Treatment of Non-small Cell Lung Cancer by Single-direction Four-hole Complete Video-assisted Thoracoscopic Lobectomy HUANG Jia, ZHAO Xiao-jing, LIN Hao, TAN Qiang, DING Zheng-ping, LUO Qing-quan. (Shanghai Lung Tumor Clinical Medical Center, Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai 200030, P. R. China) Corresponding author：LUO Qing-quan, Email：luoqingquan@hotmail. com Abstract： Objective To explore the feasibility and safety of single-direction four-hole video-assisted thoracoscopic lobectomy in the treatment of non-small cell lung cancer (NSCLC). Methods Between January 2007 and December 2010, 428 patients with NSCLC were surgically treated by single-direction complete video-assisted thoracoscopic lobectomy in Shanghai Chest Hospital. There were 186 males and 242 females; aged 33 to 78 years. All the patients were diagnosed as primary NSCLC at early clinical stage. Among the 428 patients, 134 patients underwent right upper lobectomy, 48 patients underwent right middle lobectomy, 98 patients underwent right lower lobectomy, 4 patients underwent right middle and lower lobectomy, 72 patients underwent left upper lobectomy, and 72 patients underwent left lower lobectomy. All the 428 patients were divided into two groups according to their surgical approach：a three-hole group (300 patients) and a four-hole group (128 patients).The clinical results of the two groups were analyzed. Results A total of 412 patients underwent complete video-assisted thoracoscopic lobectomy, and 16 patients (3.7%) underwent conversion to open surgery. The average operation time was 132.1 (120-180) min, average length of incision was 3.7 (3-5) cm, and average blood loss was 150.0 (50-800) ml. There was no statistical difference in extubation time, intraoperative blood loss, and postoperative hospital stay between the two groups. But the operation time of the four-hole group is significantly shorter than that of the three-hole group （P＜0.05）. The 16 patients who underwent conversion to open surgery received intraoperative blood transfusion. Five patients died of severe pulmonary infection, pulmonary embolism, and acute cerebral infarction. Fifty two patients had squamous cancer, 340 patients had adenocarcinoma, 20 patients had adenosquamous carcinoma, 8 patients had poorly differentiated carcinoma, 6 patients had big cell lung cancer, and 2 patients had carcinoid. Postoperative persistent lung air leak occurred in 4 patients, thoracic empyema in 2 patients, pulmonary infection in 4 patients, arrhythmia in 26 patients, pulmonary embolism in 2 patients, chylothorax in 2 patients, and acute cerebral infarction in 2 patients. The overall 3-year survival rate was 83.6%（358/428）. Conclusion Single-direction four-hole complete video-assisted thoracoscopic lobectomy is feasible, safe and consistent with the operation standard in the surgical treatment for NSCLC patient. It is also helpful to reduce the operation time and facilitate lymph node dissection. Key words： Video-assisted thoracoscopic surgery； Lobectomy； Single-direction； Four-hole； Non-small cell lung cancer
Objective To investigate the efficacy, early and late outcomes of video-assisted thoracic surgery (VATS) for cN0-pN2 lung cancer patients compared to open lobectomy. Methods We retrospectively reviewed 262 out of 1 754 patients’ clinical records with cN0-pN2 lung cancer who underwent VATS or open lobectomy in our center between January 2009 and December 2014. There were 107 patients in a VATS group with 50 males and 57 females at the age of 61.5±10.7 years, and 155 patients in an open lobectomy group consisting of 104 males and 51 females at the age of 59.0±8.7 years. Results There was no statistical difference in patients’ age, pulmonary function, and underlying diseases between two groups. Operation time was shorter in the open lobectomy group than that in the VATS group (P=0.044). Postoperative in-hospital time was shorter in the VATS surgery group than that in the open lobectomy group (P=0.008). There was an obvious difference in tumor’s maximum diameter (P<0.05). As for mediatinal lymph node, there was no statistical difference in station dissected and positive rate. One year overall survival rate was 91.6% in the VATS group and 81.9% in the open group. Three-year overall survival rate was 58.3% in the VATS group and 47.3% in the open lobectomy group (P<0.05). Conclusion VATS can achieve both the thoroughness and feasibility as the same as open surgery and with better early outcomes. The overall survival rate may have more to do with tumor’s maximum diameter, not the operation method. Still, it needs prospective studies to demonstrate this relationship.
