Xin Xu

Anesthesia with nontracheal intubation in thoracic surgery

OBJECTIVE To study one-lung respiration during VATS wedge resection of bullae and pulmonary nodules with nontracheal intubation, and to explore the changes of vital signs when patients return to two-lung ventilation. METHODS Twenty-two patients with normal cardiopulmonary function and absence of contraindications to epidural anesthesia were included in this study. VATS wedge resection of bullae or pulmonary nodules was performed. 0.5% Ropivacain was administrated for epidural anesthesia (T8-9), and 2 mL of 2% lidocaine was used for local anesthetic block of the intrathoracic vagus nerves. The BIS value was maintained between 50 and 70 by target-controlled infusion of propofol and remifentanil. Electrocardiogram (ECG), heart rate (HR), blood pressure (Bp), pulse oxygen saturation (SpO(2)), respiratory rate (RR), bispectral index (BIS) and urine volume were monitored. RESULTS None patients were converted to endotracheal intubation during anesthesia. MAP and SpO(2) after wound disclosure were stable (P>0.05), level of CVP significantly elevated, HR and RR increased (P<0.05), PaCO(2) increased gradually while PaO(2) remained stable. Fifteen minutes after wound closure, MAP, RR and SpO(2) returned to their pre-anesthesia levels, PH value gradually recovered, PaCO(2) tended to decrease and returned to normal one hour after wound closure. Physical agitation occurred in one case due to inadequate epidural anesthesia during skin incision. Cough before intrathoracic vagal blockade was noted in two cases (9.1%) because of lobe traction. CONCLUSIONS Nontracheal intubation is feasible in VATS wedge resection of bullae and pulmonary nodules. The patients are with stable intraoperative vital signs and none experiences hypoxemia; intraoperative hypercapnia is tolerable and transient, which can be improved quickly when bilateral lungs resume spontaneous respiration.

Long‐term outcome and cost‐effectiveness of complete versus assisted video‐assisted thoracic surgery for non‐small cell lung cancer

To compare the outcomes and costs of two methods of video‐assisted thoracoscopic surgery (VATS) major pulmonary resection in patients with clinically resectable non‐small cell lung cancer (NSCLC).

The expression and clinical significance of CLIC1 and HSP27 in lung adenocarcinoma

The purpose of this research was to study the roles of chloride intracellular channel protein 1 (CLIC1) and heat shock protein 27 (HSP27) in the clinical pathology of lung adenocarcinoma and to explore whether the expression of CLIC1 and HSP27 can be used as independent factors for the prediction of recurrence and prognosis after radical resection of lung adenocarcinoma. One hundred and three paraffin sections of lung adenocarcinoma tissues were collected, and the expression of CLIC1 and HSP27 was detected in these tumors using immunohistochemistry. The correlation of the expression of these two proteins with clinicopathological parameters and prognosis was statistically analyzed. In the 103 samples, the expression of HSP27 and CLIC1 was strongly positive in 61 (59.2%) and 49 cases (47.6%), respectively. Statistical analysis showed that the expression level of HSP27 did not significantly correlate with the patient’s age, sex, degree of tumor differentiation, T staging of tumors, and TNM staging of tumors (p > 0.05), whereas the expression of CLIC1 did significantly correlate with T staging of tumors (p = 0.029). Univariate analysis indicated that the patient’s ECOG score, T staging, N staging, TNM staging, and CLIC1 expression correlated with prognosis (p = 0.031, 0.001, 0.011, 0.013, and <0.001, respectively). Multivariate statistical analysis showed that age, T staging, and CLIC1 expression were independent associated factors for predicting the 5-year survival rate of patients (p = 0.026, 0.004, and <0.001, respectively). Age, T staging, and CLIC1 expression significantly correlated with the overall survival of post-operative lung adenocarcinoma patients. CLIC1 may be closely associated with the occurrence and development of lung adenocarcinoma and may be used as an effective marker for predicting the prognosis of this disease.

Thoracoscopic Half Carina Resection and Bronchial Sleeve Resection for Central Lung Cancer

Background. The objectives of this study were to report the surgical techniques and clinical outcome of thoracoscopic half carina resection and thoracoscopic bronchial sleeve resection for central lung cancer. Methods. Between January 2011 and November 2012, 675 patients with lung cancer underwent radical surgery by thoracoscopy, and 49 (7.3%) underwent bronchial sleeve resection. Among 49 patients, 20 (41%) received thoracoscopic bronchial sleeve lobectomy. Perioperative variables and postoperative outcomes of these cases were analyzed to evaluate the technical feasibility and safety of this operation. Results. In one patient, right upper lung sleeve resection was combined with half-carinal resection and reconstruction. In another, right medial lung sleeve resection was combined with lower right dorsal segment resection. The average time of surgery was 239 ± 51 minutes (range = 142-330 minutes), and the average time of airway reconstruction was 44 ± 17 minutes (range = 22-75 minutes). The intraoperative blood loss averaged 207 ± 96 mL (range = 80-550 mL). The median postoperative hospital stay was 10 days (interquartile range = 8-12 days). Postoperatively, extubation was achieved in the recovery room without further need for mechanical ventilation. None of the patients developed anastomotic leak. Perioperative mortality was not observed. Conclusion. Thoracoscopic bronchial sleeve resection can be considered a feasible and safe operation for selected patients with central lung cancer. The complicated anastomosis technique of half carina resection was feasible.

