The life-saving emergency thoracic endovascular aorta repair management on suspected aortoesophageal foreign body injury

BACKGROUND:Fatal aortic rupture caused by esophageal foreign body(EFB),is associated with a high mortality,but can be prevented by thoracic endovascular aorta repair(TEVAR)that performed increasingly as technology improves.This study aims to investigate the cause,management and prognosis of suspected penetrating aortoesophageal foreign body injury.METHODS:Twelve cases who met the criteria were enrolled in this study.The demographic and clinical data were reviewed for evaluating the characteristics of EFB.RESULTS:Among 12 cases enrolled,7 were males and 5 were females,with an age 27–86 years.The distance of EFB from aorta(DFA)of 7 cases were less than or equal to 0 mm,5 cases were 0–2 mm.Eleven cases were managed with TEVAR,only one case was with open surgery standby but finally treated by flexible endoscopy(FE)successfully,without TEVAR.In group with TEVAR,EFB of 7 cases were successfully removed by rigid endoscopy(RE),and one of them was failed at the first RE treatment.EFB of 2 cases were successfully removed by open surgery with TEVAR,and other 9 cases were managed by endoscopies with TEVAR.The mean length of stay of hospitalization(LOS)and length of ICU stay of patients treated by open surgery with TEVAR(18.50±2.12 days and 5.50±0.71 days)was significantly longer than those of patients treated by endoscopy with TEVAR(7.00±2.74 days and 1.33±1.12 days,P<0.001 and P=0.001,respectively).Five cases had severe complications.CONCLUSION:Rational application of TEVAR can be a life-saving management for aortoesophageal foreign body injury,and jointed with endoscopy is safe and effective with a shorter length of ICU or total hospital stay.

Correlation between thoracic aorta 18F-natrium fluoride uptake and cardiovascular risk

AIM: To investigating the relationship between thoracic and cardiac 18F-Natrium-Fluoride (18F-NaF) uptake, as a marker of ongoing calcification and cardiovascular risk factors.METHODS: Seventy-eight patients (44 females, mean age 63, range 44-83) underwent whole body 18F-NaF positron emission tomography/computed tomography. Cardiovascular risk (CVR) was used to divide these patients in three categories: Low (LR), medium (MR) and high risk (HR). 18F-NaF uptake was measured by manually drawing volumes of interest on the ascending aorta, on the aortic arch, on the descending aorta and on the myocardium; average standardized uptake value was normalized for blood-pool, to obtain target-to-background ratio (TBR). Values from the three aortic segments were then averaged to obtain an index of the whole thoracic aorta.RESULTS: A significant difference in whole thoracic aorta TBR was detected between HR and LR (1.84 ± 0.76 vs 1.07 ± 0.3, P < 0.001), but also between MR and HR-LR (1.4 ± 0.4, P < 0.02 and P < 0.01, respectively). Significance of this TBR stratification strongly varied among thoracic aorta subsegments and the lowest P values were reached in the descending aorta (P < 0.01). Myocardial uptake provided an effective CVR classes stratification (P < 0.001).Correlation between TBR and CVR was appreciable when the whole thoracic aorta was considered (R = 0.67), but it peaked when correlating the descending thoracic segment (R = 0.75), in comparison with the aortic arch and the ascending segment (R = 0.55 and 0.53, respectively).CONCLUSION: Fluoride uptake within the thoracic aorta wall effectively depicts patients’ risk class and correlates with cardiovascular risk. Descending aorta is the most effective in CVR determination.

Acute Type A Aortic Dissection—Replacement of Ascending Aorta, Aortic Arch and Antegrade Stenting of the Descending Thoracic Aorta Using the Thoraflex™Hybrid Plexus Device (Terumo Aortic)—“Frozen Elephant Trunk”: The Plymouth Way!