Objective To investigate the perioperative outcome of robot-assisted pulmonary lobectomy in treating pathological stage Ⅰ non-small cell lung cancer (NSCLC). Methods We retrospectively analyzed the clinical data of 333 consecutive p-T1 NSCLC patients who underwent robotic-assisted pulmonary lobectomy in our hospital between May 2013 and April 2016. There were 231 females (69.4%) and 102 males (30.6%) aged from 20–76 (55.01±10.46) years. Cancer was located in the left upper lobectomy in 37 (11.1%) patients, left lower lobectomy in 71 (21.3%) patients, right upper lobectomy in 105 (31.5%) patients, right middle lobectomy in 32 (9.6%) patients, right lower lobectomy in 88 (26.4%) patients. Adenocarcinoma was confirmed in 330 (99.1%) patients and squamous cell cancer was confirmed in 3 (0.9%) patients. Results Total operative time was 46–300 (91.51±30.80) min. Estimated intraoperative blood loss was 0–100 ml in 319 patients (95.8%), 101–400 ml in 12 patients (3.6%), >400 ml in 2 patients (0.6%). Four patients were converted to thoracotomy, including 2 patients due to pulmonary artery branch bleeding and 2 due to pleural adhesion.No patient died within 30 days after surgery. And no perioperative blood transfusion occurred. Postoperative day 1 drain was 0–960 (231.39±141.87) ml. Chest drain time was 2–12 (3.96±1.52) d.And no patient was discharged with chest tube. Length of hospital stay after surgery was 2–12 (4.96±1.51) d. Persistent air leak was in 12 patients over 7 days. No readmission happened within 30 days. All patients underwent lymph node sampling or dissection with 2–9 (5.69±1.46) groups and 3–21 (9.80±3.43) lymph nodes harvested. Total intraoperative cost was 60 389.66–134 401.65 (93 809.23±13 371.26) yuan. Conclusion Robot-assisted pulmonary lobectomy is safe and effective in treating p-Stage Ⅰ NSCLC, and could be an important supplement to conventional VATS. Regarding to cost, it is relatively more expensive compared with conventional VATS. RATS will be widely used and make a great change in pulmonary surgery with the progressive development of surgical robot.
ObjectiveTo explore the value of geriatric nutritional risk index (GNRI) and sarcopenia on predicting postoperative complications in elderly patients with gastric cancer. MethodsAccording to the inclusion and exclusion criteria, the elderly (aged ≥60 years) patients with gastric cancer underwent radical gastrectomy in the Department of Gastrointestinal Surgery of Xuzhou Central Hospital from January 1, 2017 to December 31, 2021 were retrospectively gathered. The occurrence of postoperative complications (grade 2 or beyond by the Clavien-Dindo classification) was analyzed. The risk factors affecting postoperative complications were analyzed by univariate and multivariate logistic regression analyses to construct the prediction model, then was visualized by drawing a nomogram. The differentiation of the nomogram between the patients with postoperative complications and without postoperative complications was evaluated by the receiver operating characteristic (ROC) curve. The accuracy of the nomogram was evaluated by the calibration curve. Further, the clinical net benefit rate was analyzed by the decision curve analysis (DCA) to evaluate the clinical practicability. ResultsA total of 236 patients were gathered, 97 (41.1%) of whom had postoperative complications during hospitalization. The results of multivariate logistic regression analysis showed that the age, gender, GNRI, sarcopenia, surgical mode, and American Society of Aneshesiologists classification were the factors influencing the postoperative complications (P<0.05). The differentiation of nomogram based on the influencing factors was well, the area under the ROC curve was 0.732. The calibration curve showed that the model prediction curve was close to the ideal curve. The clinical net benefit rate by the DCA was higher when the probability of postoperative complications was 0.18 to 0.72. ConclusionsThe efficiency of nomogram based on GNRI and sarcopenia is well for predicting the occurrence of postoperative complications in elderly patients with gastric cancer. However, the nomogram needs to be further validated by prospective studies and external data.
Objective To understand the changes of intestinal flora during perioperative period of colorectal cancer and the mechanism affecting the occurrence of postoperative anastomotic leakage, so as to improve perioperative management of patients and find possible measures to decrease the incidence rate of anastomotic leakage. Method The literature related to perioperative intestinal flora assessment, anastomotic healing, and anastomotic leakage of colorectal cancer in recent years was comprehensively searched in the CNKI, PubMed, and Embase databases and made an review. ResultsDue to the various perioperative interventions, the diversity and abundance of intestinal flora had changed after colorectal cancer surgery, and some conditional pathogenic bacteria such as Enterococcus faecalis, Pseudomonas aeruginosa, etc. increased obviously, which led to collagen degradation through the expression of bacterial collagenase or the excessive activation of matrix metalloproteinases in the host intestine, then might lead to the poor anastomotic healing and even the anastomotic leakage. ConclusionAlthough the evidence of effect of intestinal flora on anastomotic leakage mainly comes from animal experiments, it still shows the potential role of intestinal flora in the occurrence of anastomotic leakage after colorectal cancer surgery, and can be regulated by perioperative intervention, which suggests that it may provide a new strategy for prevention of anastomotic leakage.
