Is minimal access surgery for cancer associated with immunologic benefits?

Chronic postoperative pain after non-intubated uniportal VATS lobectomy

Introduction

Patients undergoing thoracic surgery are at increased risk of developing, long-lasting pain. Beyond the non-surgical factors, the type of operation, including the number of incisions, and the anesthetic assessment seemed to be important factors, although some studies are controversial. The aim of our study was to examine the presence of chronic postoperative pain after non-intubated uniportal VATS lobectomy. We examined the difference between the intubated, relaxed and non-intubated spontaneous ventilation surgical approaches in patients who underwent video-assisted thoracoscopic (VATS) uniportal lobectomy.

Methods

Demographic and postoperative data were retrospectively collected and analyzed, focusing on the use of pain medications, in 67 patients of the 140 patients selected by propensity score matching who underwent intubated (iVATS) or non-intubated (NITS) uniportal VATS lobectomy. This study focused on the use of analgesic medications 3, 6, and 12 months after surgery.

Results

Thirty-five intubated and 32 non-intubated patients were compared. Although the analgesic consumption was nearly 2% higher among the iVATS patients during the follow-up period, there were no statistically significant differences at 3 months (15.6 vs. 17.1%) (p = 0.868), at 6 months (9.4 vs. 12.4%) (p = 0.785), and at 12 months (3.3 vs. 5.9%) (p = 0.633) between the NITS and iVATS groups, respectively. More female than male patients reported chronic pain, but the difference was not statistically significant (p = 0.616). Diabetes mellitus was a statistically significant cofactor associated with chronic pain (p = 0.03), while cardiac disease (p = 0.6), perioperative morbidity (p = 0.228), prolonged air leak (p = 0.057), and repeat drainage (p = 0.626) were not.

Conclusion

Our study suggests that after non-intubation VATS lobectomies, the postoperative pain was less at 3, 6, and 12 months in NITS patients compared to iVATS patients. The 2% difference was not significant, so it may not be appropriate to claim the advantages of NITS in terms of postoperative pain.

Minimally invasive sleeve lobectomy for centrally located lung cancer: A real-world study with propensity-score matching

Background

The safety, feasibility, and prognosis of sleeve lobectomy by minimally invasive surgery (MIS) remain to be validated. The purpose of this study was to investigate outcomes in real-world patients receiving minimally invasive sleeve lobectomy in a balanced large cohort.

Methods

Between January 2013 and December 2018, 578 consecutive patients undergoing sleeve resection at a high-volume center were retrospectively analyzed. Surgical and oncologic outcomes were compared between MIS and thoracotomy patients after propensity-score matching (PSM).

Results

MIS sleeve lobectomy was increasingly used as a time-trend in real-world. Before PSM, the MIS group had smaller tumor size, more T2-stage cases, and more right upper lobe sleeve lobectomies compared to the Open group. After 1:4 PSM by patient demographics and tumoral characteristics, 100 cases of MIS and 338 cases of Open sleeve lobectomy were further analyzed. Although median operation time was longer in the MIS group than in the Open group (170.5 minutes vs.149.5 minutes, P < 0.001), patients in MIS group had significantly less estimated intraoperative blood loss (100 ml vs. 200 ml, P = 0.003), shorter drainage duration (5 days vs. 6 days, P = 0.027) and less amount of drainage (1280 ml vs. 1640 ml, P < 0.001) after surgery. Complete resection rate, combined angioplasty, number of dissected lymph nodes, post-operative length of stay, postoperative morbidity and mortality rate, and application of adjuvant therapy were similar between the two matched groups. Conversion to open thoracotomy was necessary in 13.6% patients, but with similar perioperative outcomes compared to Open cases except for longer operation time. More lower lobe sleeve lobectomies were accomplished via robot-assisted thoracoscopic surgery than via video-assisted thoracoscopic surgery (40.0% vs. 12.0%, P = 0.017) in MIS patients. Five-year overall survivals (MIS vs. Open: 72.7% vs. 64.4%, P = 0.156) and five-year progression-free survivals (MIS vs. Open: 49.2% vs. 50.5%, P = 0.605) were similar between the two matched groups.

Conclusions

MIS sleeve lobectomy is associated with similar or even better perioperative results and oncologic outcomes to open thoracotomy. Conversion to thoracotomy does not compromise perioperative outcomes. Robot surgery may be preferable for more complex sleeve resections.

Perioperative Systemic Inflammation in Lung Cancer Surgery

Systemic inflammation (SI) is a response of the immune system to infectious or non-infectious injuries that defends the body homeostasis. Every surgical intervention triggers SI, the level of which depends on the extent of damage caused by the surgery. During the first few hours after the damage, the innate or natural immunity, involving neutrophils, macrophages, and natural killer cells, plays a main role in the defense mechanism, but thereafter the adaptive immune response ensues. The number of leukocytes is elevated, the levels of lymphocytes and natural killer cells are reduced, and the cytokines released after surgery correlate with surgical damage. Minimally invasive thoracic surgery procedures induce less inflammatory response and reduce the immune defense in patients to a more moderate level compared with the open surgery procedures; this immunosuppression can be further diminished in spontaneous ventilation cases. The normal functioning of the immune defense is important in controlling the perioperative circulatory tumor cells. Moreover, elevated levels of inflammatory cytokines before immune therapy have a negative impact on the response, and significantly shorten the progression-free survival. Clinically, the lower are the levels of cytokines released during lung surgery, the lesser is the postoperative morbidity, especially pneumonia and wound infection. The return to normal levels of lymphocytes and cytokines occurs faster after spontaneous ventilation surgery. The use of locoregional anesthesia can also reduce SI. Herein, we review the current knowledge on the effects of different operative factors on postoperative SI and defense mechanism in lung cancer surgery.

Comparison of Tumor Seeding and Recurrence Rate After Laparoscopic vs. Open Nephroureterectomy for Upper Urinary Tract Transitional Cell Carcinoma

Introduction: Laparoscopic surgery for Upper Urinary Tract Urothelial Cell Carcinoma (UTUC) is still debated for its possible seeding risk and thus consequent oncological recurrences, especially for atypical ones. The aim of the study is to compare recurrence and survival after Laparoscopic vs. Open Radical Nephroureterectomy (RNU) for Upper Urinary Tract Urothelial Cancer (UTUC).

Method: A retrospective evaluation of UTUC consecutive surgeries from 2008 to 2019 was conducted, including pT ≥ 2, High Grade UTUC who underwent RNU with bladder cuff excision without concomitant lymphadenectomy in three urological tertiary centers. Statistical analyses compared recurrence and cancer specific survival, based on surgical approach, while logistic multivariate analyses and Kaplan Meyer survival curve analyzed possible risk factors for recurrence and survival.

Results: One hundred seven cases of RNU, 47 (43.9%) laparoscopic and 60 (56.1%) open, were included in this report. Preoperative characteristics were comparable between groups. However, tumor stage was higher in the Open arm [T3–T4 in 44 (73.3%) vs. 20 (43.4%) in Laparoscopic]. Mean follow-up was 91.6 months in laparoscopy RNU vs. 93.5 months in open RNU. Recurrence rate (RR) was comparable between groups (p = 0.594), and so was the site, although 3 (6.3%) peritoneal recurrences were found only in laparoscopic group (p = 0.057). At multivariate logistic regression, tumor stage and surgical approach were independent predictors of recurrence (p < 0.05), while only tumor stage was predictor of cancer specific death (p = 0.029).

