No abstract

OBJECTIVES: Compared with conventional median sternotomy, approaches used in thymectomy for myasthenia gravis and anterior mediastinal tumours have become much less invasive in recent years. We previously developed a surgical technique called single-port thymectomy (SPT) to excise the thymus through a single opening made below the xiphoid process. In this study, to show the utility of SPT, we compared factors contributing to low surgical invasiveness between SPT and conventional video-assisted thoracoscopic surgery (VATS) thymectomy. METHODS:Between January 2005 and December 2014, 146 patients underwent surgery for anterior mediastinal tumour or myasthenia gravis at our hospital. After excluding patients diagnosed with tumour invasion of nearby organs or those who had undergone concurrent removal of nearby organs, 81 patients were enrolled in this retrospective study as subjects. Patients were divided into the VATS thymectomy group (VATS group, n = 35) and the SPT group (n = 46). Surgical duration, blood loss, duration of hospital stay and the amount and duration of postoperative oral analgesics were compared between the groups. RESULTS:Operating time did not vary significantly between the VATS and SPT groups (P = 0.0853). The amount of blood loss was higher in the VATS group than in the SPT group (P < 0.0001). The duration of hospital stay was longer in the VATS group than in the SPT group (P = 0.0008). The amount of postoperative oral analgesics was significantly higher in the VATS group than in the SPT group (P = 0.0092). Similarly, the duration of postoperative oral analgesics was significantly longer in the VATS group than in the SPT group (P = 0.0312). CONCLUSIONS:Compared with VATS thymectomy, SPT required a similar operating time, was associated with less blood loss and enabled postoperative analgesics to be discontinued earlier. Therefore, it could be considered a less invasive surgical approach.

Minimally invasive surgery has replaced median sternotomy for resectable anterior mediastinal masses and is performed by various approaches. We developed a new minimally invasive surgical procedure by combining the subxiphoid approach performed through a midline camera port with the use of a robotic surgery system (Intuitive Surgical, Sunnyvale, CA, USA). A 3-cm transverse incision was made 1 cm below the xiphoid process. Then, a port designed for single-port surgery was inserted. Through this port, CO2 gas was injected at 8 mmHg. The thymus was then detached from the back of the sternum. A 1-cm skin incision was made bilaterally in the sixth intercostal space, followed by insertion of a port for the robotic system. A camera port was inserted into the subxiphoid port, to which the camera scope was mounted, and thymectomy was performed. We have performed the operation in 3 patients. In our experience, this procedure provides a good operative view in the neck region and makes verification of the phrenic nerve easy. Furthermore, with the da Vinci surgical system, which enables surgical manipulation from a correct angle due to the multijoint robotic arms, trans-subxiphoid robotic thymectomy may be a promising new thymectomy procedure.

We have previously reported single-port thymectomy (SPT) through an infrasternal approach, a procedure in which the thymus is removed through a single port. The dual-port thymectomy procedure developed by adding another port to the single-port procedure has eliminated the risk of interference between forceps operated by both hands of the surgeon and has thereby significantly simplified operative procedures. This procedure provides the same operative field as that obtained by median sternotomy and has excellent maneuverability of devices. Therefore, the dual-port procedure can be used by surgeons who have not been sufficiently trained for SPT, as an alternative procedure in the event of experiencing technical difficulty during SPT, or as a new approach for thymectomy.

Background: The objective of this study was to assess the preoperative serum carcinoembryonic antigen (CEA) level in patients with clinical stage IA non-small cell lung cancer (NSCLC) and to evaluate its clinical significance.Methods: Between January 2005 and December 2014, a total of 378 patients with clinical stage IA NSCLC underwent complete resection with systematic node dissection. The survival rate was estimated starting from the date of surgery to the date of either death or the last follow-up by the Kaplan-Meier method. Univariate analyses by log-rank tests were used to determine prognostic factors. Cox proportional hazards ratios were used to identify independent predictors of poor prognosis. Clinicopathological predictors of lymph node metastases were evaluated by logistic regression analyses. Results:The 5-year survival rate of patients with an elevated preoperative serum CEA level was significantly lower than that of patients with a normal CEA level (75.5% vs. 87.7%; P=0.02). However, multivariate analysis did not show the preoperative serum CEA level to be an independent predictor of poor prognosis. Postoperative pathological factors, including lymphatic permeation, visceral pleural invasion, and lymph node metastases, tended to be positive in patients with an elevated preoperative serum CEA level. In addition, the CEA level was a statistically significant independent clinical predictor of lymph node metastases. Conclusions: The preoperative serum CEA level was not an independent predictor of poor prognosis in patients with pathological stage IA NSCLC but was an important clinical predictor of tumor invasiveness and lymph node metastases in patients with clinical stage IA NSCLC. Therefore, measurement of the preoperative serum CEA level should be considered even for patients with early-stage NSCLC.