Objective To summarize the stemness regulation mechanism of microRNA on invasion, metastasis and chemoresistance of gastric cancer stem cells (GCSCs), and to explore the anti-tumor therapy based on miRNA targeting GCSCs. Method The literatures about the research progress of miRNA and GCSCs at home and abroad in recent years were collected and reviewed. Results MiRNA could regulate a series of important cellular processes such as proliferation, apoptosis, differentiation and epithelial-mesenchymal transition of GCSCs by participating in the expression of related target genes, which was associated with poor prognosis and high mortality of gastric cancer patients. Silencing or restoring the expression of candidate miRNA of GCSCs could provide a novel and promising approach for the treatment of gastric cancer. Conclusions GCSCs have an important relationship with the malignant biological behavior of gastric cancer, and studies have confirmed that miRNA play an important regulatory role in GCSCs. Therefore, miRNA can be used as a potential target for the treatment of gastric cancer. By regulating the expression of specific miRNA, it can inhibit tumor invasion and metastasis, and improve the sensitivity of chemotherapy drugs.
ObjectiveTo investigate the risk factors and establish the predictive pattern of the metachronous liver metastasis after curative surgery for patientswith gastric cancer. MethodsThe clinicopathologic data of patients who underwent radical gastric cancer surgery and met the inclusion and exclusion criteria from January 1, 2015 and January 1, 2018 in the First Hospital of Lanzhou University were retrospectively analyzed. The risk factors affecting metachronous liver metastasis of gastric cancer were screened out by univariate and multivariate logistic regression analysis. And a nomogram prediction model based on the risk factors screened out was established and its predictive efficiency was evaluated. ResultsA total of 203 patients were collected in this study, of whom 41 (20.4%) developed metachronous liver metastasis of gastric cancer. The results of multivariate logistic regression analysis showed that the tumor diameter ≥5 cm, increasing intraoperative bleeding, carcinoembryonic antigen (CEA) ≥5 μg/L, and lymphovascular invasion increased the risks of metachronous liver metastasis of gastric cancer (all P<0.05). The area under the receiver operating characteristic curve and its 95% confidence interval (95%CI) of the nomogram based on these risk factors in predicting metachronous liver metastasis of gastric cancer was 0.850 (0.793, 0.908), and the consistency index (95%CI) was 0.812 (0.763, 0.859). The calibration curve for predicting the risk of metachronous liver metastasis in gastric cancer by the nomogram was close to the 45° ideal curve and had a stronger calibration (Hosmer Limeshow goodness-of-fit test, χ2=2.116, P=0.347). ConclusionsThe results of this study conclude metachronous liver metastasis of gastric cancer is not low, and the patient with lymphovascular invasion, higher level of CEA (≥5 μg/L), more intraoperative bleeding, and larger tumor diameter (≥5 cm) has a higher risk of metachronous liver metastasis of gastric cancer. The nomogram prediction model established based on these risk factors has a good predictive efficiency and can provide reference for clinicians to identify high-risk patient and take early interventions.
Objective To investigate the morphological anatomical abnormal ities of high congenital dislocation of hip in adults and provide anatomical basis for the total hip arthroplasty (THA). Methods From May 1997 to July 2008, 49 patients (57 hi ps) with high congenital dislocation of hip (Hartofilakidis type III) were treated. There were 6 males and 43 females with an average age of 29.4 years old (18-56 years old). The locations were left in 24 hi ps and right in 33 hi ps. The morphological parameters (including femoral length, isthmus, height of femoral head center, neck-shaft angle, medialhead offset, anteversion angle, canal flare index, anteroposterior diameter of the true acetabulum, posterior thickness of the true acetabulum, depth of the true acetabulum) of suffering hips (dislocation group, n=57) were measured by preoperative X-ray, CT and intraoperative cl inical observation and were compared with those of contralateral hips (control group, n=41). The intraoperative situations of hip were observed. Results The height of dislocation was (45.41 ± 2.15) mm. The length difference of both lower extremities was (40.41 ± 2.02) mm. In dislocation group, isthmus was shortened; height of femoral head center, neck-shaft angle and medial head offset were decreased; and anteversion angle was increased. CT showed that the canal flare index was larger than 4.7, femoral shape was funnel-shaped according to Noble classification. Anteroposterior diameter of the true acetabulum became smaller, posterior thickness of the true acetabulum became thicker, and depth of the true acetabulum was shallower. There were statistically significant differences in the morphological parameters of femur and acetabulum between two groups (P lt; 0.05). The intraoperative measurements showed that the anteroposterior diameter of acetabulum was (32.98 ± 1.02) mm and the depth of acetabulum was (14.21 ± 0.56) mm. There was no statistically significant difference between intraoperative measurements and preoperative measurements (P gt; 0.05). The acetabulum was full of fat and fibrous tissues. Running of the sciatic nerve in 40 cases were changed and it ran upward and laterally. Conclusion When high congenital dislocation of the hip in adults is treated with THA, anatomical variation must be fully taken into account. The acetabulum is expanded toward posterosuperior, excessive reamed should be avoided to prevent femoral fractures, and appropriate or tailor-made prosthesis was selected.
