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Agrafiotis AC, Berzenji L, Koyen S, Vermeulen D, Winthagen R, Hendriks JMH, Van Schil PE. Surgical treatment of thymic epithelial tumors: a narrative review. MEDIASTINUM (HONG KONG, CHINA) 2024; 8:32. [PMID: 38881810 PMCID: PMC11176987 DOI: 10.21037/med-23-44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 01/15/2024] [Indexed: 06/18/2024]
Abstract
Background and Objective Thymic epithelial tumors (TETs) are scarce neoplasms of the prevascular mediastinum. Included in this diverse category of lesions are thymomas and thymic carcinomas (TCs). Surgery is the mainstay of treatment of tumors that are deemed resectable. However, up till now, optimal surgical access has been a subject of debate. The advent of new techniques, such as video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS), challenged the median sternotomy which was traditionally considered the access of choice. This review aims to demonstrate the current evidence concerning the surgical treatment of TET and to enlighten other controversial issues about surgery. Methods PubMed research was conducted using the terms [surgery] AND [thymic epithelial tumors] OR [thymomas] and [surgical treatment] AND [thymic epithelial tumors] OR [thymomas]. Papers concerning pediatric cases and non-English literature papers were excluded. Individual case reports were also excluded. Key Content and Findings Minimally invasive surgical techniques (MIST) such as VATS and RATS are increasingly applied in early-stage TET. Although numerous published studies have demonstrated better perioperative outcomes in early-stage TET, long-term follow-up data are still required to demonstrate the oncological equivalent of MIST to open surgery. Resection of stage III TET is more challenging. Thymectomy can be expanded en bloc to include the major vascular structures, lung, pleura, phrenic, or vagus nerve in these individuals. There is no agreement on the ideal surgical access and traditionally these patients underwent open sternotomy, sometimes combined with a thoracic access. Evidence concerning the treatment of stage IVA disease is mainly derived from retrospective case series which are highly heterogeneous in terms of the number of enrolled patients, histology, degree of pleural involvement, and timing of presentation. Conclusions New techniques in the field of minimally invasive surgery are gaining acceptance for early-stage TET but longer follow-up periods are warranted to prove their oncological outcomes. On the contrary, these techniques should be used cautiously in case of locally advanced tumors. Surgeons must not forget that the main objective is the complete resection of the lesion, which is one major predictive factor for increased survival.
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Affiliation(s)
- Apostolos C Agrafiotis
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium
- Department of Thoracic and Vascular Surgery, Wallonie Picarde Hospital Center (Centre Hospitalier de Wallonie Picarde-CHwapi), Tournai, Belgium
| | - Lawek Berzenji
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Stien Koyen
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Dries Vermeulen
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Rachel Winthagen
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Jeroen M H Hendriks
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium
- Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), University of Antwerp, Wilrijk, Belgium
| | - Paul E Van Schil
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium
- Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), University of Antwerp, Wilrijk, Belgium
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Qiu Z, Chen L, Lin Q, Wu H, Sun H, Zhou X, Hu Y, Peng L, Liu Y, Xu Q. Perioperative outcomes and mid-term effects in performing video-assisted thoracoscopic extended thymectomy for myasthenia gravis: subxiphoid versus right thoracic approaches. J Thorac Dis 2020; 12:1529-1539. [PMID: 32395290 PMCID: PMC7212138 DOI: 10.21037/jtd.2020.03.43] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background Approaches of thoracoscopic thymectomy for myasthenia gravis (MG) are debatable. The subxiphoid approach is widely utilized recent years for its better visualization of the anterior mediastinum. In the present study, we compared perioperative outcomes and mid-term effects of the extended thymectomy for MG between the subxiphoid approach and the routine right-thoracic approach. Methods One hundred and thirty-one MG patients treated with thoracoscopic extended thymectomy were analyzed. Among them, 68 patients were operated on via the subxiphoid approach and the other 63 via the conventional right-side unilateral approach. The patient outcomes were retrospectively reviewed and evaluated. Mid-term clinical outcome was assessed according to the classification system proposed by the Myasthenia Gravis Foundation of America (MGFA). Clinical efficacy and variables influencing outcome were evaluated by the Kaplan-Meier method and Cox proportional hazards regression analysis. Results Compared with the right thoracic approach, the duration of the procedure via the subxiphoid approach was significantly shorter (P=0.035), the rates of total thymectomy were higher (P=0.028), and the pain scores on postoperative days 1, 3, and 7 were significantly lower (P<0.001, P<0.001, and P=0.03, respectively). A total of 112 patients with MG were followed up. The subxiphoid approach group reported higher rates of complete stable remission (CSR) and effective treatment of MG, although these differences were not statistically significant (Z=−0.484, P=0.627). By multivariate Cox proportional hazards modes analysis, the chance of CSR was significantly increased when age <40 (OR: 2.623, 95% CI: 1.150–5.983, P=0.022), non-thymomatous MG (OR: 1.078, 95% CI: 1.101–3.316, P=0.021) and MGFA clinical classification (OR: 2.024, 95%:1.164–3.523, P=0.013). Conclusions The subxiphoid approach has shorter operation time, higher rates of total thymectomy and better quality of life compared with the lateral thoracoscopic approach. Preoperative age, pathological diagnoses and MGFA Clinical Classification are the independent risk factors for non-complete stable remission (NCSR) after thymectomy.
