Ming-Ju Hsieh

Chang Gung Memorial Hospital, T’ai-pei, Taipei, Taiwan

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Publications (47)109 Total impact

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    ABSTRACT: Single-port transumbilical surgery is a well-established platform for minimally invasive abdominal surgery. The aim of this study was to compare the hemodynamics and inflammatory response of a novel transumbilical technique with that of a conventional transthoracic technique in thoracic exploration and lung resection in a canine model. Sixteen dogs were randomly assigned to undergo transumbilical thoracoscopy (n = 8) or standard thoracoscopy (n = 8). Animals in the umbilical group received lung resection via a 3-cm transumbilical incision in combination with a 2.5-cm transdiaphragmatic incision. Animals in the standard thoracoscopy group underwent lung resection via a 3-cm thoracic incision. Hemodynamic parameters (e.g., mean arterial pressure, heart rate, cardiac index, systemic vascular resistance, and global end-diastolic volume index) and inflammatory parameters (e.g., neutrophil count, neutrophil 2',7' -dichlorohydrofluorescein [DCFH] expression, monocyte count, monocyte inducible nitric oxide synthase expression, total lymphocyte count, CD4+ and CD8+ lymphocyte counts, the CD4+/CD8+ratio, plasma Creactive protein level, interleukin-6 level) were evaluated before surgery, during the operation, and on postoperative days 1, 3, 7, and 14. Lung resections were successfully performed in all 16 animals. There were 2 surgery-related mortality complications (1 animal in each group). In the transumbilical group, 1 death was caused by early extubation before the animal fully recovered from the anesthesia. In the thoracoscopic group, 1 death was caused by respiratory distress and the complication of sepsis at 5 days after surgery. There was no significant difference between the two techniques with regard to the hemodynamic and immunologic impact of the surgeries. This study suggests that the hemodynamic and inflammatory changes with endoscopic lung resection performed by the transumbilical approach are comparable to those after using the conventional transthoracic approach. This information is novel and relevant for surgeons interested in developing new surgical techniques in minimally invasive surgery. Copyright © 2015. Published by Elsevier Ltd.
    International Journal of Surgery (London, England) 03/2015; 16. DOI:10.1016/j.ijsu.2015.02.027 · 1.65 Impact Factor
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    ABSTRACT: Background: N2-positive non-small cell lung cancer (NSCLC) exhibits extremely low survival rates. The role of surgery in operable locally advanced N2 NSCLC remains controversial. In this study, we tried to analyze the role of surgery in resectable N2 NSCLC and the relationship between survival and clinico-pathologic factors from a pathologic point of view. Methods: 108 resectable pathologic N2-positive NSCLC patients, diagnosed from January 2005 to July 2012, were enrolled in this study. We retrospectively reviewed the medical records, image studies, and pathology reports to collect the clinico-pathologic factors in these patients. Results: Those who received lobectomy (p = 0.002) and had a metastatic lymph node ratio less than 0.4 (p = 0.01) had a better overall survival rate. In addition, our study also showed that perineural invasion may play a significant role in disease-free survival (p = 0.01) Conclusions: Metastatic lymph node ratio greater than 0.4 and non-anatomic resection were poor prognostic factors for disease-free survival. Anatomic resection for selected N2 patients may play a crucial role in the overall survival rate. Perineural invasion showed an adverse impact on disease-free survival, but further investigation is warranted.
    11/2014; DOI:10.4103/2319-4170.145765
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    ABSTRACT: Purpose. Transumbilical single-port surgery has been associated with less postoperative pain and offers better cosmetic outcomes than conventional 3-port laparoscopic surgery. This study compares the safety and efficacy of transumbilical thoracoscopy and conventional thoracoscopy for lung wedge resection. Methods. The animals (n = 16) were randomly assigned to the transumbilical thoracoscopic approach group (n = 8) or conventional thoracoscopic approach group (n = 8). Transumbilical lung resection was performed via an umbilical incision and a diaphragmatic incision. In the conventional thoracoscopic group, lung resection was completed through a thoracic incision. For both procedures, we compared the surgical outcomes, for example, operating time and operative complications; physiologic parameters, for example, respiratory rate and body temperature; inflammatory parameters, for example, white blood cell count; and pulmonary parameters, for example, arterial blood gas levels. The animals were euthanized 2 weeks after the surgery for gross and histologic evaluations. Results. The lung wedge resection was successfully performed in all animals. There was no significant difference in the mean operating times or complications between the transumbilical and the conventional thoracoscopic approach groups. With regard to the physiologic impact of the surgeries, the transumbilical approach was associated with significant elevations in body temperature on postoperative day 1, when compared with the standard thoracoscopic approach. Conclusions. This study suggests that both approaches for performing lung wedge resection were comparable in efficacy and postoperative complications.