Objectives: To describe our technique for the implantation of the Thoraflex Hybrid prosthesis for replacement of the aortic arch in a safe and reproducible way. Materials: Thoraflex™ Hybrid Plexus Device (Terumo Aortic). Design: Drawing on our own experience over the past 4 years in the management of acute type A aortic dissection, we have distilled the essentials of our “Frozen Elephant Trunk” technique which have led us through our own learning curve to the improved management of this taxing condition. Method/ Results: Small extension of the median sternotomy incision along the medial border of sternocleidomastoid muscle. End to side graft anastomosis near the origin of the left subclavian artery during cooling on bypass towards 20 degrees. Attention to cardiac protection and maintenance of cerebral perfusion during the shortened corporeal arrest period. Excellent results in 24 consecutive AAAD patients with just one hospital mortality. Conclusions: We believe we are entering a new phase in the treatment of AAAD, facilitated by the availability of a hybrid prosthesis which combines expanding stent technology with familiar surgical graft material. Our particular management of the left subclavian artery and of the cerebral circulation during implantation has contributed to an expeditious and reproducible method of treating dissection within the arch of the aorta and beyond.

The Effect of the LysoPC-induced Endothelial Cell Conditioned Medium on Proliferating Cell Nuclear Antigen Expression of the Calf Thoracic Aorta Smooth Muscle Cells

In order to study the effect of and mechanism of lysophosphatidylcholine (LysoPC) on proliferation of the calf thoracic aorta smooth muscle cells (ASMCs), the ASMCs were used to observe the effects of LysoPC induced endothelial cell conditioned medium on the DNA content and proliferating cell nuclear antigen (PCNA) expression in the calf thoracic ASMCs by flow cytometry and Western Blot technique. It was found that LysoPC induced endothelial cell conditioned medium could significantly promote PCNA expression of the calf ASMCs, induce the converting of ASMCs from G 0 /G 1 phase to S phase of DNA synthesis, and increase the tyrosine phosphorylation protein expression. Tyrosine protein kinase inhibitor (TPKi) RG50864 could obviously inhibit proliferation of LysoPC induced ASMCs in a dose dependence manner. The results indicated that the effect of LysoPC promoting the proliferation of ASMCs is partly evoked by endothelial cell derived growth factors such as PDGF and so on.

Expression of p-PPARγ in the aging thoracic aorta of spontaneously hypertensive rat and inhibitory effect of rosiglitazone

Objective:To investigate the expression of phosphorylated peroxisome proliferators-activated receptor y(p-PPARY) in the aging thoracic aorta of spontaneously hypertensive rat(SHR) and the inhibitory effect of rosiglitazone on the phosphorylation of PPART.Methods:16,32 and 64 week-old Wistar-Kyoto rats(WKY) and SHR were randomly and respectively divided into WKY,SHR and SHR+rosiglitazone group(9 in each group).The rats in SHR+rosiglitazone group were treated with rosiglitazone(5 mg/kg,intragastrically) for 56 d,whereas normal saline was applied in WKY and SHR groups.Systolic blood pressure(SBP)of rats was measured by tail cuff method.Histopathological damage of thoracic aorta was analyzed using Hematoxylin-Eosin(HE) staining.Immunohistochemical staining and western blot were performed to test the level of p-PPARY protein in the thoracic aorta arising from each group.Results:The SBP in 16,32 and 64 week-old SHR were significantly higher as compared with those in matched WKY rats(P【0.05,respectively).HE staining showed increased content of smooth muscle cell,wrinkled lining endothelium and increased thickness of internal elastic lamina in the thoracic aorta of SHR.Immunohistochemical staining and western blot indicated that the levels of p-PPARY in the thoracic aorta arising from SHR were obviously higher than those in the thoracic aorta arising from WKY rats(P【0.05,respectively).Importantly,the high SBP,histopathological abnormalities of the thoracic aorta and elevated p-PPARY expression were prominently abrogated by rosiglitazone treatment in SHR(P【0.05,respectively).Furthermore,the SBP,histopathological abnormalities of the thoracic aorta and p-PPARY expression were positively correlated with age in SHR(P【0.05,respectively).Conclusions:The PPARY phosphorylation was observed in the thoracic aorta of SHR and its expression was increased by the increase of age.Furthermore,rosiglitazone inhibited the PPARY phosphorylation and suppressed vascular aging in SHR.