Conclusion: Surgical approach has no impact on recurrence site, overall survival, and RR. Still, according to our data peritoneal carcinomatosis was present only in laparoscopic arm, despite how it didn't reach statistical significance.

Uniportal video-assisted thoracic surgery for major lung resection is associated with less immunochemokine disturbances than multiportal approach

Multiportal video-assisted thoracic surgery (VATS) for major lung resection causes less immunochemokine production compared to thoracotomy. Whether uniportal VATS is similarly associated with lower early postoperative circulating levels of immunochemokines compared to multiportal VATS have not been studied. Selected patients who received uniportal or multiportal VATS major lung resection were recruited. Blood samples were collected preoperatively and on postoperative days 1 and 3 for enzyme linked immunosorbent assay of serum levels of Tissue Inhibitor of Metalloproteinase (TIMP)-1, Insulin Growth Factor Binding Protein (IGFBP)-3, and Matrix Metalloproteinase (MMP)-9. A linear mixed-effects models were used to analyze the effects of uniportal VATS on the postoperative circulating chemokine levels. From March 2014 to April 2017, 68 consecutive patients consented for the prospective study and received major lung resection by either uniportal VATS (N = 29) or multiportal VATS (N = 39) were identified. Uniportal VATS major lung resection was associated with lower post-operative levels of TIMP-1 and MMP-9 compared to multiportal VATS after controlling for the effects of the corresponding baseline level and the time of follow-up measurement. No difference was observed for the level of IGFBP-3. Less immunochemokine disturbances was observed after uniportal VATS major lung resection compared to multiportal VATS.

Low dose of methylprednisolone for pain and immune function after thoracic surgery

BACKGROUND

The purpose of this study was to evaluate the effects of single low-dose preoperative methylprednisolone (MP) on the immunological function and postoperative pain of patients undergoing elective video-assisted thoracoscopic surgery under general anesthesia.

METHODS

Eighty-one patients who underwent elective video-assisted thoracoscopic surgery were randomly assigned to the MP Group or the Control Group. The T lymphocyte subsets of CD3⁺, CD4⁺, and CD8⁺, the CD4⁺/CD8⁺ ratio at T₀ (before anesthesia), T₁ (after surgery), and T₂ (24 h after surgery) were all recorded. Postoperative rest and cough pain scores, as well as postoperative adverse effects and surgery complications were also recorded.

RESULTS

Compared to T0, the levels of CD3⁺ and CD4⁺ subsets and CD4⁺/CD8⁺ were significantly decreased, the level of CD8⁺ were increased after surgery in both groups. There was no significant difference in the variation of CD3+, CD4+, CD8⁺, and CD4+/CD8+ between the MP Group and the Control Group. Both the rest and cough pain of patients in the MP Group were significantly lower as compared to the Control Group at 2, 4, 6 and 24 hours after surgery. And the incidences of nausea and vomiting and dizziness were also significantly higher in the Control Group than those in the MP Group.

CONCLUSIONS

Preoperative single low-dose of MP (1 mg/kg) has no effect on immune function. Preoperative single low dose of MP (1 mg/kg) had effective analgesic effects and could reduce the incidence of dizziness and postoperative nausea and vomiting.

Predictors of Mortality after Surgery for Empyema Thoracis in Chronic Kidney Disease Patients

Background

Surgical treatment of empyema thoracis in patients with chronic kidney disease is challenging, and few studies in the literature have evaluated this issue. In this study, we aim to report the surgical outcomes of empyema and to analyze factors predicting perioperative mortality in patients with chronic kidney disease.

Methods

This retrospective study included data from 34 patients with chronic kidney disease (estimated glomerular filtration rate <60 mL/min/1.73 m2 for 3 or more months) who underwent surgery for empyema between 2012 and 2020. An analysis of demographic characteristics and perioperative variables, including complications, was carried out. Postoperative mortality was the primary outcome measure.

Results

Patients' age ranged from 20 to 74 years with a 29-to-5 male-female ratio. The majority (n=19, 55.9%) of patients were in end-stage renal disease (ESRD) requiring maintenance hemodialysis. The mean operative time was 304 minutes and the mean intraoperative blood loss was 562 mL. Postoperative morbidity was observed in 70.5% of patients (n=24). In the subgroup analysis, higher values for operative time, blood loss, intensive care unit stay, and complications were found in ESRD patients. The mortality rate was 38.2% (n=13). In the univariate and multivariate analyses, poor performance status (Eastern Cooperative Oncology Group >2) (p=0.03), ESRD (p=0.02), and late referral (>8 weeks) (p<0.001) significantly affected mortality.

Conclusion

ESRD, late referral, and poor functional status were poor prognostic factors predicting postoperative mortality. The decision of surgery should be cautiously assessed given the very high risk of perioperative morbidity and mortality in these patients.

Operative invasiveness does not affect the prognosis of patients with non-small cell lung cancer

Background

The relationship between operative invasiveness and the prognosis in non-small cell lung cancer (NSCLC) patients who have undergone surgery has been controversial.

Methods

Clinical data were analyzed for 463 NSCLC patients. Operative invasiveness was defined by wound length, operation time, and the postoperative C-reactive protein (postCRP) level. The operative approach was divided into video-assisted thoracic surgery (VATS) and thoracotomy.

Results

The wound length and operation time were significantly correlated with the postCRP level (correlation coefficient (CC) = 0.39, p <  0.01; CC = 0.54, p <  0.01, respectively). The postCRP level in the VATS group was significantly lower than that in the thoracotomy group (12.2 mg/dl vs 20.58 mg/dl, p <  0.01). The relapse-free survival differed significantly based on wound length (p <  0.01), operation time (p = 0.01), CRP level (p <  0.01), and operative approach (p <  0.01). The carcinoembryonic antigen level (hazard ratio [HR], 1.58; p = 0.02), pathological stage (pStage) (HR, 2.57; p <  0.01), vascular invasion (HR, 1.95; p = 0.01), and preoperative CRP level (preCRP) (HR, 1.91; p <  0.01) were identified as significant prognostic factors for relapse-free survival in a multivariate analysis. Furthermore, the multivariate analysis showed that smoking history (HR, 2.36; p = 0.03), pStage (HR, 3.26; p <  0.01), and preCRP level were significant prognostic factors for overall survival.

Conclusion

Preoperative CRP level was associated with poor prognosis. Although the VATS approach might be less invasive procedure for NSCLC patients, operative invasiveness does not affect the prognosis.

Dynamics of coagulation factor XIII activity after video-assisted thoracoscopic lobectomy for non-small cell lung cancer

Background

The present study was performed to investigate the perioperative dynamics of coagulation factor XIII (FXIII) in patients with non-small cell lung cancer undergoing video-assisted thoracoscopic surgery (VATS) lobectomy compared with open lobectomy.

Methods

Perioperative coagulation factors including FXIII were analyzed in 30 patients who underwent VATS lobectomy and 10 patients who underwent open lobectomy at Teikyo University Hospital from December 2017 to April 2019.

Results

Patients in the VATS lobectomy group showed higher FXIII activity on postoperative day (POD) 5 than patients in the open lobectomy group (P=0.028). The FXIII activity was significantly lower on POD3, POD5, and POD7 than that in the preoperative period and on POD1, even in patients who had undergone VATS lobectomy (P<0.001). No factors were found to affect the maintenance of FXIII in the VATS lobectomy group.