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Affiliation(s)
- Zhihong Qiu
- Department of Cardiothoracic Surgery, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang 330006, China
| | - Liru Chen
- Department of Cardiothoracic Surgery, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang 330006, China
| | - Qin Lin
- Department of Cardiothoracic Surgery, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang 330006, China
| | - Hao Wu
- Department of Cardiothoracic Surgery, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang 330006, China
| | - Huangtao Sun
- Department of Cardiothoracic Surgery, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang 330006, China
| | - Xin Zhou
- Department of Cardiothoracic Surgery, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang 330006, China
| | - Yeji Hu
- Department of Cardiothoracic Surgery, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang 330006, China
| | - Lei Peng
- Department of Cardiothoracic Surgery, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang 330006, China
| | - Yangchun Liu
- Department of Cardiothoracic Surgery, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang 330006, China
| | - Quan Xu
- Department of Cardiothoracic Surgery, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang 330006, China
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Batirel HF. Techniques of uniportal video-assisted thoracic surgery-esophageal and mediastinal indications. J Thorac Dis 2019; 11:S2108-S2114. [PMID: 31637045 DOI: 10.21037/jtd.2019.09.55] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Uniportal approach for esophagus and mediastinum is gaining popularity. While a transthoracic approach is applied for esophagus frequently from the 5th or 6th intercostal space on the posterior axillary line, approach to anterior mediastinum is variable with access through right/left chest, cervical and subxiphoid regions. The results of uniportal approach for esophagus and mediastinum are comparable with multiport video-assisted thoracic surgery (VATS) and open approach in terms of bleeding, oncologic adequacy and operation times. Indications are similar with open and multiportal VATS cases, however large mediastinal tumors (>5 cm) and T3-4 esophageal cancers can be challenging in the beginning in terms of oncologic adequacy of the operations. Uniportal approach for esophagus and mediastinum is utilized more frequently and initial reports show that it is feasible and its applicability and advantages will become apparent in the coming years.
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Affiliation(s)
- Hasan F Batirel
- Thoracic Surgery Department, Marmara University Hospital, Istanbul, Turkey
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Batirel HF. Minimally invasive techniques in thymic surgery: a worldwide perspective. J Vis Surg 2018; 4:7. [PMID: 29445593 DOI: 10.21037/jovs.2017.12.18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 12/18/2017] [Indexed: 11/06/2022]
Abstract
Minimally invasive surgical techniques are important in surgical management of thymic pathologies. Traditional access techniques are being replaced with minimally invasive techniques using multiportal or uniportal approach. Adoption of minimally invasive techniques for thymic malignancies has been slow due to long term recurrence concerns. Recent studies show that minimally invasive video-assisted thoracoscopic surgery (VATS) or robotic approach to early stage thymic malignancies are associated with less intraoperative bleeding, lower rate of respiratory complications, shorter chest tube duration and shorter hospital stay. Oncologic outcomes are at least equivalent to open approach. Minimally invasive approach for benign pathologies is widely applied. There are significant variations in VATS approaches for thymus, showing a multinational interest in the issue of minimizing trauma during thymectomy. Use of robotic technology is also popular, as the retrosternal area is a narrow anatomic space to manipulate conventional instruments. The evolution of minimally invasive surgery for thymus has been possible with contribution from centers all around the world. In the current practice, various approaches are being adopted and every surgeon should prefer a technique depending on surgical preference and experience.