Feasibility of complete video-assisted thoracoscopic surgery following neoadjuvant therapy for locally advanced non-small cell lung cancer

OBJECTIVE To explore the feasibility of complete video-assisted thoracoscopic surgery (c-VATS) following neoadjuvant therapy (chemotherapy, targeted therapy and radiotherapy, either alone or in combination) for the treatment of patients with non-small cell lung cancer (NSCLC). METHODS The clinical data of 43 NSCLC patients undergoing c-VATS following neoadjuvant therapy were retrospectively analyzed, including the preoperative functional indicators, staging, concurrent diseases, surgical techniques, operation time, number of lymph nodes dissected and postoperative drainage time and quantity, postoperative hospital stay, postoperative complications, and survival. RESULTS From January 2006 to March 2012, a total of 43 patients with stage IIA-IIIB NSCLC were included in this study (IIIA: 27 cases, 62.8%; IIIB: 11 cases, 25.6%), including 32 males (74.4%) and 11 females (25.6%). Forty-two patients were operated successfully, 28 underwent pulmonary lobectomies (including 9 bronchial sleeve resections), 5 had double lobectomies, 5 had wedge resections, and 4 had total pneumonectomies. Seven patients were referred to undergo Hybrid VATS (7/42, 16.7%). The mean length of the operation was 160.48±16.52 min (range, 130-180 min); the intraoperative blood loss was 253.57±117.08 mL; the number of lymph nodes dissected was 16.88±10.93; the postoperative drainage time was 1-7 d (mean: 2.62±0.96 d); and the postoperative hospital stay was 3-7 d (mean: 5.45±1.30 d). The incidence of postoperative complications was 9.5% (4/42), and the perioperative mortality was 2.4% (1/42). The 1-, 2-, and 3-year overall survival rates were 94%, 79%, and 65%, respectively. CONCLUSIONS c-VATS following neoadjuvant therapy is safe and feasible for the treatment of locally advanced NSCLC.

Heat shock protein-60 expression was significantly correlated with the prognosis of lung adenocarcinoma.

The purpose of this study was to investigate the role of heat shock protein 60 (HSP60) in the clinical pathology of lung adenocarcinoma, and to explore whether the expression of HSP60 can act as an independent predictor for tumor relapse and prognosis after radical resection of lung adenocarcinoma.

Novel Method to Repair Tracheal Defect by Pectoralis Major Myocutaneous Flap

Inflammatory myofibroblastic tumor is extremely uncommon in the trachea. Surgery is recommended when airway obstruction becomes evident. The surgical technique and material used for repairing a massive tracheal defeat is a challenge for the thoracic surgeon. We present a case of repair and reconstruction of a massive defect of the thoracic trachea and right mainstem bronchus with a pectoralis major myocutaneous flap after resection of an inflammatory myofibroblastic tumor. The myocutaneous flap provides reliable material to repair and reconstruct a massive central airway defect. This novel surgical procedure may present new strategies for the treatment of extensive defects of the trachea.

Thoracoscopic double sleeve lobectomy in 13 patients: a series report from multi-centers.

BACKGROUND This study aims to explore the feasibility and safety of video-assisted thoracic surgery (VATS) double sleeve lobectomy in patients with non-small lung cell cancer (NSCLC). METHODS Between June 2012 and August 2014, 13 NSCLC patients underwent thoracoscopic double sleeve lobectomy and mediastinal lymphadenectomy at three institutions. A retrospective analysis of clinical characteristics, operative data, postoperative events and follow-up was performed. RESULTS Thirteen NSCLC patients (median age, 60 years; range, 43-67 years) underwent thoracoscopic double sleeve lobectomy. There were no conversions to thoracotomy. Left upper lobectomy was most frequently performed (eleven patients). Median operative time was 263 minutes (range, 218-330 minutes), and median blood loss was 224 mL (range, 60-400 mL). The learning curve revealed reductions in both operative times and blood loss of ten cases from one center. Median data were duration of blocking pulmonary artery (PA) 72 minutes (range, 44-143 minutes), resected lymph nodes 24 (range, 10-46), stations of retrieved lymph nodes 6 (range, 5-9), thoracic drainage 1,042 mL (range, 500-1,700 mL), duration of thoracic drainage 5 days (range, 3-8 days), postoperative hospital stay 10 days (range, 7-20 days), and ICU stay 1 day (range, 1-2 days). One patient (1/13, 7.70%) suffered from pneumonia after surgery. There were no deaths at 30 days. Median duration of follow-up was 6 months (range, 1-26 months). And no local recurrences or distant metastasis were reported. CONCLUSIONS Thoracoscopic double sleeve lobectomy is a technically challenging, but feasible procedure for NSCLC patients and it should be restricted to skilled VATS surgeons.