    Surgical Innovation 10/2014; DOI:10.1177/1553350614552733 · 1.34 Impact Factor
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    ABSTRACT: With regard to pathologic stage IIA (pIIA) non-small cell lung cancer (NSCLC), there is a paucity of literature evaluating the risk factors for disease-free survival (DFS) and overall survival (OS). The aim of this study was to identify the prognostic factors of DFS and OS in patients with NSCLC pIIA.We performed a retrospective review of 98 stage II patients (7th edition of the American Joint Committee on Cancer) who underwent lung resection from January 2005 to February 2011. Of these, 23 patients were excluded for this study because of loss of follow-up or different substage, and 75 patients with pIIA were included for further univariate and multivariate analysis. Risk factors for DFS and OS were analyzed, including age, gender, smoking history, operation method, histology, differential grade, visceral pleural invasion, angiolymphatic invasion, and metastatic N1 lymph node ratio (LNR).Of the 75 patients with pIIA NSCLC who were examined, 29 were female and 46 were male, with a mean age of 61.8 years (range: 34-83 years). The average tumor size was 3.188 cm (range: 1.10-6.0 cm). Under univariate analysis, angiolymphatic invasion and metastatic N1 LNR were risk factors for DFS (P = 0.011, P = 0.007). Under multivariate analysis, angiolymphatic invasion and metastatic N1 LNR were all independent risk factors for DFS, while adjuvant chemotherapy and higher metastatic N1 LNR were independent prognostic factors for OS.For patients with pIIA, higher metastatic N1 LNR and angiolymphatic invasion were related to poor DFS. In addition to DFS, higher metastatic N1 LNR was also a poor prognostic factor for OS rates and adjuvant therapy effectiveness. Clinical physicians should devise different postsurgical follow-up programs depending on these factors, especially for patients with high risk.
    Medicine 10/2014; 93(20):e102. DOI:10.1097/MD.0000000000000102 · 4.87 Impact Factor
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    ABSTRACT: Purpose The use of video-assisted thoracoscopic surgery (VATS) in patients with thymoma remains controversial. We sought to evaluate the perioperative and oncological outcomes after VATS resection for stage I and II thymoma and to compare the outcomes with those obtained after median sternotomy (MST). Methods Between 1991 and 2007, a total of 140 patients with stage I and II thymoma underwent surgery at the Chang Gung Memorial Hospital. Of them, 58 underwent MST, 61 VATS, and 21 thoracotomy. Using a propensity score based on four variables (myasthenia gravis, tumor size on CT images, age, and Masaoka stage), 48 VATS-treated patients were matched to 48 patients who received MST. Outcomes compared included perioperative complications, length of stay, tumor recurrence, and survival. Results No operative deaths occurred in this study. VATS was associated with fewer intraoperative blood loss, and more patients in the VATS group were extubated in the operating room after surgery compared with the MST group (37.5 vs. 12.5 %, respectively, P = 0.005). The mean length of stay was shorter in the VATS group than in the MST group (5.8 vs. 7 days, respectively; P = 0.008). After a median follow-up of 53 months, five patients developed recurrent tumors (four pleural and one pericardial). No statistically significant differences were found in the 5-year survival rates between the two study groups. Conclusions VATS appears feasible for patients with stage I and II thymoma and is associated with better perioperative outcomes than MST. The oncological outcomes are also similar.
    Annals of Surgical Oncology 09/2014; 22(4). DOI:10.1245/s10434-014-4068-9 · 3.94 Impact Factor
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    ABSTRACT: Transthoracic thoracoscopic lobectomy is the preferred method of surgical treatment for early lung cancer. Current methods require a transthoracic approach and are associated with chronic postoperative pain in up to 25 % of patients. Single-port transumbilical uniport surgery may offer advantages over multiport surgery with less postoperative pain and better cosmetic results. The aim of this study was to evaluate the feasibility of a transumbilical anatomic lobectomy of the lung (TUAL) in a canine model.