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Affiliation(s)
- Hasan Fevzi Batirel
- Department of Thoracic Surgery, Marmara University School of Medicine, Istanbul, Turkey
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Zieliński M, Rybak M, Solarczyk-Bombik K, Wilkojc M, Czajkowski W, Kosinski S, Fryzlewicz E, Nabialek T, Szolkowska M, Pankowski J. The Zakopane Pulmonary Hospital experience on subxiphoid thymectomy. J Vis Surg 2017; 3:2. [PMID: 29078565 DOI: 10.21037/jovs.2016.12.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 11/16/2016] [Indexed: 11/06/2022]
Abstract
BACKGROUND To present the technique of minimally invasive extended thymectomy performed through the subxiphoid-bilateral subcostal video-assisted thoracoscopic surgery (VATS) approach, with double elevation of the sternum for nonthymomatous myasthenia gravis (MG). METHODS The whole dissection was performed through the 4-7 cm transverse subxiphoid incision with single 10 mm extra-long bariatric laparoscopy ports inserted subcostally to the right and left chest cavities for videothoracoscope and subsequently for chest tubes. The sternum was elevated with two hooks connected to the sternal frame (Rochard bar, Aesculap-Chifa, Nowy Tomysl, Poland). The lower hook was inserted through the subxiphoid incision and the superior hook was inserted percutaneously, after the mediastinal tissue including the major mediastinal vessels were dissected from the inner surface of the sternum. The fatty tissue of the anterior mediastinum and the aorta-pulmonary window was completely removed. RESULTS There were 147 patients (62 patients operated on for thymomas, 75 patients for nonthymomatous MG and 10 for rethymectomies) in the period 1.1.2009-30.3.2016. There was no mortality and morbidity. The mean operative time was 109.1 min (range, 75-150 min). CONCLUSIONS The subxiphoid approach combined with bilateral single port subcostal VATS and double elevation of the sternum enables very extensive thymectomy in case of nonthymomayous MG.
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Affiliation(s)
- Marcin Zieliński
- Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
| | - Mariusz Rybak
- Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
| | | | - Michal Wilkojc
- Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
| | | | - Sylweriusz Kosinski
- Department of Anaesthesiology and Intensive Care, Pulmonary Hospital, Zakopane, Poland
| | - Edward Fryzlewicz
- Department of Anaesthesiology and Intensive Care, Pulmonary Hospital, Zakopane, Poland
| | - Tomasz Nabialek
- Department of Anaesthesiology and Intensive Care, Pulmonary Hospital, Zakopane, Poland
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Hirai K, Enomoto Y, Usuda J. For which thoracic operation is U-VATS superior? J Vis Surg 2017; 3:103. [PMID: 29078664 DOI: 10.21037/jovs.2017.07.06] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 06/28/2017] [Indexed: 11/06/2022]
Abstract
In this special issue, I review the types of thoracic surgery that uniportal video-assisted thoracic surgery (U-VATS) is most suited to.
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Affiliation(s)
- Kyoji Hirai
- Department of Thoracic Surgery, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Yutaka Enomoto
- Department of Thoracic Surgery, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Jitsuo Usuda
- Division of Thoracic Surgery, Nippon Medical School, Tokyo, Japan
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Matilla JR, Klepetko W, Moser B. Thymic minimally invasive surgery: state of the art across the world-Europe. J Vis Surg 2017; 3:70. [PMID: 29078633 DOI: 10.21037/jovs.2017.04.01] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 03/29/2017] [Indexed: 11/06/2022]
Abstract
In this brief review of selected peer-reviewed literature on thymic minimally-invasive surgery (MIS) we sought to identify if there is a unique approach to thymic MIS on the European continent.
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Affiliation(s)
- José Ramon Matilla
- Department of Thoracic Surgery, Medical University Vienna, Vienna, Austria
| | - Walter Klepetko
- Department of Thoracic Surgery, Medical University Vienna, Vienna, Austria
| | - Bernhard Moser
- Department of Thoracic Surgery, Medical University Vienna, Vienna, Austria
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Chen H, Xu G, Zheng W, Chen C. Video-assisted thoracoscopic extended thymectomy using the subxiphoid approach. J Vis Surg 2016; 2:157. [PMID: 29078543 PMCID: PMC5638370 DOI: 10.21037/jovs.2016.09.02] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 09/01/2016] [Indexed: 11/06/2022]
Abstract
Minimally invasive thoracoscopic surgery has become an inevitable trend in the treatment of anterior mediastinal tumors and other thoracic diseases. Many surgical approaches may be used for video-assisted thoracoscopic surgery (VATS) thymectomy. Some researchers have proven that that VATS thymectomy using the subxiphoid approach is technically safe and feasible. Compared with the transthoracic approach, the subxiphoid approach is considered to provide a better view of the bilateral pleural cavities and to cause relatively less pain; it is thus considered a less invasive surgical approach. In this article, we summarize our experience with various incision designs, specific surgical procedures, and key operative manipulations that are crucial for successful performance of subxiphoid VATS extended thymectomy.