Conclusion

The postoperative decrease of FXIII activity differed between patients who underwent VATS lobectomy and those who underwent open lobectomy. Based on the characteristics of FXIII, the FXIII activity may be a good marker of the invasiveness of VATS lobectomy versus open lobectomy.

Video-assisted thoracoscopic surgery for thoracic empyema in patients on maintenance hemodialysis

OBJECTIVE

Thoracic empyema in uremic patients on maintenance hemodialysis is a challenging situation. The clinical characteristics are rarely reported, and the surgical outcomes remain unclear. We report our experience with video-assisted thoracoscopic surgery in these patients during 10-year period of time.

METHODS

Between 2005 and 2015, we retrospectively reviewed the clinical characteristics, bacteriological studies, and thoracoscopic surgical results of 23 empyema patients undergoing maintenance hemodialysis.

RESULTS

The mean patient age was 67.1 ± 12.9 years. All patients had additional preexisting systemic diseases. The mean duration of hemodialysis was 34.7 ± 25.8 months. The infections causing empyema were pneumonia in 11 (47.8%), blood stream infection in 8 (34.8%), and uremic pleuritis in 4 (17.4%). Among the 22 identified microorganisms, the most common pathogen was methicillin-resistant Staphylococcus aureus (31.8%). After thoracoscopic surgery, 8 patients (34.8%) required additional procedures for complications, including 2 patients who required repeated thoracoscopy for hemothorax and 6 (26.1%) patients who required open drainage for residual empyema. The mean hospital stay was 62.4 days, and 6 patients (26.1%) died in the hospital. Univariate and multivariate analyses revealed that maintenance hemodialysis longer than 5 years was a significant factor associated with in-hospital mortality (odds ratio: 14.8, 95% confidence interval 1.5-151.6; p < 0.0001).

CONCLUSION

While surgical management of thoracic empyema in uremic patients undergoing maintenance hemodialysis is associated with high rates of complication and mortality, thoracoscopic surgery is feasible, especially for patients undergoing hemodialysis for less than 5 years.

[Video-assisted thoracoscopic thymectomy in myasthenia gravis. New approach]

AIM

To present possibility and technical aspects of anesthetic management during video-assisted thoracoscopic thymectomy in patients with myasthenia gravis.

MATERIAL AND METHODS

The article describes the proposed modified anesthetic method that is suitable for video-assisted thoracoscopic thymectomy in patients with myasthenia gravis. Nine patients with myasthenia underwent VATS-thymectomy. Anesthesia was performed with artificial airway and auxiliary ventilation without muscle relaxants administration.

Laparoscopic Nissen fundoplication: The effects of high-concentration supplemental perioperative oxygen on the inflammatory and immune response: A randomised controlled trial

Background

A number of studies have been reported on the effects of high-concentration oxygen (HCO) on cytokine synthesis, with controversial results. We assessed the effect of administration of perioperative HCO on systemic inflammatory and immune response in patients undergoing laparoscopic Nissen fundoplication (LNF).

Materials and Methods

Patients (n = 117) were assigned randomly to an oxygen/air mixture with a fraction of inspired oxygen (FiO₂) of 30% (n = 58) or 80% (n = 59). Administration was commenced after induction of anaesthesia and maintained for 6 h after surgery. White blood cells, peripheral lymphocytes subpopulation, human leucocyte antigen-DR (HLA-DR), neutrophil elastase, interleukin (IL)-1 and IL-6 and C-reactive protein (CRP) were investigated.

Results

A significantly higher concentration of neutrophil elastase, IL-1, IL-6 and CRP was detected post-operatively in the 30% FiO₂group patients in comparison with the 80% FiO₂group (P < 0.05). A statistically significant change in HLA-DR expression was recorded post-operatively at 24 h, as a reduction of this antigen expressed on monocyte surface in patients from 30% FiO₂group; no changes were noted in 80% FiO₂group (P < 0.05).

Conclusions

This study demonstrated that perioperative HCO (80%), during LNF, can lead to a reduction in post-operative inflammatory response, and possibly, avoid post-operative immunosuppression.

The role of physiotherapy in patients undergoing pulmonary surgery for lung cancer. A literature review

This review aims to appraise the role of physiotherapy care in patients submitted to pulmonary surgery, in preoperative, perioperative, and postoperative phases. Pulmonary surgery is the gold standard treatment for patients with lung cancer if it is completely resectable. However, the major impairments and complications induced by surgery are well known. Physiotherapy has been regularly used both in the preparation of the surgical candidates; in their functional recovery in the immediate postoperative period, and in the medium/long term but there is a lack of concise evidence-based recommendations. Therefore, the aim of this review is to appraise the literature about the role of physiotherapy interventions in patients undergoing lung surgery for lung cancer, in preoperative, perioperative, postoperative and maintenance stages, to the recovery and well-being, regardless of the extent of surgical approach. In conclusion, physiotherapy programs should be individually designed, and the goals established according to surgery timings, and according to each subject's needs. It can also be concluded that in the preoperative phase, the main goals are to avoid postoperative pulmonary complications and reduce the length of hospital stay, and the therapeutic targets are respiratory muscle training, bronchial hygiene and exercise training. For the perioperative period, breathing exercises for pulmonary expansion and bronchial hygiene, as well as early mobilization and deambulation, postural correction and shoulder range of motion activities, should be added. Finally, it can be concluded that in the postoperative phase exercise training should be maintained, and adoption of healthy life-style behaviours must be encouraged.

Minimally invasive surgery for upper gastrointestinal cancer: Our experience and review of the literature

Minimally invasive surgery (MIS) for upper gastrointestinal (GI) cancer, characterized by minimal access, has been increasingly performed worldwide. It not only results in better cosmetic outcomes, but also reduces intraoperative blood loss and postoperative pain, leading to faster recovery; however, endoscopically enhanced anatomy and improved hemostasis via positive intracorporeal pressure generated by CO2 insufflation have not contributed to reduction in early postoperative complications or improvement in long-term outcomes. Since 1995, we have been actively using MIS for operable patients with resectable upper GI cancer and have developed stable and robust methodology in conducting totally laparoscopic gastrectomy for advanced gastric cancer and prone thoracoscopic esophagectomy for esophageal cancer using novel technology including da Vinci Surgical System (DVSS). We have recently demonstrated that use of DVSS might reduce postoperative local complications including pancreatic fistula after gastrectomy and recurrent laryngeal nerve palsy after esophagectomy. In this article, we present the current status and future perspectives on MIS for gastric and esophageal cancer based on our experience and a review of the literature.

Comparison of postoperative immune function in patients with thoracic esophageal cancer after video-assisted thoracoscopic surgery or conventional open esophagectomy

AIM

The aim of the study was to compare postoperative immune function in patients with thoracic esophageal cancer (EC) after video-assisted thoracoscopic surgery (VATS) or conventional open esophagectomy.

PATIENTS AND METHODS

Medical records were retrospectively analyzed for 228 patients with thoracic EC treated at a single hospital using VATS (n = 52) or conventional open esophagectomy (n = 176). Proportions of CD3(+), CD4(+), CD8(+), and natural kill (NK) cells, as well as the ratio of CD4(+) to CD8(+) cells, were measured in the two groups using flow cytometry on preoperative day (PrD) 1 and postoperative days (PoD) 1 and 7.

