Jia-an Ding

The role of survivin on overall survival of non-small cell lung cancer, a meta-analysis of published literatures

The prognostic value of survivin for survival of patients with non-small cell lung cancer (NSCLC) remains controversial. The authors performed a meta-analysis of the literatures in order to clarify its impact. Published studies were identified using an electronic search in order to aggregate the available survival results. To be eligible, a study had to have dealt with survivin assessment in NSCLC patients on the primary site and have analyzed survival according to survivin expression. There were 10 eligible studies and data from eight studies where non-location specific immunohistochemistry (IHC) definition system, in situ hybridization (ISH) and RT-PCR used were combined to present the impact of survivin on overall survival (OS) of NSCLC. The level of survivin expression correlated with the OS of NSCLC patients significant (RR 1.88, 95% CI 1.31-2.70, P=0.0006). Data of seven studies were combined to demonstrate that the level of survivin correlated with the OS of NSCLC patients who had received radical surgeries (RR 1.79, 95% CI 1.45-2.20, P<0.00001). Data from three studies were combined to find that the level of nuclear survivin did not have impact on OS of NSCLC patients (RR 1.58, 95% CI 0.87-2.85, P=0.13). Positive-survivin expression might be a prognostic factor for NSCLC patients, nuclear survivin positivity could not work as a prognostic factor for NSCLC patients based on current clinical data. Larger clinical trails with widely accepted assessment methods are necessary to define the precise prognostic significance for survivin in NSCLC patients.

Surgical treatment for pulmonary aspergilloma: a 35-year experience in the Chinese population

The surgical treatment of pulmonary aspergilloma is challenging and controversial. This study was designed to evaluate the clinical profile, indications and surgical outcomes of pulmonary aspergilloma operated on in our institute. A total of 256 patients with pulmonary aspergilloma underwent surgical treatment from 1975 to 2010. The patients were divided into two groups: Group A (simple aspergilloma, n = 96) and Group B (complex aspergilloma, n = 160). The principal underlying lung disease was tuberculosis (71.1%). The surgical procedures consisted of 212 lobectomies in both groups; eight cavernoplasties, 10 bilobectomies, 16 pneumonectomies and six thoracoplasties in Group B; four segmentectomies and six wedge resections in Group A. Postoperative complications occurred in 40 patients (15.6%). The major complications were residual pleural space (3.9%), prolonged air leak (3.1%), bronchopleural fistula (1.6%), excessive bleeding (1.6%), respiratory insufficiency (1.9%) and empyema (1.2%). No intraoperative deaths occurred. The overall mortality within 30 days post-operation was 1.2%, occurring only in Group B. There was no statistically significant difference in the postoperative morbidity between Groups A and B (P = 0.27). With the good selection of patients, meticulous surgical techniques and good postoperative management, aggressive surgical treatment with anti-fungal therapy for pulmonary aspergilloma is safe and effective, and can achieve favourable outcomes.

Surgical Treatment of Bronchiectasis: A Retrospective Analysis of 790 Patients

BACKGROUND The global incidence of bronchiectasis is increasing, and this disease is prevalent in rural China. This study examined operative mortality, morbidity, and outcomes of surgery for bronchiectasis at a single institution in China. METHODS We retrospectively reviewed the medical records of 790 consecutive patients who underwent surgery for bronchiectasis in our department between January 1989 and December 2008. Localized bronchiectasis was diagnosed by high-resolution computed tomography. The persistence of symptoms after failure of nonsurgical treatment was an indication for surgery. Cystic fibrosis patients were excluded from this study. RESULTS The study sample included 790 patients (466 male, 324 female) who underwent 810 operations for bronchiectasis. Mean age at time of surgery was 41.6 years (range, 6 to 79 years). Several surgical procedures were used: lobectomy (497; 62.9%), segment resection (37; 4.7%), pneumonectomy (90; 11.3%), bilobectomy (56; 7.1%), and lobectomy and segmentectomy (110; 14.0%). There were no intraoperative deaths. Nine (1.1%) patients died in the postoperative period. Univariate analysis showed that advanced age (p = 0.04) and renal failure (p = 0.001) were associated with postoperative mortality, and multivariate analysis revealed that preoperative renal failure was associated with mortality (p = 0.025). The mean follow-up time was 4.2 years (range, 10 months to 10 years). After surgery, 478 (60.5%) patients were asymptomatic, 111 (14.1%) had improved, and 117 (14.8%) showed no improvement or worsened condition. CONCLUSIONS Localized bronchiectasis is usually the indication for surgical resection, which is a safe procedure with acceptable operative morbidity, mortality, and outcomes.