    Surgical Endoscopy 05/2014; DOI:10.1007/s00464-014-3561-3 · 3.31 Impact Factor
  • Journal of Thoracic Disease 01/2014; 6(1):61-63. DOI:10.3978/j.issn.2072-1439.2014.01.02 · 1.78 Impact Factor
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    ABSTRACT: Abstract Background: Chronic wound discomfort and intercostal neuralgia are well-known postoperative complications of video-assisted thoracoscopic surgery (VATS). To explore the possibility of a surgical platform that would cause less postoperative discomfort and avoid these complications, this study evaluated the feasibility of transumbilical lung wedge resection in a canine model. Materials and Methods: Twelve dogs (4 in the nonsurvival group and 8 in the survival group) were used in this study. Transumbilical thoracoscopy was performed using a homemade metallic tube via umbilical and diaphragmatic incisions with the animal in a supine position. After thoracic exploration, wedge resection was performed on the lung using an endoscopic stapling device placed through the transumbilical and transdiaphragmatic incisions under direct bronchoscopic guidance. The animals were sacrificed 30 minutes after the procedure (nonsurvival group) or 14 days postsurgery (survival group) for necropsy and histological evaluations. Results: Eleven preplanned lung wedge resections were completed in a median time of 101 minutes (range, 65-175 minutes) with one exception due to inadequate stapling in the early phase of the experiment. There was one death directly related to postoperative massive airleaks and sepsis in the survival group. The other 7 animals had an uneventful postoperative period. Necropsies at 2 weeks after surgery confirmed successful lung resections and revealed no evidence of vital organ injury. Two animals exhibited complete healing of the diaphragmatic incision. Liver herniation was identified in 1 of 5 animals with partial wound healing. Conclusions: This preliminary animal study demonstrates that large lung wedge resection can be performed with mechanical staplers via a single transumbilical incision. Future studies will investigate the cardiopulmonary and immunologic effects of transumbilical VATS compared with conventional VATS.
    Journal of Laparoendoscopic & Advanced Surgical Techniques 07/2013; DOI:10.1089/lap.2012.0533 · 1.19 Impact Factor
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    ABSTRACT: Background. To date there are no practical platforms for performing natural orifice transluminal endoscopic surgery in the thoracic cavity. This study evaluates the feasibility of transumbilical thoracosopy for lung biopsy and pericardial window creation. Methods. Eleven dogs (6 in the nonsurvival group and 5 in the survival group) were used for this study. A homemade metallic tube was advanced into the abdominal cavity via a 12-mm umbilical incision. The metallic tube was advanced into the thoracic cavity through a subxyphoid diaphragmatic incision under video guidance. Access to the thoracic cavity was achieved by a flexible bronchoscope via the metallic tube. Surgical lung biopsy and pericardial window creation were performed using an electrocautery loop and needle knife. The animals were euthanized 20 minutes after the surgery was complete (nonsurvival group) or 14 days postsurgery (survival group) for necropsy evaluation. Results. Eight pericardial window creations and 21 of 22 preplanned lung biopsies were completed in a median time of 72.18 minutes (range 50-105 minutes). One dog in the nonsurvival group died after tension pneumothorax due to postprocedure massive air leaks. In the survival group, the postoperative period was uneventful in all 5 dogs. Autopsies revealed no signs of vital organ injury and complete healing of the diaphragmatic incision occurred in all animals. Conclusions. The study demonstrated that transumbilical thoracoscopic surgical lung biopsy and pericardial window creation is feasible. The safety and efficacy of the transumbilical approach need to be verified by a more detailed survival study.