Abstract OBJECTIVES The aim of the present study was to examine some initial results and learning curves concerning subxiphoid single-port thymectomy (SSPT), thereby clarifying the safety of this surgical approach and describing the precautions for adopting it. METHODS From March 2011 to August 2019, a total of 203 patients underwent thymectomy for either anterior mediastinal tumours or myasthenia gravis at Fujita Health University Hospital. Of these 203 patients, 147 patients who had undergone SSPT were selected as participants for the present study. RESULTS Of the 147 cases, transition to a different approach was required in three (2.0%) cases: two (1.3%) cases transitioned to median sternotomy, whereas one (0.7%) case transitioned to the side chest trans-intercostal approach. The two cases that transitioned to median sternotomy were the second cases for different operators after they began performing this technique. There were six (4.0%) cases with complications and no deaths. The operation time cumulative summation learning curve analysis revealed that the curves descended from the 38th case. In the 83 cases handled by one surgeon, the learning curves descended from the 31st case. CONCLUSIONS SSPT is a safe modality with few complications and no associated cases of mortality reported. Operators are required to experience 31–38 cases until the operation time for SSPT was stabilized. Special care should be exercised to prevent vascular damage in the vicinity of the innominate veins during the early stages after SSPT introduction.

In patients who underwent video-assisted thoracoscopic surgery for pulmonary metastases from CRC, we identified two independent unfavorable prognostic factors for DFS: a high CEA level before metastasectomy and a greater number of pulmonary metastases. These factors can be used to identify higher- and lower-risk subgroups, which may help with selecting patients who would benefit the most from video-assisted thoracoscopic pulmonary metastasectomy.

Background: This study aimed to investigate the initial results of an endoscopic surgical approach for the treatment of intramediastinal ectopic parathyroid adenoma and to evaluate the effectiveness of a singleincision resection using the subxiphoid approach. Methods: Five cases of patients (1.89%) were diagnosed with ectopic mediastinal parathyroid tumor and underwent resection from 2008 to 2017 in Fujita Health University Hospital. They were retrospectively analyzed. Results: Four patients underwent single-port mediastinal tumor resection using the subxiphoid approach and 1 patient underwent multi-port mediastinal tumor resection using the lateral thoracic approach.The operation time was 134±83.52 min, and the amount of blood loss was 81.8±173.41 mL. The rate of conversion to thoracotomy was 0%, and no intraoperative or postoperative complications were observed.The amount of postoperative oral analgesics was 112.83±209.12 tablets, and their administration period was 561.6±1,229.5 days. The length of hospital stay was 4±2.35 days, and the duration of chest tube drainage was 1.33±1.95 days. The patient who underwent multi-port mediastinal tumor resection using the lateral thoracic approach reported postoperative pain. Serum calcium levels decreased from 10.56±1.52 mg/dL preoperatively to 8.96±0.5 mg/dL postoperatively, and serum phosphorous levels increased from 2.84±0.42 mg/dL preoperatively to 3.6±0.51 mg/dL postoperatively. Intact-PTH hormone levels decreased from 221±169.84 pg/dL preoperatively to 70.2±44.28 pg/dL postoperatively. No recurrence of hyperparathyroidism has been observed in any patient. Conclusions: The single-incision mediastinal tumor resection via the subxiphoid approach, without going through the intercostal space, is considered as a useful endoscopic surgical approach for the treatment of mediastinal ectopic parathyroid adenomas due to the limited occurrence of post-thoracotomy pain syndrome and the superior esthetic outcomes associated with the procedure as compared to thoracotomy and median sternotomy.