Effect of swirling flow on LDL and ox-LDL uptake in rabbit thoracic aorta

Object To elucidate the physiological significance of the spiral flow in the arterial system from the viewpoint of atherogenic lipid transport,an ex vivo experimental comparative

Effect of bFGF on expression of MMPs mRNA on the rat thoracic aorta after ballon injury and cultured VSMCS

Background:Extracellular matrix (ECM) plays a very important role in the development ofrestenosis after PTCA The MMPs,enymes specialized in degradation of ECM,probably partciptesin extracelular matrix remodeling after balloon injury,but the factors that regulates MMPs activity arenot completely understood Basic fibroblast growth factor (bFGF),as a mitogen for a variety of cellstypes,influences metabolism of ECM.However,if effects on MMPs are not known.Methodsand Results:24 male Wistar rats were divided randomly into control group,balloon-injuried group andbFGF-treated group.The rats of control group were not treated.The rats in balloon-injuried group weredamaged by balloon and the thoracic aortas were harvested after two weeks.In the bFGF-treated grorp,balloon injury and the injuried vessels were collected after two weeks.The northern blot was used toinvestigate the MMP1,MMP2 and MMP9 mRNA expression of vesss.At the same time,the effectsof differet dose bFGF (0ng/ml,40ng/ml,80ng/ml and 120ng/ml) on the MMPs expression of culturedVSMCs were examined The results showed the bFGF can selectively increase the expression ofMMP1 and MMP9 mRNA without effect on the MMP2 on the injuried rat thoracic aorta,and dosedependently increase the MMP1 mRNA expression of cultured VSMCs without MMP2 and MMP9expression Conclusion:bFGF selectively increased MMPs mRNA expression on both injuried ratthoracic aorta and cultured VSMCs.This effect may be related to the degradation of ECM,remodelingof vessel after injuty.

A Prospective Survey Comparing Patients’ Experience of a Nurse-Led Clinic and Consultant-Led Clinic for Surveillance of Patients with Dilatation of the Intrathoracic Aorta

Background: Increasing workload in consultant-led clinics often means patients to wait a long time for clinic appointments. To address this, there is an increasing trend in developing nurse-led clinics across many specialities in the National Health Service. This study aims to assess whether the implementation of a nurse-led clinic in thoracic aortic surgery will optimise the utilisation of health care services and improve overall patient satisfaction. Methods: 80 follow-up patients were asked to complete a questionnaire following their appointment in an aortic clinic, which was led either by a consultant (n = 40) or an aortic specialist nurse (n = 40). All patients seen by a nurse in the clinic were assessed by a consultant surgeon prior to the clinic for suitability. No new patients were seen by a nurse. Any patient with an aortic dimension of 5 cm or greater was seen by the consultant. If there were any complicated clinical features, the patient was seen in the consultant-led clinic. Patients were asked questions about their time spent with the respective health care professionals across 12 categories (punctuality, preparedness, understanding of concerns, clarity of speech, listening, respect, explaining, letting you talk, putting you at ease, emotional support, advice and advice for next follow-up). Patients rated each category using an ordinal scale from 0 - 10. Results: Patient scores were greater in nurse-led clinics compared to consultant-led clinics across a number of categories although only punctuality reached significance (mean 9.2 vs. 6.8, p 0.05). Conclusion: Patients were highly satisfied with the nurse-led clinic across all categories, with greater satisfaction for punctuality. These findings suggest that a nurse-led clinic can be implemented for the management of carefully selected thoracic aortic surgery patient without reduction in patient satisfaction.

Endoscopic trans-esophageal submucosal tunneling surgery:A new therapeutic approach for diseases located around the aorta ventralis

AIM To assess the efficiency of endoscopic trans-esophageal submucosal tunneling surgery(EESTS) technique for diseases located around the aorta ventralis.METHODS Nine pigs were assigned to EESTs. The procedures were as follows: First, a long esophageal submucosal tunnel was established. Second, full-thickness myotomy was created. Third, an endoscope was entered into the abdominal cavity through a muscle incision and the endoscope was around the aorta ventralis. Eventually,celiac trunk ganglion neurolysis, partial hepatectomy and splenectomy, partial tissue resection in the area of the posterior peritoneum, and endoscopic submucosal dissection(ESD) combined with lymph node dissection were performed. The animals were given antibiotics for 5 d and necropsied 7 d after surgery.RESULTS In all surgeries, one pig died from intraperitoneal hemorrhage after doing partial splenectomy, while the other pigs were alive after successfully operating other surgeries. For surgery of celiac trunk ganglion damage, at necropsy, there was no exudation in the abdominal cavity. Regarding surgery of partial hepatectomy, the wound with part healing was observed in the left hepatic lobe, and no bleeding or obvious exudation was seen. In surgery of partial splenectomy, massive hemorrhage was observed on the splenic wound surface, and the metal clips could not stop bleeding. After surgery of retroperitoneal tissue resection, mild tissue adhesion was observed in the abdominal cavity of one animal, and another one suffered from severe infection. For surgery of ESD and lymph node dissection, a moderate tissue adhesion was observed.CONCLUSION EESTS is a feasible and safe technique for diseases located around the aorta ventralis.