    Surgical Innovation 04/2013; 21(1). DOI:10.1177/1553350613484825 · 1.34 Impact Factor
  • Yu-Ling Chang · Yun-Fang Tsai · Yi-Cheng Wu · Ming-Ju Hsieh
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    ABSTRACT: BACKGROUND:: Little is known regarding the short-term quality of life (QoL) and predictive factors for QoL after esophagectomy for cancer in Eastern countries. OBJECTIVE:: The aims of this study were to assess QoL and symptoms within 1 and 6 months after surgery for esophageal cancer (EC) and to identify factors predictive of QoL within 6 months after esophagectomy in Taiwan. METHODS:: A longitudinal, prospective design was used, where convenience samples of 99 patients who had undergone esophagectomy for cancer were recruited from 2 medical centers in northern Taiwan. All participants responded to a questionnaire with a QLQ-C30 (Quality of Life Questionnaire-Cancer) core and a QLQ-OES18 (esophageal module of the European Organization for Research and Treatment [EORTC] QLQ-C30) module in structured interviews at baseline and 1 and 6 months after surgery. RESULTS:: The results showed significant decline in social function and global QoL; fatigue, insomnia, eating problems, reflux, and dry mouth were major problems within 6 months. Body mass index, body weight loss before surgery, activity performance status, and anastomosis site showed no significant association with the function and symptom aspect of QoL. Surgical complications, advanced cancer, neoadjuvant therapy before surgery, and tumor location other than at the EC junction had significant deleterious effects on several aspects of QoL. CONCLUSIONS:: This study describes the demographics of EC and short-term changes in QoL and also the predictive impact factor for QoL after surgery for EC. IMPLICATIONS FOR PRACTICE:: Knowledge of risk factors for poor postoperative QoL would be useful for health providers in detecting and prioritizing problems and treatment options in a busy clinical site.
    Cancer nursing 01/2013; DOI:10.1097/NCC.0b013e318277dc53 · 1.93 Impact Factor
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    ABSTRACT: Natural orifice transluminal endoscopy has been developed for abdominal surgical procedures. The aim of this study was to compare the surgical outcome between a novel transoral approach and a standard transthoracic approach for the thoracic cavity in a canine model. Twenty-eight dogs were assigned to transoral (n = 14) or standard thoracoscopy (n = 14). Each group underwent thoracic exploration, pre-determined surgical lung biopsy, and pericardial window creation. Blood draws were obtained before surgery and at postoperative days 1, 3, 7, and 14. Operative time, complications, laboratory parameters, hemodynamic parameters, and inflammatory parameters were compared between the two procedures. The animals were monitored for two weeks and necropsy were performed for surgical outcome evaluation. The thoracic procedures were successfully performed in all of the dogs, with the exception of one animal in the transoral group. There were no serious acute or delayed complications related to surgery. There was no difference between the two surgical groups for each of the hemodynamic parameters that were evaluated. Regarding the immunological impact of the surgeries, transoral thoracoscopy was associated with significant elevations in interleukin 6 and c-reactive protein levels on postoperative days 1 and 3, respectively, when compared with the standard thoracoscopy. All dogs recovered well, without signs of mediastinitis or thoracic infection. Necropsy revealed absence of infection, no injury to vital organs, and confirmed the success of the novel procedure. This study suggests that both techniques were comparable with respect to procedure success rate, hemodynamic impact, and inflammatory changes. Furthermore, there was no difference in the incidence of postoperative discomfort between groups.
    PLoS ONE 01/2013; 8(1):e50338. DOI:10.1371/journal.pone.0050338 · 3.53 Impact Factor
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    ABSTRACT: Higher extent of lymph node dissection (LND) is beneficial in primarily resected esophageal cancer patients by providing accurate staging and better tumor control. Achieving pathological complete response (pCR) after chemoradiotherapy (CRT) also represents better outcome. We studied the controversial question whether higher LND could further improve survival after pCR. Between 1996 and 2007, Esophageal squamous cell carcinoma (ESCC) patients with pCR after CRT were included. Based on the median number of dissected lymph node, patients were divided into two groups (Group 1: Lower LND; Group 2: Higher LND). We compared the demographic features, perioperative outcomes, recurrence, and survival between groups. The cohort comprised 101 patients (100 males and one female) with a mean age of 58 years. There were 56 and 45 patients in Group 1 and 2, respectively. Clinical features and perioperative outcome were similar between groups. During a mean follow-up of 78.8 months, 32 (33.7%) patients died of the disease and 35.8% of patients developed recurrence. There was no difference in locoregional (11.3% vs. 9.5%, P=0.78) or distant recurrence (22.6% vs. 33.3%, P=0.18) between the two groups. Patients with lowest LND also had similar outcomes as those with the highest LND. The 5-year disease specific survival rate was 65 and 64% in Group 1 and 2, respectively. In ESCC patients, the number of negative lymph nodes had no prognostic impact after pCR.
