Chest tube drainage versus video-assisted thoracoscopic surgery for a first episode of primary spontaneous pneumothorax:a systematic review and meta-analysis

Primary spontaneous pneumothorax affects up to 28 patients per 100 000 population yearly and is commonly resolved by chest tube drainage. However, drainage is also known to be associated with ipsilateral recurrence rates ranging from 25% to 43%. Preventive video-assisted thoracoscopic surgery (VATS) may be an effective alternative to diminish these recurrence rates and its associated morbidity. The aim of this study was to compare the efficacy of chest tube drainage and VATS as first line treatments of an initial episode of primary spontaneous pneumothorax. The MEDLINE, EMBASE, CENTRAL and Clinicaltrials.gov databases were searched through 16 September 2018. Data regarding the ipsilateral recurrence rate and the length of hospitalization were extracted and submitted to meta-analysis using the random-effects model and the I-2 test for heterogeneity. Two randomized controlled trials and 2 observational studies were included, enrolling a total of 479 patients. Pairwise analysis demonstrated significantly reduced ipsilateral recurrence rates [odds ratio 0.15, 95% confidence interval (CI) 0.07-0.33; P <0.00001] and length of hospitalization (standardized mean difference -2.19, 95% CI -4.34 to -0.04; P = 0.046) in favour of VATS. However, a significant level of heterogeneity was detected for the length of hospitalization (I-2 = 97%; P <0.00001). Subgroup analysis that stratified study design found no statistical differences regarding recurrence rate. In conclusion, VATS can be an effective and attractive alternative to standard chest tube drainage, with reduced ipsilateral recurrence rates and length of hospitalization. However, given the low quality of the majority of included studies, more well-designed randomized controlled trials are necessary to strengthen the current evidence

Surgical mediastinal lymph node staging for non-small-cell lung carcinoma

BACKGROUND: The current preferred approach for surgical mediastinal staging of non-small-cell lung carcinoma is video-assisted mediastinoscopy. An alternative technique in which lymph nodes are resected instead of biopsied is video-assisted mediastinoscopic lymphadenectomy (VAMLA) that is suggested to be superior in detecting N2 disease. Yet, evidence is conflicting and furthermore limited by sample size. The objective was to compare mediastinal staging through VAMLA and video-assisted mediastinoscopy. METHODS: A single-center cohort study was conducted. All consecutive patients that underwent surgical mediastinal staging of non-small-cell lung carcinoma by VAMLA (2011 to 2018) were compared to historic video-assisted mediastinoscopy controls (2007 to 2011). Patients with negative surgical mediastinal staging underwent subsequent anatomical resection with systematic regional lymphadenectomy. Primary outcome was the sensitivity and negative predictive value for detecting N2 disease. RESULTS: Two-hundred-sixty-nine video-assisted mediastinoscopic lymphadenectomies and 118 video-assisted mediastinoscopies were performed. The prevalence of N2 disease was 20% and 26% respectively in the VAMLA and video-assisted mediastinoscopy group, while the rate of unforeseen pN2 resulting from lymph node dissection during anatomical resection was 4% and 11%, respectively. Invasive staging using VAMLA demonstrated superior sensitivity of 0.82 and a negative predictive value of 0.96 when compared to video-assisted mediastinoscopy (0.62 and 0.89, respectively), offering a 64% decrease in risk of unforeseen pN2 following anatomical resection. However, VAMLA is also associated with a 75% risk increase on complications (P=0.36). CONCLUSIONS: We conclude that performing invasive mediastinal lymph node assessment for staging of non-small-cell lung carcinoma, VAMLA should be the preferred technique with superior sensitivity and negative predictive value in detecting N2 disease. Though, VAMLA is also associated with an increased risk of complications

Photographic documentation and severity quantification of pectus excavatum through three-dimensional optical surface imaging

Conventional photography is commonly used to visually document pectus excavatum and objectively assess chest wall changes over time without repeated exposure to ionising radiation, as in our centre since 2008. However, as conventional photography is labour-intensive and lacks three-dimensional (3D) information that is essential in 3D deformities like pectus excavatum, we developed a novel imaging and processing protocol based on 3D optical surface imaging. The objective of this study was to report our developed protocol to visually document pectus excavatum through 3D imaging. We also investigated the absolute agreement of the 3D image- and conventional photography-derived pectus excavatum depth to investigate whether both techniques could be used interchangeably to measure pectus excavatum depth and assess its evolution. The protocol consisted of three consecutive steps: patient positioning and instructions, data acquisition, and data processing. Three-dimensional imaging through the developed protocol was feasible for all 19 participants. The 3D image- and photography-derived pectus excavatum depth demonstrated good to excellent agreement (intraclass correlation coefficient: 0.97; 95%-confidence interval: 0.88 to 0.99; p < 0.001). In conclusion, 3D imaging through the developed protocol is a feasible and attractive alternative to document the surface geometry of pectus excavatum and can be used interchangeably with conventional photography to determine pectus severity. Clinical registration number: NCT04185870

18F-Fludeoxyglucose-Positron Emission Tomography/Computed Tomography and Laparoscopy for Staging of Locally Advanced Gastric Cancer: A Multicenter Prospective Dutch Cohort Study (PLASTIC)

Importance: The optimal staging for gastric cancer remains a matter of debate. Objective: To evaluate the value of 18F-fludeoxyglucose-positron emission tomography with computed tomography (FDG-PET/CT) and staging laparoscopy (SL) in addition to initial staging by means of gastroscopy and CT in patients with locally advanced gastric cancer. Design, Setting, and Participants: This multicenter prospective, observational cohort study included 394 patients with locally advanced, clinically curable gastric adenocarcinoma (≥cT3 and/or N+, M0 category based on CT) between August 1, 2017, and February 1, 2020. Exposures: All patients underwent an FDG-PET/CT and/or SL in addition to initial staging. Main Outcomes and Measures: The primary outcome was the number of patients in whom the intent of treatment changed based on the results of these 2 investigations. Secondary outcomes included diagnostic performance, number of incidental findings on FDG-PET/CT, morbidity and mortality after SL, and diagnostic delay. Results: Of the 394 patients included, 256 (65%) were men and mean (SD) age was 67.6 (10.7) years. A total of 382 patients underwent FDG-PET/CT and 357 underwent SL. Treatment intent changed from curative to palliative in 65 patients (16%) based on the additional FDG-PET/CT and SL findings. FDG-PET/CT detected distant metastases in 12 patients (3%), and SL detected peritoneal or locally nonresectable disease in 73 patients (19%), with an overlap of 7 patients (2%). FDG-PET/CT had a sensitivity of 33% (95% CI, 17%-53%) and specificity of 97% (95% CI, 94%-99%) in detecting distant metastases. Secondary findings on FDG/PET were found in 83 of 382 patients (22%), which led to additional examinations in 65 of 394 patients (16%). Staging laparoscopy resulted in a complication requiring reintervention in 3 patients (0.8%) without postoperative mortality. The mean (SD) diagnostic delay was 19 (14) days. Conclusions and Relevance: This study's findings suggest an apparently limited additional value of FDG-PET/CT; however, SL added considerably to the staging process of locally advanced gastric cancer by detection of peritoneal and nonresectable disease. Therefore, it may be useful to include SL in guidelines for staging advanced gastric cancer, but not FDG-PET/CT