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RPT is less technically challenging as it eliminates the need for sewing and trimming of esophageal remnant. This technique is safe and efficient, and is particularly suited to those who do not have access to the Orvil device when performing Ivor Lewis MIE.

Background:Regulatory T-cells (Treg) play key roles in suppressing cell-mediated immunity in cancer patients. Little is known about perioperative Treg fluctuations in nonsmall cell lung cancer (NSCLC). Video-assisted thoracoscopic (VATS) lobectomy, as a minimal invasive procedure for treating NSCLC, may have relatively less impact on the patient's immune system. This study aimed to observe perioperative dynamics of circulating Treg and natural killer (NK) cell levels in NSCLC patients who underwent major lobectomy by VATS or thoracotomy.Methods:Totally, 98 consecutive patients with stage I NSCLC were recruited and assigned into VATS or thoracotomy groups. Peripheral blood samples were taken on 1-day prior to operation, postoperative days (PODs) 1, 3, 7, 30, and 90. Circulating Treg and NK cell counts were assayed by flow cytometry, defined as CD4+CD25+CD127low cells in CD4+ lymphocytes and CD56+16+CD3− cells within CD45+ leukocytes respectively. With SPSS software version 21.0 (SPSS Inc., USA), differences between VATS and thoracotomy groups were determined by one-way analysis of variance (ANOVA), and differences between preoperative baseline and PODs in each group were evaluated by one-way ANOVA Dunnett t-test.Results:In both groups, postoperative Treg percentages were lower than preoperative status. No statistical difference was found between VATS and thoracotomy groups on PODs 1, 3, 7, and 30. On POD 90, Treg percentage in VATS group was significantly lower than in thoracotomy group (5.26 ± 2.75 vs. 6.99 ± 3.60, P = 0.012). However, a higher level of NK was found on all PODs except on POD 90 in VATS group, comparing to thoracotomy group.Conclusions:Lower Treg level on POD 90 and higher NK levels on PODs 1, 3, 7, 30 in VATS group might imply better preserved cell-mediated immune function in NSCLC patients, than those in thoracotomy group.

Postoperative iatrogenic diaphragmatic hernia after thoracoscopic lobectomy is extremely rare. We present a 55-year-old female patient who developed an iatrogenic diaphragmatic hernia with gastric perforation several months after VATS (video-assisted thoracic surgery) left upper lobectomy with systematic lymphadenectomy. During the readmission, urgent laparotomy was performed. Intraoperatively, the choledochoscopy was introduced into left thoracic cavity through the diaphragmatic defect for dissecting the secondary inflammatory adhesions and achieving satisfactory hemostasis. It appears to be an efficient and feasible approach for the patients who have been diagnosed as delayed diaphragmatic hernia concomitant with remarkable intra-abdominal findings and have a history of thoracic surgery. We consider that delayedonset diaphragmatic hernia should be suspected in patients complaining of nausea or vomiting after VATS procedure, although it is very rare. Figure 1B). The diagnosis of diaphragmatic hernia with gastric perforation was confirmed by barium swallow ( Figure 1C). Therefore, urgent laparotomy was scheduled. Intraoperatively, the stomach was incarcerated in the chest through the diaphragmatic defect (Figure 2A). The thoracic cavity was also inspected closely under the choledochoscopy which was inserted through the diaphragmatic defect. Due to the secondary inflammation of perforation, the adhesion which located between the lesser curvature of stomach and thorax was carefully dissected. Meanwhile, the thoracic hemostasis was verified using by ultrasonic activated scissor under the choledochoscopy ( Figure 2B). Subsequently, the stomach was gently reduced into the abdominal cavity. On account of gastric gangrene and secondary perforation, partial stomach was needed to be resected and nasojejunal tube was placed as well. Thereafter, the diaphragmatic defect was repaired with non-absorbable interrupted sutures. The postoperative recovery of the second surgery was uneventfully. Up to present, the patient was still well and no evidence of cancer recurrence was detected. DiscussionIatrogenic diaphragmatic hernia is a rare complication of thoracic and abdominal surgery (5). The low incidence of iatrogenic diaphragmatic hernia might be the result of a high misdiagnosis rate. Though the rare occurrence of J Thorac Dis 2016;8(6):E399-E402 jtd.amegroups.com iatrogenic diaphragmatic hernia, the mortality following emergency surgery for strangulated or perforated bowel or stomach rises to between 20% and 80% (6). To our knowledge, no document was found to describing the delayed complication several months after VATS left upper lobe (LUL) lobectomy. In this case, the left lower lobe (LLL) was completely adhered to diaphragm and the adhesions had been dissected with ultrasonic scissor in the first surgery. After reviewing the initial surgical procedure which may lead to diaphragmatic hernia, we suppose that a weak point (or an imperceptible perforation) in the diaphragm might have been provoked by the ultrasoni...

This case series demonstrates the successful use of autogenous rib grafts in the reconstruction of the manubrium after resection. We consider that the reconstruction technique is a safe and effective alternative to a complex problem.