    Journal of Surgical Oncology 09/2012; 106(4):436-40. DOI:10.1002/jso.23103 · 2.84 Impact Factor
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    ABSTRACT: Extensive lymph node dissection (LND) is beneficial in primarily resected esophageal cancer patients. Such benefit was believed to be seen in neoadjuvant chemoradiotherapy (CRT)-treated patients, but evidence was inconsistent. We hypothesized that CRT might offset the benefit of LND in certain subgroup of patients, especially in major responders. The clinical pathological data and survival of esophageal squamous cell carcinoma patients who received curative resection after CRT between 1996 and 2007 were analyzed. On the basis of the mean LND number of the cohort, patients were divided into two groups: group 1, lower LND, and group 2, higher LND. The cohort comprised 303 patients (295 men and 8 women) with a mean age of 55.4 years. There were 179 patients in group 1 and 124 patients in group 2. One hundred one patients had pathological complete response (pCR). There were more pCR in group 1 (38 vs. 26.6 %, P = 0.039) and more lymph node positive cases in group 2 (16 vs. 27.4 %, P = 0.018). Extent of LND had no survival difference in the entire cohort (overall survival 32 vs. 38 %, P = 0.31). With the stratification analysis according to tumor response, inadequate LND exhibited negative impact in patients who did not experience pCR (P = 0.027). Without adequate LND, the survival of ypTxN0 was equally poor as ypN-positive cases (overall survival 15 vs. 16 %, P = 0.791). In the pCR group, the extent of LND had an impact on survival. The effect of LND was influenced by tumor response after CRT. There is a strong survival benefit for extensive LND after CRT in esophageal squamous cell carcinoma, especially in non-pCR patients.
    Annals of Surgical Oncology 05/2012; 19(11):3500-5. DOI:10.1245/s10434-012-2402-7 · 3.94 Impact Factor
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    ABSTRACT: The success of natural orifice transluminal endoscopic surgery (NOTES) depends on an adequate exploration of surgical regions. Currently, limited data are available regarding the optimal position for the NOTES approach for thoracic surgery. This study therefore aimed to evaluate the effectiveness of transoral thoracic exploration in a canine model placed in a lateral decubitus position. A total of 14 dogs were used in this study. Transoral thoracoscopy was performed using a custom-made metal tube via an incision over the vestibular incision with the animal in a supine position. After thoracic exploration, the animal was placed in a lateral decubitus position. The thoracic intervention (surgical lung biopsy, pericardial window creation, and dorsal sympathectomy) was performed by passing a flexible bronchoscope through the lumen of a metal tube. The mean operative time for this procedure was 70 min (range 45-100 min). For 12 dogs, all procedures were completed without major complications. However, for one dog, the exploration of the thoracic cavity was incorrect (the right lower lobe had been misinterpreted as the left lower lobe). Another dog had minor bleeding because of an intercostal artery injury that occurred during sympathectomy. The posterior aspect of the thoracic cavity can be exposed via a transoral approach with the animal in a lateral decubitus position. This approach may be considered as an adjuvant to the supine approach, in which exploration of the posterior thoracic cavity is restricted.
    Surgical Endoscopy 05/2012; 26(10):2988-92. DOI:10.1007/s00464-012-2296-2 · 3.31 Impact Factor
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    ABSTRACT: As a well-known pivotal factor of 4E-binding protein 1 (4E-BP1) in controlling cancer proliferation, high expression of its phosphorylated form (p-4E-BP1) has been reported to be associated with poor outcome in various human cancers without pretreated with chemoradiotherapy (CRT). However, no data is available regarding the implication of p-4E-BP1 expression after CRT. Therefore, we conducted this study. The expression of p-4E-BP1 was semiquantitatively examined with immunohistochemical staining in 60 ypT1T2 esophageal squamous cell carcinoma (SCC) patients and verified by western blot analysis in representative cases. The impact of p-4E-BP1 expression intensity on cancer recurrence and survival was assessed in combination with clinical and pathological descriptors. The 5-year disease specific survival (DSS) rate of patients with high p-4E-BP1 expression was significantly lower than that of patients with lower p-4E-BP1 expression (5 year DSS: 58% vs. 8.6%, P = 0.00064). Furthermore, in a multivariate analysis by Cox regression model, high p-4E-BP1 expression was confirmed to be an independent prognostic factor (HR: 2.269; unfavorable, P = 0.024) for DSS, while lymph node (HR: 3.016; unfavorable, P = 0.005) was also significant prognostic factor. High p-4E-BP1 expression was specifically associated with locoregional recurrence (LR; P < 0.05). The locoregional control rate reached 97.1% in low p-4E-BP1 tumors. High p-4E-BP1 expression after CRT is a predictor for LR and worse survival in esophageal SCC patients.