RESULTS

Proportions of CD3(+), CD4(+), and NK cells as well as the CD4+/CD8+ ratio decreased significantly from PrD1 to PoD1 in both the VATS and open esophagectomy groups. In the VATS group, these parameters had returned to preoperative levels (PrD1) by PoD7. These parameters in open esophagectomy group increased from PoD1 to PoD7 but also lowered significantly to PrD1 by PoD7. The proportion of CD8(+) cells was similar between the two groups at all time points tested.

CONCLUSION

Patients may experience less postoperative immune suppression after VATS than after conventional open esophagectomy, and they may recover preoperative immune function more quickly.

Video-assisted thoracoscopic surgery lobectomy for lung cancer versus thoracotomy: a less decrease in sVEGFR2 level after surgery

BACKGROUND

Angiogenic and anti-angiogenic factors play an important role in tumor biology and tumor recurrence after surgical resection. Antiangiogenic factors such as vascular endothelial growth factor (VEGF)-receptor 1 (sVEGFR1) and sVEGFR2, two soluble form receptor proteins of VEGF, are critical for angiogenesis. VEGF can be sequestered by soluble forms of these receptors, which result in decreasing VEGF amount available to bind to its receptor on vascular endothelial cell surface. This study aimed to investigate the influences of video-assisted thoracoscopic surgery (VATS) lobectomy and open by thoracotomy for early stage non-small cell lung cancer (NSCLC) on postoperative circulating sVEGFR1 and sVEGFR2 levels.

METHODS

Forty-eight lung cancer patients underwent lobectomy through either VATS (n=26) or thoracotomy (n=22). Blood samples were collected from all patients preoperatively and postoperatively on days 1, 3 and 7. ELISA analysis was used to determine the plasma levels of sVEGFR1 and sVEGFR2. Data are reported as means and standard deviations, and were assessed with the Wilcoxon signed-Rank test (P<0.05).

RESULTS

For all patients undergoing lobectomy, postoperative sVEGFR1 levels on days 1 and 3 were markedly increased, while postoperative sVEGFR2 levels on days 1 and 3 were significantly decreased. Moreover, VATS group had significantly higher plasma level of sVEGFR2 postoperative in comparison with open thoracotomy (OT) on day 1 (VATS 6,953±1,535 pg/mL; OT 5,874±1,328 pg/mL, P<0.05).

CONCLUSIONS

Major pulmonary resection for early stage NSCLC resulted in the increased sVEGFR1 and decreased sVEGFR2 productions. VATS is associated with enhanced anti-angiogenic response with higher circulating sVEGFR2 levels compared with that with OT. Such differences in anti-angiogenic response may have an important effect on cancer biology and recurrence after surgery.

Effects of low and standard intra-abdominal pressure on systemic inflammation and immune response in laparoscopic adrenalectomy: A prospective randomised study

BACKGROUND:

The advantages of laparoscopic adrenalectomy (LA) over open adrenalectomy are undeniable. Nevertheless, carbon dioxide (CO₂) pneumoperitoneum may have an unfavourable effect on the local immune response. The aim of this study was to compare changes in the systemic inflammation and immune response in the early post-operative (p.o.) period after LA performed with standard and low-pressure CO₂ pneumoperitoneum.

MATERIALS AND METHODS:

We studied, in a prospective randomised study, 51 patients consecutively with documented adrenal lesion who had undergone a LA: 26 using standard-pressure (12-14 mmHg) and 25 using low-pressure (6-8 mmHg) pneumoperitoneum. White blood cells (WBC), peripheral lymphocyte subpopulation, human leucocyte antigen-DR (HLA-DR), neutrophil elastase, interleukin (IL)-6 and IL-1, and C-reactive protein (CRP) were investigated.

RESULTS:

Significantly higher concentrations of neutrophil elastase, IL-6 and IL-1 and CRP were detected p.o. in the standard-pressure group of patients in comparison with the low-pressure group (P < 0.05). A statistically significant change in HLA-DR expression was recorded p.o. at 24 h, as a reduction of this antigen expressed on the monocyte surface in patients from the standard group; no changes were noted in low-pressure group patients (P < 0.05).

CONCLUSIONS:

This study demonstrated that reducing the pressure of the pneumoperitoneum to 6-8 mmHg during LA reduced p.o. inflammatory response and averted p.o. immunosuppression.

Single port VATS: recent developments in Asia

Single port video-assisted thoracic surgery (VATS) is the most recent evolution in minimally invasive thoracic surgery. With increasing global popularity, the single port VATS approach has been adopted by experienced thoracic surgeons in many Asian countries. From initial experience of single port VATS lobectomy to the more complex sleeve resection procedures now forming part of daily practice in some Asia institutes, the region has been the proving ground for single port VATS approaches' feasibility and safety. In addition, certain technical refinements in single port VATS lung resection and lymph node dissection have also sprung from Asia. Novel equipment designed to facilitate single port VATS allowing further reduce access trauma are being realized by the partnership between surgeons and the industries. Advanced thoracoscopes and staplers that are narrower and more maneuverable are particularly important in the smaller habitus of patients from Asia. These and similar new generation equipment are being applied to single port VATS in novel ways. As dedicated thoracic surgeons in the region continue to striving for excellence, innovative ideas in single incision access including subxiphoid and embryonic natural-orifice transluminal endoscopic surgery (e-NOTES) have been explored. Adjunct techniques and technology used in association with single port VATS such as non-intubated surgery, hybrid operating room image guidance and electromagnetic navigational bronchoscopy are all in rapid development in Asia.

Thoracoscopic Lobectomy for Non-small Cell Lung Cancer

Lobectomy is the gold standard treatment in operable patients with surgically resectable non-small cell lung cancer. Thoracoscopic lobectomy has emerged as an option for surgeons facile with the technique. Video-assisted thoracoscopic surgery (VATS) is used for a variety of indications, but its efficacy as a reliable oncologic procedure makes it appealing in the treatment of non-small cell lung cancer. Fewer postoperative complications and decreased postoperative pain associated with VATS procedures can lead to shorter lengths of stay and lower overall costs. Thoracoscopic surgery continues to evolve, and uniportal, robot-assisted, and awake thoracoscopic procedures have all shown promising results.

Postoperative Regulatory T-Cells and Natural Killer Cells in Stage I Nonsmall Cell Lung Cancer Underwent Video-assisted Thoracoscopic Lobectomy or Thoracotomy

BACKGROUND

Regulatory T-cells (Treg) play key roles in suppressing cell-mediated immunity in cancer patients. Little is known about perioperative Treg fluctuations in nonsmall cell lung cancer (NSCLC). Video-assisted thoracoscopic (VATS) lobectomy, as a minimal invasive procedure for treating NSCLC, may have relatively less impact on the patient's immune system. This study aimed to observe perioperative dynamics of circulating Treg and natural killer (NK) cell levels in NSCLC patients who underwent major lobectomy by VATS or thoracotomy.

METHODS

Totally, 98 consecutive patients with stage I NSCLC were recruited and assigned into VATS or thoracotomy groups. Peripheral blood samples were taken on 1-day prior to operation, postoperative days (PODs) 1, 3, 7, 30, and 90. Circulating Treg and NK cell counts were assayed by flow cytometry, defined as CD4 + CD25 + CD127 low cells in CD4 + lymphocytes and CD56 + 16 + CD3- cells within CD45 + leukocytes respectively. With SPSS software version 21.0 (SPSS Inc., USA), differences between VATS and thoracotomy groups were determined by one-way analysis of variance (ANOVA), and differences between preoperative baseline and PODs in each group were evaluated by one-way ANOVA Dunnett t-test.

