcinoma using thoracoscopic images and deep learning.

PURPOSE: To develop deep learning models using thoracoscopic images to identify visceral pleural invasion (VPI) in patients with clinical stage I lung adenocarcinoma, and to verify if these models can be applied clinically. METHODS: Two deep learning models, one based on a convolutional neural network (CNN) and the other based on a vision transformer (ViT), were applied and trained via 463 images (VPI negative: 269 images, VPI positive: 194 images) captured from surgical videos of 81 patients. Model performances were validated via an independent test dataset containing 46 images (VPI negative: 28 images, VPI positive: 18 images) from 46 test patients. RESULTS: The areas under the receiver operating characteristic curves of the CNN-based and ViT-based models were 0.77 and 0.84 (p = 0.304), respectively. The accuracy, sensitivity, specificity, and positive and negative predictive values were 73.91, 83.33, 67.86, 62.50, and 86.36% for the CNN-based model and 78.26, 77.78, 78.57, 70.00, and 84.62% for the ViT-based model, respectively. These models' diagnostic abilities were comparable to those of board-certified thoracic surgeons and tended to be superior to those of non-board-certified thoracic surgeons. CONCLUSION: The deep learning model systems can be utilized in clinical applications via data expansion.

Effectiveness and failure factors of manual aspiration using a small needle for large pneumothorax in stable patients.

Background: Manual aspiration as the initial management of a large pneumothorax in a clinically stable patient has been reported to be safe and effective. However, the effect with smaller needles, the number of aspiration, the indication other than spontaneous pneumothorax and failure factors are unknown. We assessed the effectiveness and failure risk factors of manual aspiration up to three using a 20- or 22-gauge (G) needle in patients with a large, clinically stable pneumothorax. Methods: We included 107 clinically stable patients with large pneumothorax. Patients who were unstable, required a ventilator, underwent chest tube drainage or had an observed small pneumothorax, bilateral pneumothorax, hemopneumothorax, or postoperative pneumothorax were excluded. Up to three aspirations were performed using 20- or 22-G intravenous needles. When the aspiration volume was ≥2,500 mL or lung expansion did not occur, a chest tube was placed. Results: The first aspiration was successful in 57 patients (53.3%), the second in 16 patients (59.3%), and the third in eight patients (80.0%). No patient experienced any obvious complications or required emergent hospitalization or surgery after aspiration. Aspiration failure was correlated with an inter-pleural distance >20 mm at the level of the hilum [odds ratio (OR): 4.93; 95% confidence interval (CI): 1.49-22.71; P=0.0075], spontaneous secondary pneumothorax (OR: 3.11; 95% CI: 1.14-8.76; P=0.027), and ≤24 h from onset to presentation (OR: 2.95; 95% CI: 1.12-8.26; P=0.028). There were no significant differences in intrathoracic pressure after aspiration or plasma factor XIII levels between patients with resolved and persistent pneumothorax. Conclusions: Manual aspiration up to three times using a small needle might be one of a treatment option in clinically stable patients with any large pneumothorax. Aspiration failure was correlated with an inter-pleural distance >20 mm at the level of the hilum, spontaneous secondary pneumothorax, and ≤24 h from onset to presentation.

Adverse factors and postoperative neuropathic pain in challenging video-assisted thoracoscopic surgery.

BACKGROUND: Whether challenging video-assisted thoracoscopic surgery (VATS) is a minimal invasive surgery remains controversial. This study aimed to analyze causes of challenging conventional multiple-port VATS (CVATS) and conversion to thoracotomy and postoperative pain to provide indications for VATS. METHODS: This was a two-center retrospective study. Challenging VATS was defined as CVATS with operation time ≥5 hours and it was converted to thoracotomy. This study included patients who were admitted to Joetsu General Hospital (Joetsu, Niigata, Japan) and Toyama University Hospital (Toyama, Japan) for elective CVATS between April 2013 and March 2019. The exclusion criteria were as follows: a planned thoracotomy, uniportal VATS, robot-assisted thoracoscopic surgery, and simultaneous resection of extrathoracic organs. RESULTS: A total of 911 (91.6%) patients underwent CVATS. Of these cases, 876 (96.2%) were suitable VATS cases. On the contrary, 35 cases (3.8%) were recognized as challenging VATS. In 21 (2.3%) cases, VATS took ≥5 hours, and 14 (1.5%) VATS cases were converted to thoracotomy. The causes were severe adhesions (62.9%), air leak (45.7%), body position changes (22.9%), large tumor (14.3%), bronchoplasty or angioplasty (8.6%), and bleeding (2.9%). The minimum diameter of large tumors was 61.4 mm (53-67 mm). In 15 (71.4%) patients, VATS took ≥5 hours, and 10 (71.4%) patients who were converted to thoracotomy developed postoperative neuropathic pain. CONCLUSIONS: In this study, VATS ≥5 hours and conversion from VATS to thoracotomy were complicated by postoperative neuropathic pain. In case of bronchoplasty, angioplasty, and large tumor with minimum diameter ≥5 cm, a thoracotomy approach would be appropriate depending on the skill and experience of the surgeon. In cases of local or vascular sheath adhesion, if operation progress is delayed, it may be necessary to set a time limit and decide to convert to thoracotomy, considering patient's safety first.

Utility of the sliding lung sign for the prediction of preoperative intrathoracic adhesions.