Enhanced recovery after surgery in elderly patients with non-small cell lung cancer who underwent video-assisted thoracic surgery

BACKGROUND This study was designed to investigate the clinical outcomes of enhanced recovery after surgery(ERAS)in the perioperative period in elderly patients with nonsmall cell lung cancer(NSCLC).AIM To investigate the potential enhancement of video-assisted thoracic surgery(VATS)in postoperative recovery in elderly patients with NSCLC.METHODS We retrospectively analysed the clinical data of 85 elderly NSCLC patients who underwent ERAS(the ERAS group)and 327 elderly NSCLC patients who received routine care(the control group)after VATS at the Department of Thoracic Surgery of Peking University Shenzhen Hospital between May 2015 and April 2017.After propensity score matching of baseline data,we analysed the postoperative stay,total hospital expenses,postoperative 48-h pain score,and postoperative complication rate for the 2 groups of patients who underwent lobectomy or sublobar resection.RESULTS After propensity score matching,ERAS significantly reduced the postoperative hospital stay(6.96±4.16 vs 8.48±4.18 d,P=0.001)and total hospital expenses(48875.27±18437.5 vs 55497.64±21168.63 CNY,P=0.014)and improved the satisfaction score(79.8±7.55 vs 77.35±7.72,P=0.029)relative to those for routine care.No significant between-group difference was observed in postoperative 48-h pain score(4.68±1.69 vs 5.28±2.1,P=0.090)or postoperative complication rate(21.2%vs 27.1%,P=0.371).Subgroup analysis showed that ERAS significantly reduced the postoperative hospital stay and total hospital expenses and increased the satisfaction score of patients who underwent lobectomy but not of patients who underwent sublobar resection.CONCLUSION ERAS effectively reduced the postoperative hospital stay and total hospital expenses and improved the satisfaction score in the perioperative period for elderly NSCLC patients who underwent lobectomy but not for patients who underwent sublobar resection.

Coarctation of the aorta:Management from infancy to adulthood

Coarctation of the aorta is a relatively common form of congenital heart disease, with an estimated incidence of approximately 3 cases per 10000 births. Coarctation is a heterogeneous lesion which may present across all age ranges, with varying clinical symptoms, in isolation, or in association with other cardiac defects. The first surgical repair of aortic coarctation was described in 1944, and since that time, several other surgical techniques have been developed and modified. Additionally, transcatheter balloon angioplasty and endovascular stent placement offer less invasive approaches for the treatment of coarctation of the aorta for some patients. While overall morbidity and mortality rates are low for patients undergoing intervention for coarctation, both surgical and transcatheter interventions are not free from adverse outcomes. Therefore, patients must be followed closely over their lifetime for complications such as recoarctation, aortic aneurysm, persistent hypertension, and changes in any associated cardiac defects. Considerable effort has been expended investigating the utility and outcomes of various treatment approaches for aortic coarctation, which are heavily influenced by a patient's anatomy, size, age, and clinical course. Here we review indications for intervention, describe and compare surgical and transcatheter techniques for management of coarctation, and explore the associated outcomes in both children and adults.

Management of adults with coarctation of aorta

Coarctation of the aorta(CoA)is a relatively common congenital cardiac defect often causing few symptoms and therefore can be challenging to diagnose.The hallmark finding on physical examination is upper extremity hypertension,and for this reason,CoA should be considered in any young hypertensive patient,justifying measurement of lower extremity blood pressure at least once in these individuals.The presence of a significant pressure gradient between the arms and legs is highly suggestive of the diagnosis.Early diagnosis and treatment are important as long-term data consistently demonstrate that patients with CoA have a reduced life expectancy and increased risk of cardiovascular complications.Surgical repair has traditionally been the mainstay of therapy for correction,although advances in endovascular technology with covered stents or stent grafts permit nonsurgical approaches for the management of older children and adults with native CoA and complications.Persistent hypertension and vascular dysfunction can lead to an increased risk of coronary disease,which,remains the greatest cause of long-term mortality.Thus,blood pressure control and periodic reassessment with transthoracic echocardiography and threedimensional imaging(computed tomography or cardiac magnetic resonance)for should be performed regularly as cardiovascular complications may occur decades after the intervention.