RESULTS

In both groups, postoperative Treg percentages were lower than preoperative status. No statistical difference was found between VATS and thoracotomy groups on PODs 1, 3, 7, and 30. On POD 90, Treg percentage in VATS group was significantly lower than in thoracotomy group (5.26 ± 2.75 vs. 6.99 ± 3.60, P = 0.012). However, a higher level of NK was found on all PODs except on POD 90 in VATS group, comparing to thoracotomy group.

CONCLUSIONS

Lower Treg level on POD 90 and higher NK levels on PODs 1, 3, 7, 30 in VATS group might imply better preserved cell-mediated immune function in NSCLC patients, than those in thoracotomy group.

Physiologic and immunologic effects of subxiphoid pulmonary lobectomy compared with transthoracic pulmonary lobectomy in a canine survival model

BACKGROUND

Subxiphoid thoracoscopic surgery has been used in various thoracic surgical procedures. The aim of this study is to compare the physiological and inflammatory responses between subxiphoid thoracoscopic surgery and standard transthoracic thoracoscopic surgery for anatomic pulmonary lobectomy in a canine model.

METHODS

Nineteen dogs were assigned to subxiphoid (n=10) or standard thoracoscopy (n=9). Animals in the subxiphoid and standard thoracoscopy group received anatomic lobectomy via a 3-cm xiphoid and thoracic incision, respectively. Physiological and inflammatory parameters were compared between the two groups before surgery, during the operation, and on postoperative days 1, 3, 7, and 14. The animals were sacrificed and necropsied at 2 weeks after surgery.

RESULTS

All procedures were performed successfully with no conversion nor complication. The physiologic changes were similar in both groups. There was no observable different between the two groups in terms of C-reactive protein (CRP) level, interleukin-6 (IL-6) level, neutrophil count, neutrophil 20,70-dichlorodihydrofluorescein (DCFH) expression, monocyte count, monocyte inducible nitric oxide synthase (iNOS), and CD4/CD8 ratios. However, the reduction of total lymphocyte count, CD4, and CD8 lymphocyte counts were observed in the subxiphoid anatomic lobectomy group on postoperative day 7, which was significantly lower than that of the standard transthoracic thoracoscopic approach.

CONCLUSIONS

Subxiphoid thoracoscopic surgery resulted in similar physiologic impact and surgical outcome to those of standard transthoracic thoracoscopic surgery. Nevertheless, subxiphoid thoracoscopic surgery is associated with more pronounced immunosuppression than the standard transthoracic thoracoscopic approach.

Operative outcomes of thoracoscopic lobectomy for non-small-cell lung cancer

Aim

We examined the advantages of thoracoscopy over thoracotomy in terms of perioperative outcomes and toleration of adjuvant chemotherapy.

Methods

Between April 2010 and March 2013, 657 patients with non-small-cell lung cancer who underwent lobectomy were classified into thoracoscopy (308 patients) and thoracotomy (349 patients) groups and compared.

Results

The thoracoscopy group had less blood loss compared to the thoracotomy group ( p < 0.001). When limiting the analysis to pathological stage I patients, the results were similar ( p < 0.001). In addition, the difference in blood loss between the 2 groups was greater in patients with severe pleural adhesions. The postoperative morbidity of the thoracoscopy group was significantly less than that of the thoracotomy group (13.3% vs. 21.2%, p < 0.001), and this result was similar when analyzing the pathological stage I patients (12.6% vs. 20.6%, p = 0.001). A higher percentage of the thoracoscopy group received both the full planned course and dose of adjuvant chemotherapy compared to the thoracotomy group (84.2% vs. 65.8%, p = 0.032).

Conclusions

These results indicate that totally thoracoscopic lobectomy is the more beneficial surgical approach with regard to the incidence of postoperative complications and toleration of adjuvant chemotherapy.

Routine clinical markers of the magnitude of the systemic inflammatory response after elective operation: a systematic review

BACKGROUND

Operative injury to the body from all procedures causes a stereotypical cascade of neuroendocrine, cytokine, myeloid, and acute phase responses. This response has been examined commonly by the use of cortisol, interleukin-6 (IL-6), white cell count, and C-reactive protein (CRP). We aimed to determine which markers of the systemic inflammatory response were useful in determining the magnitude of injury after elective operations.

METHODS

A systematic review of the literature was performed using surgery, endocrine response, systemic inflammatory response, cortisol, IL-6, white cell count, and CRP. For each analyte the studies were grouped according to whether the operative injury was considered to be minor, moderate, or major and then by the operative procedure.

RESULTS

A total of 164 studies were included involving 14,362 patients. The IL-6 and CRP responses clearly were associated with the magnitude of operative injury and the invasiveness of the operative procedure. For example, the peak CRP response increased from 52 mg/L with cholecystectomy to 123 mg/L with colorectal cancer resection, 145 mg/L with hip replacement, 163 mg/L after abdominal aortic aneurysm repair, and 189 mg/L after open cardiac surgery. There also appeared to be a difference between minimally invasive/laparoscopic and open procedures such as cholecystectomy (27 vs 80 mg/L), colorectal cancer resection (97 vs 133 mg/L), and aortic aneurysm repair (132 vs 180 mg/L).

CONCLUSION

Peak IL-6 and CRP concentrations consistently were associated with the magnitude of operative injury and operative procedure. These markers may be useful in the objective assessment of which components of Enhanced Recovery after Surgery are likely to improve patient outcome and to assess the possible impact of operative injury on immune function.

Modern impact of video assisted thoracic surgery

With advancement in technology, experience and training over the last two decades, video assisted thoracic surgery (VATS) has become widely accepted and utilized all over the world. VATS started as a diagnostic tool in the early 1990s, technique of VATS lobectomy evolved and became safer over the next 10-15 years and now it is being used for more advanced and hybrid operations. VATS has contributed to the development of minimally invasive surgical interventions for other thoracic disorders like mediastinal tumors and esophageal cancer as well. This article looks at the advantages of VATS, technique advancements and its applications in other thoracic operations and its influence on the present and future of thoracic surgery.

Uniportal VATS in Asia

The history of uniportal Video-assisted thoracic surgery (VATS) stretches back almost a decade with the treatment of simple thoracic conditions. As the technique matures with increasing ability to tackle the full spectrum of thoracic surgical diseases, most notably major lung resections for lung tumours, the spread of uniportal VATS across the globe has been phenomenal. VATS centres in Asia are now performing uniportal VATS, and developing their individual styles and techniques with great successes. The enthusiasm from surgeons, demand from patients, as well as the dynamism and diversity of uniportal VATS in the region have helped fuel this excitement and change. The 1st Asian Single Port VATS Symposium in 2013 heralded the beginning of academic exchange between uniportal VATS centres in Asia and experts from around the world. Wetlabs in the region will provide further training for thoracic surgeons interested in super-specializing in uniportal VATS. The future of this approach will hinge on good regional collaboration, research and training.

Complete video-assisted thoracoscopic surgery for lung cancer in 400 patients

BACKGROUND

We report the results of complete video-assisted thoracoscopic surgery for treatment of primary non-small cell lung cancer, which was performed completely through the monitor in 400 consecutive patients.