Video-Assisted Thoracic Surgery for Bronchiectasis

BACKGROUND Bronchiectasis is one of the common diseases diagnosed in the world. No major improvement for the treatment approaches and limited efficacy promote a big challenge for management of this disease. Video-assisted thoracoscopic surgery (VATS) offers a new choice for the treatment of bronchiectasis. The purpose of this study was to present our experience of VATS for bronchiectasis and to compare this with thoracotomy in our institution. METHODS We reviewed the medical records of patients who underwent VATS lobectomy and general lobectomy for bronchiectasis between January 2005 and December 2009. RESULTS A total of 279 patients underwent thoracotomy, 52 patients underwent attempted VATS lobectomy. Fifty-two patients from 279 patients for thoracotomy were selected and compared with the VATS group. Pleural adhesion was observed in 15 patients (28.8%) in VATS. The VATS lobectomy was converted to open thoracotomy in 7 patients. There was no difference in the blood loss and median operative time between the two groups, but the patients with VATS had shorter length of stay in hospital (p=0.045), fewer complications (p=0.039) than those with thoracotomy. Forty-nine (94%) and 46 (88%) patients fully recovered after operation by VATS and thoracotomy, respectively. CONCLUSIONS Video-assisted thoracoscopic lobectomy in localized bronchiectasis is a safe and more efficient procedure in selected patients with better recovery.

Surgical Management of Secondary Spontaneous Pneumothorax in Elderly Patients with Chronic Obstructive Pulmonary Disease: Retrospective Study of 107 Cases

BACKGROUND Aim of the study was to assess the results of surgery for secondary spontaneous pneumothorax (SSP) in the elderly with COPD at Shanghai Pulmonary Disease Hospital. METHODS From 1 January 1993 to 30 June 2007, the operation for SSP was performed in 107 elderly patients (> or = 60y) with COPD. All patient data was reviewed retrospectively. RESULTS Morbidity was 25.2 % and mortality was 4.7 %. The total effective rate of intrapleural injection of human fibrinogen for the treatment of postoperative persistent air leaks was 86.7 %. Multivariate analyses of postoperative air leaks suggest that patients undergoing pleurodesis (OR 0.189, 95 % CI 0.045-0.790, P = 0.022) have a decreased risk of postoperative air leaks. Multivariate analyses of postoperative complications suggest that patients with higher PaCO (2) (OR 0.890, 95 % CI 0.814-0.973, P = 0.011) have an increased risk and patients undergoing pleurodesis (OR 4.319, 95 % CI 1.398-13.349, P = 0.011) have a decreased risk. CONCLUSIONS Surgical intervention is recommended in selected elderly COPD patients with SSP, with hypercapnia known as an operative contraindication. Additionally, surgery offers the advantage of intraoperative pleurodesis for the prevention of prolonged postoperative air leaks, while intrapleural injection of human fibrinogen is an effective procedure in the treatment of air leaks.

Free Rectus Abdominis Musculocutaneous Flap for Chronic Postoperative Empyema

Chronic postoperative empyema remains a challenge for thoracic surgeons. Free musculocutaneous flap transplantation may provide a good alternative option in the treatment of these refractory complications after pulmonary resections. Three patients with chronic postoperative empyemas combined with bronchopleural fistulas underwent obliteration of the empyema tracts with free rectus abdominis musculocutaneous flap transplantations. Surgical treatment was a two-stage procedure that consisted of open-window thoracostomy, followed by obliteration of the pleural cavity using a free transfer of the ipsilateral, full-thickness rectus muscle flap and microanastomoses. No postoperative complications occurred, and the 3 patients resumed normal daily activities. Free rectus abdominis musculocutaneous flap transplantation is safe and effective in the management of chronic postoperative empyema with bronchopleural fistula.

A comparative study of video-assisted thoracoscopic resection versus thoracotomy for neurogenic tumours arising at the thoracic apex.