Gastroparesis after video-assisted thoracic surgery:A case report

BACKGROUND Video-assisted thoracic surgery(VATS)lobectomy is a common treatment for patients with early-stage lung cancer.Some patients can experience slight gastrointestinal discomfort after lobectomy for a moment.Gastroparesis is a gastrointestinal disorder that can be severe;it is associated with an increased risk of aspiration pneumonia and impaired postoperative recovery.Here,we report a rare case of gastroparesis after VATS lobectomy.CASE SUMMARY A 61-year-old man underwent VATS right lower lobectomy uneventfully but had an obstruction of the upper digestive tract 2 d after surgery.Acute gastroparesis was diagnosed after emergency computed tomography and oral iohexol X-ray imaging.After gastrointestinal decompression and administration of prokinetic drugs,the patient’s gastrointestinal symptoms improved.Since perioperative medication was applied according to the recommended dose and there was no evidence of electrolyte imbalance,intraoperative periesophageal vagal nerve injury was the most likely underlying cause of gastroparesis.CONCLUSION Although gastroparesis is a rare perioperative complication following VATS,clinicians should be on the alert when patients complain about gastrointestinal discomfort.When surgeons resect paraesophageal lymph nodes with electrocautery,excessive ambient heat and compression of paraesophageal hematoma might induce vagal nerve dysfunction.

Vasorelaxation Effect of Gastrodin on Isolated Thoracic Aorta Rings of Rats

Objective： To study the effect of gastrodin on isolated thoracic aorta rings of rats and to investigate the potential mechanism. Methods： A perfusion model of isolated thoracic aorta rings of rats was applied. The effect of cumulative gastrodin （5, 50, 100,150, 200, and 250 μ mol/L） on endothelium-intact aorta rings was investigated. The same procedure was applied to observe the effect of gastrodin on endotheliumintact/denuded aorta rings pre-contracted with 10.8 mol/L phenylephrine hydrochloride （PE）. The aorta rings incubated by 200 mmol/L gastrodin in the Ca2＋-free （K-H） solution was contracted by using PE. The effect of 200 mmol/L gastrodin on endothelium-denuded aorta rings pre-contracted with 60 mmol/L KCI was also observed. Results： Compared with the denuded gastrodin group, the intact gastrodin group could significantly relax the PE-contracted aorta rings （P〈0.01）. In Ca2＋-free （K-H） solution KHS, the PE-induced contraction rate of aorta rings pre-incubated by gastrodin was 6.5%± 0.7%, which was significantly less than the control group （11.8% ± 0.9%, P〈0.01）. However, after 3 mmol/L CaCl2 was added, the Ca2＋-induced contraction in the gastrodin group （51.7% ±2.4%） was similar to that in the control group （49.8% ± 2.8%）. The contractile rate of rings in the KCI-contracted gastrodin group （96.3%± 0.6%） was not significantly different from that in the control group （96.8± 1.2%）. Conclusions： Gastrodin has the effect of vasorelaxation on isolated thoracic aorta rings of rats. The mechanism of the vasorelaxation of gastrodin may mainly work through the inhibition of inositol 1,4, 5-trisphosphosphate receptor on the sarcoplasmic reticulum of the arterial smooth muscle, which leads to the reduction of the Ca2. released from the sarcoplasmic reticulum.

Comparative study on the effect of interventional and conservative therapy on the prognosis of patients with ruptured descending thoracic aorta