PATIENTS AND METHODS

Between September 25, 2002 and August 25, 2011, a retrospective database of 400 consecutive patients who underwent complete video-assisted thoracoscopic surgery for treatment of primary non-small cell lung cancer was reviewed. Demographic, histopathologic, preoperative, perioperative, postoperative, and outcome variables were assessed using standard descriptive statistics and Kaplan-Meier survival analyses.

RESULTS

Operating time was 258.13 ± 62.53 min, volume of blood loss was 253.21 ± 206.66 mL, duration of drainage was 3.6 ± 3.2 days, volume of drainage was 708.1 ± 522.8 mL, the postoperative respiratory complication rate was 14.8%, the reoperation rate was 1.3%, and operative mortality was 1.0%. The 5-year postsurgical survival rates for pathologic stages I, II, and III were 93.9%, 62.0%, and 61.6%, respectively; the 3-year postsurgical survival rate for pathologic stage IV was 40.0%

CONCLUSIONS

Complete video-assisted thoracoscopic surgery for treatment of primary non-small cell lung cancer is associated with safety and acceptable postoperative complication rates, operative mortality rates, and survival rates.

Acute thoracic empyema: clinical characteristics and outcome analysis of video-assisted thoracoscopic surgery

BACKGROUND/PURPOSE

Acute thoracic empyema is a common clinical problem worldwide, resulting in substantial morbidity and mortality. The objective of this study was to report its clinical characteristics and to evaluate whether thoracoscopic surgery is associated with a lower rate of in-hospital mortality compared with nonoperative drainage.

METHODS

Between 2001 and 2010, we retrospectively reviewed the clinical characteristics, bacteriological studies, and treatment outcomes of 602 patients with acute thoracic empyema. Thoracoscopic surgery was performed in 417 (69.2%) patients, while the remaining patients underwent nonoperative drainage. After treatment, 77 patients (12.8%) died in the hospital. A propensity score-based process, matched on potential risk factors for in-hospital mortality, was performed to select patients with equalized potential prognostic factors in the thoracoscopy and nonoperative groups. The log-rank test was used to compare the survival time with discharge between the two matched groups.

RESULTS

Multivariate analysis showed that age, malignancy, chronic lung disease, chronic renal insufficiency, liver cirrhosis, polymicrobial infection, and positive bacterial culture were risk factors for in-hospital mortality. The propensity score-matched analysis showed that the in-hospital mortality difference was significant (p = 0.014) and the Kaplan-Meier survival analysis revealed a higher survival rate to discharge (p < 0.001 by log-rank test), both favoring thoracoscopy over nonoperative drainage.

CONCLUSION

Acute thoracic empyema carries a high mortality rate, especially in elderly patients with coexisting medical conditions and polymicrobial and positive bacterial cultures. Our study results also showed that thoracoscopy is feasible and might provide better chances for survival in borderline operable patients than nonoperative drainage.

Video-assisted thoracic surgery in lung cancer resection: a meta-analysis and systematic review of controlled trials

OBJECTIVES

: This meta-analysis sought to determine whether video-assisted thoracic surgery (VATS) improves clinical and resource outcomes compared with thoracotomy (OPEN) in adults undergoing lobectomy for nonsmall cell lung cancer.

METHODS

: A comprehensive search was undertaken to identify all randomized (RCT) and nonrandomized (non-RCT) controlled trials comparing VATS with OPEN thoracotomy available up to April 2007. The primary outcome was survival. Secondary outcomes included any other reported clinical outcome and resource utilization. Odds ratios (OR), weighted mean differences (WMD), or standardized mean differences (SMD), and their 95% confidence intervals (95% CI) were analyzed as appropriate.

RESULTS

: Baseline prognosis was more favorable for VATS (more females, smaller tumor size, less advanced stage, histology associated with peripheral location and with more indolent disease) than for OPEN in non-RCTs, but not RCT. Postoperative complications were significantly reduced in the VATS group compared with OPEN surgery when both RCT and non-RCT were considered in aggregate (OR 0.48, 95% CI 0.32-0.70). Although overall blood loss was significantly reduced with VATS compared with OPEN (-80 mL, 95% CI -110 to -50 mL), the incidence of excessive blood loss (generally defined as >500 mL) and incidence of re-exploration for bleeding was not significantly reduced. Pain measured via visual analog scales (10-point VAS) was significantly reduced by <1 point on day 1, by >2 points at 1 week, and by <1 point at week 2 to 4. Similarly, analgesia requirements were significantly reduced in the VATS group. Postoperative vital capacity was significantly improved (WMD 20, 95% CI 15-25), and at 1 year was significantly greater for VATS versus OPEN surgery (WMD 7, 95% CI 2-12). The incidence of patients reporting limited activity at 3 months was reduced (OR 0.04, 95% CI 0.00-0.82), and time to full activity was significantly reduced in the VATS versus OPEN surgery (WMD -1.5, 95% CI -2.1 to -0.9). Overall patient-reported physical function scores did not differ between groups at 3 years follow-up. Hospital length of stay was significantly reduced by 2.6 days despite increased 16 minutes of operating time for VATS versus OPEN. The incidence of cancer recurrence (local or distal) was not significantly different, but chemotherapy delays were significantly reduced for VATS versus OPEN (OR 0.15, 95% CI 0.06-0.38). The need for chemotherapy reduction was also decreased (OR 0.37, 95% CI 0.16-0.87), and the number of patients who did not receive at least 75% of their planned chemotherapy without delays were reduced (OR 0.41, 95% CI 0.18-0.93). The risk of death was not significantly reduced when RCTs were considered alone; however, when non-RCTs (n = 18) were included, the risk of death at 1 to 5 years was significantly reduced (OR 0.72, 95% CI 0.55-0.94; P = 0.02) for VATS versus OPEN. Stage-specific survival to 5 years was not significantly different between groups.

CONCLUSIONS

: This meta-analysis suggests that there may be some short term, and possibly even long-term, advantages to performing lung resections with VATS techniques rather than through conventional thoracotomy. Overall, VATS for lobectomy may reduce acute and chronic pain, perioperative morbidity, and improve delivery of adjuvant therapies, without a decrease in stage specific long-term survival. However, the results are largely dependent on non-RCTs, and future adequately powered randomized trials with long-term follow-up are encouraged.

Surgical trauma and immune functional changes following major lung resection

Video-assisted thoracic surgery (VATS) has evolved greatly over the last two decades. VATS major lung resection for early stage non-small cell lung carcinoma (NSCLC) has been shown to result in less postoperative pain, less pulmonary dysfunction postoperatively, shorter hospital stay, and better patient tolerance to adjuvant chemotherapy compared with patients who underwent thoracotomy. Several recent studies have even reported improved long-term survival in those who underwent VATS major lung resection for early stage NSCLC when compared with open technique. Interestingly, the immune status and autologous tumor killing ability of lung cancer patients have previously been associated with long-term survival. VATS major lung resection can result in an attenuated postoperative inflammatory response. Furthermore, the minimal invasive approach better preserve patients' postoperative immune function, leading to higher circulating natural killer and T cells numbers, T cell oxidative activity, and levels of immunochemokines such as insulin growth factor binding protein 3 following VATS compared with thoracotomy. Apart from host immunity, the angiogenic environment following surgery may also have a role in determining cancer recurrence and possibly survival. Whether differences in immunological and biochemical mediators contribute significantly towards improved clinical outcomes following VATS major lung resection for lung cancer remains to be further investigated. Future studies will also need to address whether the reduced access trauma from advanced thoracic surgical techniques, such as single-port VATS, can further attenuate the postoperative inflammatory response.