OBJECTIVES The surgical outcome of neurogenic tumours arising at the thoracic apex remains largely undefined. In this retrospective study, we compared the efficacy and safety of thoracoscopic surgery and thoracotomy for neurogenic tumours at the thoracic apex in 63 patients who received surgical treatment between 1992 and 2012 at our medical centre. METHODS Forty-four (69.8%) patients received thoracotomy (Group A) and 19 (30.2%) patients underwent video-assisted thoracoscopic surgery (Group B). Operative time, estimated blood loss (EBL), postoperative length of hospital stay and nervous system complications were recorded. RESULTS The two groups of patients were comparable in demographic and baseline characteristics except that Group A patients had a significantly larger tumour size (mean, 4.9 ± 1.0 cm) than Group B patients (mean, 4.1 ± 1.2 cm; P = 0.01). The mean operative time was markedly greater for Group A (120.2 ± 41.2 min) than Group B (93.2 ± 34.5 min; P = 0.009). Group A had significantly greater EBL (245.23 ± 197.78 ml) than Group B (117.4 ± 138.2 ml; P < 0.001). Total tumour resection was achieved in all patients and all neurogenic tumours were benign. The mean length of postoperative hospital stay was markedly longer in Group A (7.0 ± 2.1 days) than Group B (4.8 ± 2.0; P < 0.001). Postoperatively, brachial plexus injury was found in 1 patient (2.3%) in Group A and 4 patients (21.1%) in Group B (P = 0.026). CONCLUSIONS Though thoracoscopic surgery is associated with diminished blood loss, reduced operative time and shortened hospital stay, it has a markedly increased incidence of brachial plexus injury.

Subxiphoid uniportal video-assisted thoracoscopic surgery (VATS) for lobectomy: a report of 105 cases

BACKGROUND To address the feasibility and advantages of subxiphoid uniportal video-assisted thoracoscopic surgery (VATS) for lobectomy. METHODS Since August 2014, 105 cases of subxiphoid uniportal VATS lobectomy were successfully performed. The clinical information was retrospectively analyzed. RESULTS 96 cases underwent unilateral operation and 9 underwent bilateral operations. Surgeries were successfully performed with a complication rate of 10.5%. The average pain scores 8 hours, day 1, 2 and 3 after surgery, as well as the day before discharge were 2.39±0.99, 2.06±0.85, 1.68±0.87, 1.29±0.78, and 0.48±0.51, respectively, which were significantly lower than those in the control group (standard intercostal uniportal VATS) (P<0.001). CONCLUSIONS The subxiphoid uniportal VATS lobectomy is safe and reliable, which is appropriate for bilateral lung diseases, and significantly relieves postoperative incision pain.

Radical mediastinal nodal removal improves disease-free survival for pulmonary low-grade malignant tumors

PURPOSE To investigate the prognostic role of radical lymph node dissection in treatment for pulmonary Low Grade Malignant Tumors (LGMTs); specifically, on the extent of nodal removal and its impact on long-term survival. METHODS A total of 93 LGMTs cases underwent surgical resection and were histopathologically confirmed. Overall survival rates and disease-free survival were respectively calculated according to the extent of lymph node resection and histopathological grades of tumors. Risk factors of nodal involvement and survival predictors were calculated via multivariate analysis. Life table, Kaplan-Meier, and Cox regression models were used for the statistical analysis. RESULTS Thirty-eight cases of carcinoid, 17 adenoid cystic carcinomas, and 38 mucoepidermoid carcinomas were included in the current study. Twenty-one cases were high-grade and 72 were low-grade. A total of 813 lymph nodes were removed, at an average of 8.7±5.4 nodes per patient. The numbers of harvested nodes were 11.8±4.5, in the study group via radical nodal removal and 4.0±2.4 nodes per patient in the nodal sampling group. Eleven cases showed lymph nodal involvement (5 mediastinal and 6 hilar lymph node metastasis). No significant differences of overall survival was found among the different histological types (p=0.939), or the extent of nodal removal (p=0.971). Meanwhile, there was a significant difference of disease-free survival (DFS) rates according to the extent of nodal removal (5-YS: 97% of radical nodal dissection vs. 78% of nodal sampling, p=0.038). Overall survival and disease-free survival were closely associated with histological grading (OS: 78% of high grade vs. 97% of low grade, p=0.001; DFS: 57% of high grade vs. 97% of low grade, p<0.0001). CONCLUSIONS Radical lymph node dissection improved disease-free survival for pulmonary low-grade malignant tumors, although no obvious improvement on overall survival was noticed. Histological grade was the most important prognostic factor in LGMTs.

Reconstruction of the Lower Trachea Using a Pedicled Autologous Bronchial Flap

We describe a technique used in a patient for resection of adenoid cystic carcinoma arising from the left main bronchus and extending along the lateral wall of the lower trachea without carinal invasion. A flap was mobilized from the noninvolved lateral wall of the left main bronchus, which was left attached to the carina. This was used to close the defect in the lower trachea with the implantation of the left main bronchus, avoiding a tracheal sleeve pneumonectomy. Clinical course of this case was good. The pedicled autologous bronchial flap provides reliable material to repair and reconstruct a massive central airway defect.