Complete video-assisted thoracoscopic surgery (VATS) bronchial sleeve lobectomy

BACKGROUND To explore the effectiveness of video-assisted thoracoscopic surgery (VATS) bronchial sleeve resection and reconstruction. METHODS The clinical data of patients who had received VATS bronchial sleeve lobectomy in our center from January 2008 to February 2015 were retrospectively analyzed. RESULTS Totally 118 patients (105 men and 13 women) received the VATS bronchial sleeve lobectomy. The procedures included sleeve resection of right upper lobe (n=59), right middle lobe (n=7), right lower lobe (n=8), left upper lobe (n=34), and left lower lobe (n=10). The lesions were confirmed to be squamous cell carcinoma (n=68), adenocarcinoma (n=16), mucoepidermoid carcinoma (n=8), adenosquamous carcinoma (n=7), large cell carcinoma (n=1), carcinoids (n=5), and others (n=13; including small cell carcinoma, pleomorphic carcinoma, and inflammatory myofibroblastic tumor). Operations lasted 118-223 min [mean ± standard deviations (SD): 124.00±31.75 min]. The length of removed bronchus was 1.50-2.00 cm (mean ± SD: 1.75±0.26 cm). The duration of bronchial anastomosis (from the first puncture to the completion of knotting) was 15-42 min (mean ± SD: 30.20±7.97 min). The number of dissected lymph node stations (at least three mediastinal lymph node stations, including station 7) was 5-9 stations (mean ± SD: 6.50±1.18 min). The number of dissected lymph nodes was 10-46 (mean ± SD: 26.00±10.48). The intraoperative blood loss was 20-400 mL (mean ± SD: 71.00±43.95 mL), and no blood transfusion was performed. All patients were observed in intensive care unit (ICU) for 1 day. Postoperative drainage was performed for 3-8 days (mean ± SD: 5.00±1.49 days). Postoperative hospital stay was 3-8 days (mean ± SD: 5.10±2.07 days). CONCLUSIONS VATS bronchial sleeve resection and reconstruction is a safe and feasible technique.

Video-assisted thoracoscopic surgery segmentectomy by non-intubated or intubated anesthesia: a comparative analysis of short-term outcome

BACKGROUND The aim of this study was to reveal the short-term outcomes of video-assisted thoracoscopic surgery (VATS) segmentectomy without tracheal intubation compared with intubated general anesthesia with one-lung ventilation (OLV). METHODS We performed a retrospective review of our institutional database of consecutive 140 patients undergoing VATS anatomical segmentectomy from July 2011 to June 2015. Among them, 48 patients were treated without tracheal intubation using a combination of thoracic epidural anesthesia (TEA), intrathoracic vagal blockade, and sedation (non-intubated group). The other 92 patients were treated with intubated general anesthesia (intubated group). Safety and feasibility was evaluated by comparing the perioperative profiles and short-term outcomes of these two groups. RESULTS Two groups had comparable surgical durations, intraoperative blood loss, postoperative chest tube drainage volume, and numbers of dissected lymph nodes (P>0.05). Patients who underwent non-intubated segmentectomy had higher peak end-tidal carbon dioxide (EtCO2) during operation (44.81 vs. 33.15 mmHg, P<0.001), less white blood cell changes before and after surgery (△WBC) (6.08×10(9) vs. 7.75×10(9), P=0.004), earlier resumption of oral intake (6.76 vs. 17.58 hours, P<0.001), shorter duration of postoperative chest tube drainage (2.25 vs. 3.16 days, P=0.047), less cost of anesthesia (¥5,757.19 vs. ¥7,401.85, P<0.001), and a trend toward shorter postoperative hospital stay (6.04 vs. 7.83 days, P=0.057). One patient (2.1%) in the non-intubated group required conversion to intubated OLV since a significant mediastinal movement. In the intubated group, there was one patient (1.1%) required conversion to thoracotomy due to uncontrolled bleeding. The incidence difference of postoperative complications between groups was not significant (P=0.248). There was no in-hospital death in either group. CONCLUSIONS Compared with intubated general anesthesia, non-intubated thoracoscopic segmentectomy is a safe, technically feasible and economical alternative with comparable short-term outcomes. Patients underwent non-intubated thoracoscopic segmentectomy could gain a prompt recovery.