ObjectiveTo analyze the perioperative outcome of consecutive 1 000 patients undergoing robotic lung resection and summarize surgical experience.MethodsWe retrospectively reviewed the clinical data of 1 000 patients undergoing robotic lung resection between May 2009 and June 2018 in Shanghai Lung Tumor Clinical Medical Center. Robotic lobectomy was compared with traditional VATS over the same period using a propensity-matched analysis. There were 327 males and 673 females at average age of 56.21±11.33 years. Lobectomy was performed in 866 patients (11 bilobectomy included), sublobar resection was performed in 129 patients, sleeve lobectomy was performed in the remaining 5 patients. Pathology was as follows: adenocarcinoma in 875 patients, squamous carcinoma in 52 patients, benign tumors in 73 patients. 90.5% of the primary lung cancer were in stage Ⅰ.ResultsThe mean operative time was 90.31±19.70 min; 95.70% of patients’ estimated blood loss was less than 100 ml. Conversion rate to thoracotomy was 0.90% (9 patients) . The average lymph node station and count harvested was 5.59±1.36 and 9.60±3.21 respectively. The mean volume of chest tube drainage on the first postoperative day was 229.19±131.67 ml. Median chest tube time was 3.85±1.43 d. There was 1 in-hospital death due to pulmonary embolism. A total of 189 patients had postoperative complications (18.90%) whose majority was postoperative air leak more than 5 days. The mean overall hospital costs was 92 710.53±12 367.23 Yuan. Compared with VATS, RATS was associated with significant reduction in intraoperative blood loss, time to chest tube removal and postoperative hospital stay. The operative time, conversion rate, lymph nodes removed, morbidity and mortality were similar between the two groups.ConclusionRobotic-assisted lung resection is safe and effective with low conversion rate and less complications, and it can overcome many disadvantages of traditional VATS.
Objective To determine the risk factors of anastomotic leakage after elective colectomy in elderly patients with colon cancer, and to establish a model for predicting the risk of postoperative anastomotic leakage based on these factors. Methods The clinical data of 122 over 65 years old elderly patients who underwent colon cancer surgery in the First Hospital of Lanzhou University from January 2018 to December 2021 were analyzed retrospectively. Single factor analysis and multivariate logistic regression were used to analyze the potential risk factors for anastomotic leakage. A nomogram predictive model was established based on the determined independent risk factors, and the predictive performance of the model was evaluated by the receiver operating characteristic curve. Results Among the 122 patients included in this study, 10 had postoperative anastomotic leakage and 112 had no anastomotic leakage. Single factor analysis results showed that the occurrence of anastomotic leakage was associated with body mass index, smoking, combined diabetes, age-adjusted Charlson comorbidity index, intraoperative and postoperative blood transfusion within 2 days, preoperative hemoglobin, preoperative albumin, and preoperative prognostic nutritional index (P＜0.05). The results of multivariate logistic regression analysis showed that smoking [OR=15.529, 95%CI (1.529, 157.690), P=0.020], age-adjusted Charlson comorbidity index [OR=1.742, 95%CI (1.024, 2.966), P=0.041], and intraoperative and postoperative blood transfusion within 2 days [OR=82.223, 95%CI (1.265, 5 343.025), P=0.038] were independent risk factors for anastomotic leakage. A nomogram predictive model was established based on three independent risk factors. The area under the receiver operating characteristic curve of the model was 0.897 [95%CI (0.804, 0.990)], and its corrected C-index value was 0.881, indicating that the model had good predictive ability for the risk of anastomotic leakage. Conclusions Smoking, higher age-adjusted Charlson comorbidity index, and intraoperative and postoperative blood transfusion within 2 days are important risk factors for anastomotic leak in elderly patients undergoing elective colon cancer resection. This nomogram predictive model based on the combination of the three factors is helpful for surgeons to optimize treatment decisions and postoperative monitoring.