    Journal of Surgical Oncology 03/2012; 105(3):288-92. DOI:10.1002/jso.22097 · 2.84 Impact Factor
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    ABSTRACT: The correlation between high tumor podoplanin (PP) immunoreactivity and poor outcome in patients with non-chemoradiotherapy(CRT) pretreated upper aerodigestive tract squamous cell carcinoma (SCC) has been reported recently. Little is known about the implication of PP expression after CRT. Therefore, we conducted this study. We evaluated the PP immunoreactivity in ypT3N0 esophageal SCC patients by using immunohistochemistry. The impact of PP expression intensity in tumors on patient survival was judged in combination with clinical and pathological descriptors. Our study included 109 males and 4 females (mean age, 57.6 years; range, 38-79 years). PP immunoreactivity was expressed in tumors in 95% of patients and 38% of patients had high PP expression. High PP expression tumors had positive association with lymphovascular invasion (LVI). Multivariate analyses revealed tumor PP immunoreactivity and circumferential resection margin (CRM) status as independent prognostic factors. Patients with positive CRM and high PP expression had shortest survival followed by those with either positive CRM or high PP expression, and then by patients with neither positive CRM nor high PP expression (5-year disease-specific survival: 5%, 20%, 40%, P < 0.001). Tumor PP immunoreactivity in conjunction with CRM status are useful markers to identify aggressive post-CRT treated ypT3N0 stage esophageal SCC.
    Journal of Surgical Oncology 02/2012; 105(2):183-8. DOI:10.1002/jso.22068 · 2.84 Impact Factor
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    ABSTRACT: Objectives The benefits of video-assisted thoracoscopic surgery (VATS) for performing pulmonary metastasectomy are considered controversial. This case-matched study aimed to compare long-term outcomes after surgical resection of pulmonary metastases from colorectal cancer using different approaches (VATS vs. thoracotomy). Methods Between 1997 and 2008, 143 patients with colorectal cancer who had received their first pulmonary metastasectomy were selected. Fifty-three patients underwent a surgical procedure that utilized a thoracotomy approach (Group 1), and 90 patients underwent a surgical procedure that used a VATS-based approach (Group 2). After being matched for tumor number, diameter (measured by computed tomography), and surgical procedure (wedge resection or lobectomy), 35 pairs of patients were finally enrolled. Study endpoints included tumor recurrence and survival. ResultsThere was no hospital mortality in both groups. Within the mean follow-up period of 50 months, 47.1% patients developed a recurrence (52% at the pulmonary level and 48% at systemic level), and 52.9% of the patients were alive at the time of analysis. There was no difference between Groups 1 and 2 in terms of overall recurrences (54 vs. 40%, p=0.23), all pulmonary recurrences (25.7 vs. 22.9%, p=0.78), and same side lung recurrences (14.3 vs. 20%, p=0.75). The 5-year overall survival (OS) after lung resection was 43 and 51% in Groups 1 and 2, respectively (p=0.21). Conclusions Our case-matched study showed that survival outcome of pulmonary metastasectomy using VATS is not inferior to that of open thoracotomy in selected cases.
    The Thoracic and Cardiovascular Surgeon 01/2012; 60(6):398-404. DOI:10.1055/s-0031-1295574 · 1.08 Impact Factor
  • Yun-Hen Liu · Yi-Cheng Wu · Ming-Ju Hsieh · Po-Jen Ko
    The Journal of thoracic and cardiovascular surgery 08/2011; 142(2):458-60. DOI:10.1016/j.jtcvs.2010.11.005 · 3.99 Impact Factor

Publication Stats

244 Citations
109.00 Total Impact Points


  • 2001–2015
    • Chang Gung Memorial Hospital
      • Division of Thoracic and Cardiovascular Surgery
      T’ai-pei, Taipei, Taiwan
  • 2014
    • Xiamen Chang Gung Hospital
      Amoy, Fujian, China
  • 2010–2014
    • Chang Gung University
      • College of Medicine
      Hsin-chu-hsien, Taiwan, Taiwan