Background Rupture of descending thoracic aorta is a rare but lethal disease. Compared with open surgery,thoracic endovascular aortic repair(TEVAR)becomes a less invasive procedure in emergent management of patients with feasible anatomy. Nevertheless,mortality remains high as well as morbidity despite successful operation. The purpose of this study was to compare TEVAR with conservative therapy on the 30-day mortality of patients with ruptured descending thoracic aorta. Methods Retrospective analysis of patients admitted to our hospital with descending thoracic aortic rupture was performed. Patients presented with rupture of descending thoracic aorta with feasible anatomy for TEVAR between Jan 2014 and June 2019 were included. Patients were divided into operative and conservative group depending on which therapy they received. Patients received TEVAR were defined as the operative group,while those received conservative therapy were defined as conservative treatment group. Results There were twenty-six patients in total,including fifteen aortic dissections,nine were thoracic aneurysms,and two were traumatic injuries. Theie mean age was 60±13 years with only two female. Seven patients(27%)presented with shock and twenty-two(85%)was accompanied with hemothorax on admission. Nineteen patients(73%)accepted emergent TEVAR with 100% primary technical success,and the other seven received conservative treatment. In operative group,infection(89%)and respiratory failure(63%)occurred after TEVAR. The in-hospital mortality for operative and conservative treatment group was 26% and 57% respectively(P=0.18). Operative group had lower 30-day mortality(26% vs. 86%,P=0.021). Conclusions TEVAR is associated with improved early outcome in patients with ruptured descending thoracic aorta.[S Chin J Cardiol 2019;20(3):140-145]

Endovascular repair of a tuberculous aneurysm of descending thoracic aorta

Tuberculous aortic aneurysm （TBAA） is an extremely rare clinical event with life-threatening implication. Management for this condition is challenging and its therapeutic option has not been yet established. A few recent reports described endovascular repair rather than open surgery as the method for treatment. Although this remains controversial,endovascular exclusion has been gaining acceptance for some surgeons. We present a case of TBAA who was treated by endovascular stent grafting for a descending thoracic aortic aneurysm with simultaneous anti-tuberculous medication.The outcome was favorable.

Video-assisted thoracic surgery―the past, present status and the future

Video-assisted thoracic surgery (VATS) has developed very rapidly in these two decades, and has replaced conven-tional open thoracotomy as a standard procedure for some simple thoracic operations as well as an option or a complementary procedure for some other more complex operations. In this paper we will review its development history, the present status and the future perspectives.

Evolving thoracic surgery: from open surgery to single port thoracoscopic surgery and future robotic

Thoracic Surgery is a continuous evolving specialty. In the past, thoracic surgeons had to make large incisions in order to operate any pathology inside the chest. This often meant big, painful and ugly scars and long recovery times after surgery. But he history of thoracic surgery changed since the begining of video-assisted thoracoscoDic surgery （VATg3

Application of video-assisted thoracic surgery in the standard operation for thoracic tumors

Objective： To evaluate the short-term outcomes of video-assisted thoracic surgery （VATS） for thoracic tumors. Methods： The data of 1,790 consecutive patients were retrospectively reviewed. These patients underwent VATS pulmonary resections, VATS esophagectomies, and VATS resections of mediastinal tumors or biopsies at the Cancer Institute ＆ Hospital, Chinese Academy of Medical Sciences between January 2009 and January 2012. Results： There were 33 patients converted to open thoracotomy （OT, 1.84%）. The overall morbidity and mortality rate was 2.79% （50/1790） and 0.28% （5/1790）, respectively. The overall hospitalization and chest tube duration were shorter in the VATS lobectomy group （n=949） than in the open thoracotomy （OT） lobectomy group （n=753）. There were no significant differences in morbidity rate, mortality rate and operation time between the two groups. In the esophageal cancer patients, no significant difference was found in the number of nodal dissection, chest tube duration, morbidity rate, mortality rate, and hospital length of stay between the VATS esophagectomy group （n=8 1） and open esophagectomy group （n=81）. However, the operation time was longer in the VATS esophagectomy group. In the thymoma patients, there was no significant difference in the chest tube duration, morbidity rate, mortality rate, and hospital length of stay between the VATS thymectomy group （n=41） and open thymectomy group （n=41）. However, the operation time was longer in the VATS group. The median tumor size in the VATS thymectomy group was comparable with that in the OT group. Conclusions： In early-stage （Ⅰ/Ⅱ） non-small cell lung cancer patients who underwent lobectomies, VATS is comparable with the OT approach with similar short-term outcomes. In patients with resectable esophageal cancer, VATS esophagectomy is comparable with OT esophagectomy with similar morbidity and mortality. VATS thymectomy for Masaoka stage I and II thymoma is feasible and safe, and tumor size is not contraindicated. Longer follow-ups are needed to determine the oncologic equivalency of VATS lobectomy, esophagectomy, and thymectomy for thymoma vs. OT.