BACKGROUND: To assess the potential of the ultrasonographic sliding lung sign to detect severe intrathoracic adhesions before surgery. METHODS: This was a prospective, single-center, observational study including all patients aged 20-89 years undergoing elective thoracic surgery. Patients with pneumothorax, pyothorax, hemothorax, chylothorax, and hydrothorax were excluded. We recorded the ultrasound sliding lung sign, surgical characteristics, and follow-up parameters: past medical history, respiratory function, chest X-ray findings, and computed tomography (CT) findings. Severe intrathoracic adhesion was defined as the need for adhesiolysis requiring more than 30 minutes. RESULTS: A total of 168 patients consented to participate. All 15 patients without the sliding lung sign had hard severe adhesions [specificity 100%, sensitivity 88.2%, positive predictive value (PPV) 100%, negative predictive value (NPV) 98.7%, and area under curve (AUC) 0.94]. There were two false-negative results, both of which were soft adhesions. Although blunting of the costophrenic (CP) angle, CT findings, past medical history, and restrictive lung disease were identified as significant risk factors of severe intrathoracic adhesion, all areas under the curve were low (0.71, 0.71, 0.69, 0.61, respectively). Thoracotomy frequency, intraoperative bleeding, operative time, and postoperative hospitalization were significantly greater in these patients than in those with non-severe adhesions. CONCLUSIONS: The ultrasound sliding lung sign could be used to predict severe intrathoracic adhesions before surgery. Preoperative confirmation of the ultrasound sliding lung sign is important for planning surgical approaches and implementing appropriate safety management.

Use of Quickfix for tape fixation of chest tubes: a multi-center doctor-nurse questionnaire survey and fixing strength comparison study.

BACKGROUND: Several tape fixations for chest tube were proposed, although none have a clear scientific basis. We performed a multicenter survey study to investigate the fixation of chest tubes using an available adhesive tape. We evaluated the strength of tape fixation and the effect of the skin coating material used on the fixation strength. METHODS: A multi-center questionnaire survey was administered in hospitals with a thoracic surgery division. The net promoter score (NPS) was used to measure the medical staff's satisfaction with an adhesive tape fixation. Fixing strength was calculated as follows: a chest tube was fixed using each taping method to a polyethylene plate and was pulled out in the long axis direction. While pulling out, the maximum resistance force [Newton (N)] and total resistance force [Joule (J)] were measured to calculate the fixing strength. RESULTS: The doctors' NPS showed no significant difference between handmade tape fixation and Quickfix {7 [5-8] vs. 10 [5-10] points, P=0.34}. The nurses' NPS showed no significant difference between handmade tape fixation and Quickfix {5 [5-8] vs. 5 [5-7] points, P=0.72}. The average maximum resistance force was the highest for Quickfix (1.36 J, 65.4 N) and a type of handmade fixation (three sheets stuck with foundation tape plus Y-shape slit plus Ω-shape tape; 1.61 J and 54.0 N). The fixation strength of Quickfix did not decrease with a skin coating agent (from 1.24 to 1.11 J and 63.0 to 66.6 N), although that of a handmade tape fixation decreased (from 1.49 to 0.90 J, 52.6 to 38.1 N). CONCLUSIONS: Quickfix provided secure fixation, regardless of the tube size or skin coating. Quickfix may be the best for standardized fixation because it is not only a stronger agent but is safe, simple, inexpensive, reliable, and can be used successfully by anyone.

A case of a pulmonary mucosa-associated lymphoid tissue lymphoma with chromosomal aberration (49, XX, +3, +i(6)(p10), +mar).

We report a case of a primary pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma with chromosomal aberration (49, XX, +3, +i(6)(p10), +mar). A 59-year-old woman was referred to our hospital for an abnormal chest shadow detected during a routine health check-up in 2014. Chest computed tomography revealed a 3.2- × 2.3- × 2.0-cm tumour shadow in the right middle lobe. Transbronchial biopsy did not result in the diagnosis of the tumour. Accordingly, as the tumour could have been malignant, right middle lobectomy was performed via video-assisted thoracic surgery. On the basis of the results of immunohistochemical staining and gene analysis, the tumour was diagnosed as a primary pulmonary MALT lymphoma with chromosomal aberration (49, XX, +3, +i(6)(p10), +mar).

Efficacy of 50 mg pregabalin for prevention of postoperative neuropathic pain after video-assisted thoracoscopic surgery and thoracotomy: a 3-month prospective randomized controlled trial.

BACKGROUND: This study analyzed the preventive effect of 50 mg/day pregabalin on postoperative neuropathic pain, and any additional benefits related to sleep and respiratory function. METHODS: This prospective randomized controlled study included lung resection patients 20-89 years of age. Patients were randomly assigned to the treatment (pregabalin; initial dose, 50 mg/day) or control (non-steroidal anti-inflammatory drugs) group. Pregabalin patients received non-steroidal anti-inflammatory drugs and pregabalin (25 mg, twice daily) from the second postoperative day. Pain scores, neuropathic pain, analgesic use, respiratory function, and insomnia scale scores for 3 months after surgery were evaluated. RESULTS: This study included 46 patients who received pregabalin and 46 control patients. Pregabalin patients had significantly less postoperative neuropathic pain than control patients (19.6% vs. 41.3%; P=0.0404), and their duration of neuropathic pain was significantly shorter (30 vs. 90 days; P=0.024). The onset of postoperative neuropathic pain, insomnia scale scores, and respiratory function were similar between groups. No pregabalin-related adverse events were reported. CONCLUSIONS: Pregabalin (50 mg/day) had a significant preventive effect on postoperative neuropathic pain after thoracic surgery, without side effects. Early postoperative administration of pregabalin would help prevent neuropathic pain and provide better pain control after thoracic surgery.