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Affiliation(s)
- Hao Chen
- Department of Thoracic Surgery, Fujian Medical University, Fujian Union Hospital, Fuzhou 350001, China
| | - Guobing Xu
- Department of Thoracic Surgery, Fujian Medical University, Fujian Union Hospital, Fuzhou 350001, China
| | - Wei Zheng
- Department of Thoracic Surgery, Fujian Medical University, Fujian Union Hospital, Fuzhou 350001, China
| | - Chun Chen
- Department of Thoracic Surgery, Fujian Medical University, Fujian Union Hospital, Fuzhou 350001, China
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Zhao J, Wang J, Zhao Z, Han Y, Huang L, Li X, Lu Q, Zhou Y. Subxiphoid and subcostal arch thoracoscopic extended thymectomy: a safe and feasible minimally invasive procedure for selective stage III thymomas. J Thorac Dis 2016; 8:S258-64. [PMID: 27014472 DOI: 10.3978/j.issn.2072-1439.2016.02.42] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Video-assisted thoracoscopic surgery (VATS) has been applied to resection of small and well-encapsulated thymomas. However, few data are available regarding to the application of VATS in stage III thymomas. METHODS A novel subxiphoid and subcostal arch approach for thoracoscopic extended thymectomy was developed by us. From January 2014 to August 2015, 14 patients with stage III thymoma were treated by using this new technique in the Department of Thoracic Surgery, Tangdu hospital, Xi'an, China. These patients were retrospectively reviewed and analyzed. RESULTS Among the 14 patients, 1 patient was converted to transsternal approach owning to invasion of the superior vena cava. The other 13 patients with thymomas invading the pericardium, lung tissues and left innominate vein (LIV), were successfully operated on by using this new technique. The average operation time was 120.0±32.7 min (80-170 min), the average volume of estimated blood loss was 51.5±44.8 min (10-150 mL) and the average postoperative hospital stay was 4.8±1.5 days (3-9 days). There was no perioperative death. Two patients suffered postoperative complications including one patient with atrial fibrillation (AF) and the other one with myasthenic crisis (MC). The postoperative pain score decreased dramatically from 3.8±1.0 [3-6] at 24 hours to 1.5±0.9 [0-6] at 48 hours, and finally to 0 at 3 months after surgery (P=0.000). The patients reported a higher cosmetic score of 92.6±2.7 [90-96]. There was no tumor recurrence and the five patients with myasthenia gravis had improvement and did not need any medication until follow-up. CONCLUSIONS Based on our limited experience, the subxiphoid and subcostal arch thoracoscopic extended thymectomy is safe and feasible for selective stage III thymoma, and might reduce the postoperative pain and provide satisfied cosmetic effect.
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Affiliation(s)
- Jinbo Zhao
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China
| | - Juzheng Wang
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China
| | - Zhengwei Zhao
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China
| | - Yong Han
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China
| | - Lijun Huang
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China
| | - Xiaofei Li
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China
| | - Qiang Lu
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China
| | - Yongan Zhou
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an 710038, China
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Zieliński M, Rybak M, Wilkojc M, Fryzlewicz E, Nabialek T, Pankowski J. Subxiphoid video-assisted thorascopic thymectomy for thymoma. Ann Cardiothorac Surg 2015; 4:564-6. [PMID: 26693156 DOI: 10.3978/j.issn.2225-319x.2015.10.04] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Marcin Zieliński
- 1 Department of Thoracic Surgery, 2 Department of Anaesthesiology and Intensive Care, 3 Department of Pathology, Pulmonary Hospital, Zakopane, Poland
| | - Mariusz Rybak
- 1 Department of Thoracic Surgery, 2 Department of Anaesthesiology and Intensive Care, 3 Department of Pathology, Pulmonary Hospital, Zakopane, Poland
| | - Michal Wilkojc
- 1 Department of Thoracic Surgery, 2 Department of Anaesthesiology and Intensive Care, 3 Department of Pathology, Pulmonary Hospital, Zakopane, Poland
| | - Edward Fryzlewicz
- 1 Department of Thoracic Surgery, 2 Department of Anaesthesiology and Intensive Care, 3 Department of Pathology, Pulmonary Hospital, Zakopane, Poland
| | - Tomasz Nabialek
- 1 Department of Thoracic Surgery, 2 Department of Anaesthesiology and Intensive Care, 3 Department of Pathology, Pulmonary Hospital, Zakopane, Poland
| | - Juliusz Pankowski
- 1 Department of Thoracic Surgery, 2 Department of Anaesthesiology and Intensive Care, 3 Department of Pathology, Pulmonary Hospital, Zakopane, Poland
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