Multi-center experience in an optimized right upper lobectomy surgical procedure in China.

BACKGROUND: This multi-center study was aimed at retrospectively evaluating the feasibility, safety, clinical outcomes, and surgical learning curve of an optimized procedure for right upper lobectomy (RUL), which is challenging because of the anatomical structures and features of this lobe. METHODS: This study included 45 RUL cases of robot-assisted thoracoscopy (RATS) in a pilot cohort and 187 RUL cases of video-assisted thoracoscopy (VATS) in three cohorts. A total of 121 and 111 patients underwent traditional and optimized RUL, respectively. The optimized surgical procedure was performed to consecutively transect the superior arterial trunk and bronchus, and finally disconnect the pulmonary vein and posterior ascending artery with interlobar fissures. Clinical and radiological data were reviewed retrospectively. RESULTS: Optimized RUL can be performed successfully by RATS or VATS. The optimized procedure yielded better clinical outcomes than the traditional procedure, including shorter operation times, less blood loss, fewer complications, shorter hospital times, lower costs, and a lower likelihood of postoperative intermedius bronchial kinking. Additionally, for calcified interlobar lymph nodes, the optimized VATS group was less likely to be converted to thoracotomy than the traditional group. The skills required to perform optimized VATS RUL can be gained by surgeons after 12 to 15 cases. The two RUL procedures in the pilot cohort showed similar disease-free survival. CONCLUSIONS: The optimized RUL was safe, economical, and feasible, with a short learning curve and satisfactory disease-free survival.

[Video-assisted thoracic surgery: clinical experience among 1264 patients].

OBJECTIVE: To summarize the clinical experience in video-assisted thoracic surgery (VATS). METHODS: From December 1993 to December 2005 1264 patients, 894 males and 370 females, aged 38.9 +/- 12.0, underwent VATS, including bullectomy in 622 cases, resection of mediastinal tumor or cyst in 119 cases, resection of esophageal diseases in 107 cases, lobectomy or wedge-shaped lung resection in 215 cases, lung volume reduction surgery (LVRS) in 17 cases, treatment of thoracic injury in 28 cases, treatment of other thoracic diseases in 72 cases, and biopsy in 84 cases. For the resection of esophageal carcinoma VATS was conducted via the right approach, the esophagus was dissociated, the lymph nodes were resected, upper-abdominal incision was made, the stomach was dissociated and drawn up to the neck region, a cervical incision was made to anastomose the stomach and the residue of esophagus. RESULTS: Operation was completed by VATS successfully in 1230 patients, and 34 cases were converted to traditional thoracotomy because of thoracic adhesion or to radically treat the malignant tumors. Major complications occurred in 45 cases (3.56%), including air-leak lasting more than 7 days in 30 cases, post-operative bleeding in 4 cases (3 of which received VATS once more for hemostasis and the other underwent thoracotomy), hydrothorax or pneumothorax in 3 cases that underwent water-closed drainage, esophageal mucous rupture in 4 cases with achalasia and one case with leiomyoma, all of which underwent repair immediately, infection of pleural cavity in one case after the resection of esophageal diverticulum, and pneumonia in one case after LVRS. One patient with spontaneous pneumothorax and respiratory failure died 5 days after the bullectomy. Spontaneous pneumothorax occurred in 10 patients 2 months to 2 years after VATS 3 of which underwent bullectomy and pleurodesis by VATS once more. CONCLUSION: Spontaneous pneumothorax and some benign thoracic diseases are the major indications of VATS; however, great care should be expended to decide to treat malignant diseases by VATS. It is very important to train the surgeons who are to practice VATS. The practice of VATS should be individualized.

[The role of Smad4 and MAPK proteins in signal transduction pathway in non-small cell lung cancer].

OBJECTIVE: To investigate the expression of Smad4 in non-small cell lung cancer (NSCLC), its correlation with MAPK (mitogen activated protein kinase) and their clinical significance in NSCLC. METHODS: Western blotting and RT-PCR were employed to test 42 resected lung cancers and normal lung tissues for the expression of Smad4. Imunohistochemistry was used to detect Smad4 and subtribes of MAPK in 71 paraffin samples. RESULTS: The level of protein and mRNA expression of Smad4 in lung cancer tissues were 0.2092 +/- 0.1308 and 0.3986 +/- 0. 1982, respectively, lower than those in normal tissues (0.7852 +/- 0.4386 and 1.1206 +/- 0.6772, P < 0.05). The expression of p38, ERK1 and Smad4 was associated with TNM staging (P = 0.000, 0.000 and 0.005, respectively) and JNK1 with tumor location (P = 0.028) and staging (P = 0.000). There was a correlation between p38 and Smad4 (P = 0.000). The expression of Smad4 (P = 0.0001), p38 (P = 0.0000) and JNK1 (P = 0.0208), tumor differentiation (P = 0.0059) and staging (P = 0.0000) were significantly correlated with prognosis of NSCLC by univariate analysis. Smad4 (P = 0.019), p38 (P = 0.044), tumor differentiation (P = 0.003), and staging (P = 0.020) were correlated with prognosis tested by multivariable analysis. Taking p38 and Smad4 together, we found that the negative expression of p38 and positive expression of Smad4 were associated with a better prognosis of NSCLC (P = 0.000). CONCLUSION: Smad4 could be of importance for the initiation and development of NSCLC. There is a significant correlation between main proteins of TGF-beta/smad4 and those of ras-MAPK signal transduction pathways. The expression of Smad4 is inhibited by p38. Smad4, as well as p38, tumor differentiation and staging can be used as prognostic factors of NSCLC.