Angiogenic response to major lung resection for non-small cell lung cancer with video-assisted thoracic surgical and open access

Background. Angiogenic factors following oncological surgery is important in tumor recurrence. Vascular endothelial growth factor (VEGF), angiopoietin 1 (Ang-1), Ang-2, soluble VEGF-receptor 1 (sVEGFR1) and sVEGFR2 may influence angiogenesis. This prospective study examined the influence of open and video-assisted thoracic surgery (VATS) lung resections for early stage non-small cell lung cancer (NSCLC) on postoperative circulating angiogenic factors. Methods. Forty-three consecutive patients underwent major lung resection through either VATS (n = 23) or Open thoracotomy (n = 20) over an 8-month period. Blood samples were collected preoperatively and postoperatively on days (POD) 1 and 3 for enzyme linked immunosorbent assay determination of angiogenic factors. Results. Patient demographics were comparable. For all patients undergoing major lung resection, postoperative Ang-1 and sVEGFR2 levels were significantly decreased, while Ang-2 and sVEGFR1 levels markedly increased. No significant peri-operative changes in VEGF levels were observed. Compared with open group, VATS had significantly lower plasma levels of VEGF (VATS 170 ± 93 pg/mL; Open 486 ± 641 pg/mL; P = 0.04) and Ang-2 (VATS 2484 ± 1119 pg/mL; Open 3379 ± 1287 pg/mL; P = 0.026) on POD3. Conclusions. Major lung resection for early stage NSCLC leads to a pro-angiogenic status, with increased Ang-2 and decreased Ang-1 productions. VATS is associated with an attenuated angiogenic response with lower circulating VEGF and Ang-2 levels compared with open. Such differences in angiogenic factors may be important in lung cancer biology and recurrence following surgery.

Laparoscopic total colectomy and ileorectal anastomosis (IRA), supported by an enhanced recovery programme in cases of familial adenomatous polyposis

AIM

Familial adenomatous polyposis (FAP) is associated with an almost 100% chance of colorectal cancer by the age of 50 years. Surgery is the only prophylaxis. The study compared the outcome of prophylactic laparoscopic colectomy and ileorectal anastomosis (IRA) with conventional open surgery.

METHOD

A case-control study was carried out including all cases of proven FAP undergoing prophylactic laparoscopic colectomy with IRA between 1 April 2006 and 31 March 2008 using a standardized technique within an enhanced recovery programme (ERAS). All data were collected prospectively. Controls were identified retrospectively from patients who underwent open prophylactic IRA before 31 March 2008 and were matched for age, gender, BMI and ASA. Outcomes included duration of surgery, complications, length of stay, readmission and mortality.

RESULTS

During the study period 25 patients underwent laparoscopic IRA. The median operating time was longer in the laparoscopic group (235 vs 180 mins, P < 0.0001) but the median hospital stay was shorter (6 vs 9 days, P = 0.002). Overall there were fewer complications in the laparoscopic group (20%vs 40%, P = 0.3).

CONCLUSION

Laparoscopic prophylactic colectomy with IRA in FAP is safe and feasible, and combined with ERAS leads to accelerated recovery and possibly fewer complications than open surgery. FAP patients undergoing prophylactic IRA should be offered laparoscopic surgery.

Thoracic empyema in patients with liver cirrhosis: clinical characteristics and outcome analysis of thoracoscopic management

OBJECTIVE

Thoracic empyema in cirrhotic patients is a challenging situation, and the clinical characteristics are rarely reported. The objective of this study was to report the clinical characteristics among this group and to evaluate whether thoracoscopic intervention would affect clinical outcomes.

METHODS

Between 2001 and 2010, we retrospectively reviewed the clinical characteristics, bacteriologic studies, and treatment outcomes of 63 cirrhotic patients with thoracic empyema. A propensity-score based process, matched on age, sex, diabetes mellitus, malignancy, cause, and Child-Pugh classification (A, B, or C), was performed to equalize potential prognostic factors in thoracoscopy and nonthoracoscopy groups. The Kaplan-Meier curve and log-rank test were applied to compare the survival to discharge between the 2 matched groups.

RESULTS

The median patient age was 61 years. Thirty-two patients (51%) underwent thoracoscopic management, and the remaining patients underwent thoracocentesis or tube thoracostomy. The median hospital stay was 28 days, and 19 patients (30%) had in-hospital mortality. Multivariate analysis showed that Child-Pugh C disease and positive blood cultures were risk factors for in-hospital mortality (P = .016 and .027, respectively), whereas thoracoscopic management may be favorable for survival (P = .041). The propensity score-matched analysis showed a significant reduction in intensive care unit stay (P = .044) in the thoracoscopy group. Kaplan-Meier survival analysis revealed a higher survival to discharge, favoring thoracoscopy over non-thoracoscopy treatment (P = .035).

CONCLUSIONS

Management of thoracic empyema in cirrhotic patients is complicated and associated with a high mortality. With proper patient selection, thoracoscopic management is feasible and may provide a better chance of survival.

Technical advances in mediastinal surgery: videothoracoscopic approach to posterior mediastinal tumors

Videothoracoscopic approach to posterior mediastinal tumors is a safe operation in experienced hands. This approach produces results comparable to the other conventional surgical techniques for excision. This article describes the operative procedure and summarizes the advantages of this approach.

Recent advances in video-assisted thoracoscopic approach to posterior mediastinal tumours

Minimal invasive video-assisted thoracic surgery can be a safe alternative technique in the assessment, diagnosis and surgical resection of posterior mediastinal tumours. Video-assisted thoracic surgery may be particularly suited for the management of posterior mediastinal tumours as most are benign. Surgical technique continues to evolve from the classic 3-port access in order to tackle more complex tumours positioned at the apical and inferior recesses of the posterior mediastinum. The preoperative identification of dumbbell tumours is important to facilitate arrangements for a single-stage combined resection for both the intra-thoracic and intraspinal tumour. Results from Video-assisted thoracic surgery posterior mediastinal tumour resection are comparable with conventional surgical techniques in terms of symptomatic improvement, recurrence and survival. Video-assisted thoracic surgery approach has been shown to result in less post-operative pain, improved cosmesis, shorter hospital stay, and more rapid recovery and return to normal activities. In over a decade, video-assisted thoracic surgery has gradually matured and is now a promising therapeutic alternative to open approach. In certain selected patients, video-assisted thoracic surgery may be considered the standard of care for conditions of the posterior mediastinum. Recent developments in robotic surgery for the management of mediastinal tumours are promising, however, long-term results are pending.

Impact of Video-Assisted Thoracoscopic Major Lung Resection on Immune Function

Video-assisted thoracoscopic major lung resection for early stage non-small-cell lung carcinoma has been associated with less postoperative pain, better preserved pulmonary function, shorter hospital stay, and enhanced tolerance of adjuvant chemotherapy compared to thoracotomy. Initial concerns regarding safety, oncological clearance, and cost effectiveness were unfounded. Several recent trials have reported improved long-term survival in patients with early stage non-small-cell lung carcinoma undergoing video-assisted thoracoscopic major lung resection, compared to the open technique, although there are inconsistencies. Interestingly, the immune status and autologous tumor killing ability of lung cancer patients have previously been associated with long-term survival. Video-assisted thoracoscopic lung resection results in an attenuated postoperative inflammatory response, but more importantly, it better preserves postoperative immune function. Circulating natural killer and T-cell numbers, T-cell oxidative activity, and levels of immunochemokines such as insulin growth factor binding protein-3 are higher after video-assisted thoracoscopic surgery than after thoracotomy. Recently, interest has developed in the role of the angiogenesis factor, vascular endothelial growth factor, after cancer surgery. Whether differences in immunological and biochemical mediators contribute towards improved long-term survival following video-assisted thoracoscopic major lung resection for cancer remains to be confirmed.

Host response to colorectal cancer

It has long been established that inflammation and immunity play critical roles in the pathogenesis, control and eventual metastasis of cancers. With the advent of more sophisticated animal models and immunohistochemical techniques a greater understanding of the immune system and its interactions has occurred. Individual immune cells are dynamic structures that have variable behaviour controlled by complex interactions in the tumour microenvironment. In the setting of colorectal cancer it was first observed that peritumoral inflammatory infiltrates were associated with improved prognosis. Immunohistochemistry has shown the individual cells types within these infiltrates. It now appears that an adaptive immune response, differentiated along the T-helper 1 pathway controls tumour invasion and metastasis. Furthermore, the immune system exerts selection pressure leading to the evolution of tumour cell variants that can induce tolerance and disable adaptive immunity. These tumour cells then use the mechanisms of innate immunity to facilitate further growth, angiogenesis, invasion and eventual metastasis. These issues are investigated with particular relevance to colorectal cancer. Using the immune response to defeat CRC has been under intense investigation but has so far been unsuccessful. Nevertheless, researchers remain optimistic that immunotherapy will play an important role in the treatment of this common disease.

Descending necrotizing mediastinitis: a 10-year surgical experience in a single institution

OBJECTIVE

Early diagnosis and aggressive surgical drainage are very important for successful treatment of descending necrotizing mediastinitis. However, the surgical techniques used for this condition remain controversial. We report our 10-year experience of managing this devastating disease, focusing on the multidisciplinary, minimally invasive operative procedures and the unique bacteriologic factors in Taiwan.

METHODS

Between January 1997 and January 2007, we retrospectively reviewed 18 patients with descending necrotizing mediastinitis who were treated in the National Taiwan University Hospital. Diagnosis and Endo classification were confirmed by computed tomography of the neck and chest.

RESULTS

Eight women and 10 men were included in this study. The mean age was 57.8 +/- 15.2 years. Cervical drainage was performed in the involved area in all patients. The methods for mediastinal drainage included transcervical (n = 10), video-assisted thoracic surgical drainage (n = 6), subxiphoid drainage (n = 1), and mediastinoscopy-assisted drainage (n = 1). We could not rescue 3 patients because of uncontrolled sepsis before surgery, for a mortality rate of 16.7%. Klebsiella pneumoniae uniquely represents the most common pathogen in diabetic patients (P = .01), leading to more complicated courses in older patients (P =.04) and requiring more surgical interventions (P =.05) than other pathogens.

CONCLUSION

Transcervical mediastinal drainage is first justified in patients with limited disease in the upper mediastinum. For those with involvement of the lower anterior mediastinum, an additional subxiphoid approach is suggested. Cervicotomy with video-assisted mediastinal drainage is an excellent combination for involvement of the posterior mediastinum and pleural space. Klebsiella pneumoniae uniquely represents the most important and threatening causative pathogen for diabetic patients with descending necrotizing mediastinitis.

Video-assisted thoracic surgery major lung resection can be safely taught to trainees

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) major lung resection for lung cancer has been an important part of thoracic surgical training program in our institution. In this study, we compared the results of VATS major lung resection performed by surgical trainees with those performed by experienced thoracic surgeons with specialist interest in VATS.

METHODS

From January 2002 to October 2006, the clinical data of 111 consecutive patients scheduled for VATS major lung resection were prospectively entered into the computerized clinical management system of the local health authority; these include patient demographics, comorbidity, operating time, postoperative complications, and outcome. We retrospectively compared the data of patients who were operated on by trainees with those who were operated on by experienced VATS surgeons.

RESULTS

One hundred and eleven patients with clinical stage I and II lung cancer underwent VATS major lung resection. Fifty-one (46%) of the procedures were performed by consultant surgeons and 60 VATS lung resections (54%) were performed by supervised trainees. Patients' demography and risk factors were comparable between the two groups. Trainees spent more time in performing the operation as compared with experienced VATS surgeons (mean operating time 162 minutes, p = 0.01). There was no significant difference in intraoperative or postoperative complications and outcomes between the two groups.

CONCLUSIONS

Video-assisted thoracic surgery major lung resection for early stage nonsmall-cell lung cancer can be taught to residents who work under the supervision of experienced VATS surgeons. Video-assisted thoracic surgery major lung resection for lung cancer should be an integral part of thoracic surgical training program.

The immunomodulatory effects of laparoscopic surgery

Laparoscopic alternatives to conventional surgical procedures confer many advantages to patients including reduced postoperative pain, shortened convalescence and, perhaps, improved disease-related outcomes. The diminished degree of immune dysfunction apparent with these techniques may underpin these beneficial aspects. However, minimal access is accompanied by various ancillary anesthetic and mechanical associations (including the induction of a carbon dioxide pneumoperitoneum), which must be considered in addition to reduced tissue trauma when attempting to correlate cause with effect. Furthermore, the opportunity to establish causation between the immunomodulatory aspects of laparoscopy and subsequent clinical outcome by prospective, randomized study is difficult because of the rapid incorporation of minimal access techniques into clinical practice. Therefore, experimental in vitro and in vivo studies must be used to complement the limitations of clinical studies in this area. Although the initial investigations into the immunological effects of laparoscopy are encouraging, many of the intricacies associated with this approach still await elaboration.

Preoperative but not postoperative systemic inflammatory response correlates with survival in colorectal cancer

BACKGROUND

The aim of the present study was to evaluate the relationship between the preoperative and postoperative systemic inflammatory response and survival in patients undergoing potentially curative resection for colorectal cancer.

METHODS

One hundred and eighty patients with colorectal cancer were studied. Circulating concentrations of C-reactive protein (CRP) were measured before surgery and in the immediate postoperative period.

RESULTS

The peak in CRP concentration occurred on day 2 (P < 0.001). During the course of the study 59 patients died, 30 from cancer and 29 from intercurrent disease. Day 2 CRP concentrations were dichotomized. In univariable analysis, advanced tumour node metastasis stage (P = 0.002), a raised preoperative CRP level (P < 0.001) and the presence of hypoalbuminaemia (P = 0.043) were associated with poorer cancer-specific survival.

CONCLUSION

Preoperative but not postoperative CRP concentrations are associated with poor tumour-specific survival in patients undergoing potentially curative resection for colorectal cancer.

Variation in the Approach to VATS Lobectomy: Effect on the Evaluation of Surgical Morbidity Following VATS Lobectomy for the Treatment of Stage I Non–Small Cell Lung Cancer

Recent advances in imaging, chemical pathology, and target therapy have made it necessary to redefine the role of surgery in the therapeutic algorithm in the management of lung cancer. Although video-assisted thoracic surgery lobectomy with hilar and mediastinal lymph node dissection was proposed over a decade ago to treat early lung cancer, this technique is currently not widely practiced, despite many documented advantages. This article examines the role of video-assisted thoracic surgery lobectomy in the treatment of early lung cancer and, in particular, variations in the approach and published results.