Oleg Valentinovich Pikin

Objective. To identify clinical and morphological factors associated with favorable neurological outcomes after extended thymectomy in patients with generalized myasthenia gravis. Material and methods. A single-center retrospective study with prospective component included 103 patients with generalized myasthenia gravis who underwent extended thymectomy in 2009–2021. The primary endpoint was improvement in the Myasthenia Gravis Foundation of America (MGFA) Postintervention Status classification: sustained remission, pharmacological remission, or minimal manifestations. Potential predictors included thymus morphology, thymoma, period between manifestation and surgery, immunopathogenetic variant of myasthenia, preoperative QMG score, age, gender and characteristics of disease onset. Results. Improvement was achieved in 73 out of 103 patients (70.9%) after 3 years. Favorable outcome was more common in thymic hyperplasia compared to thymic involution (75.5% vs 66.0%), in patients without thymoma than in those with thymoma (73.3% vs 53.8%), as well as in case of surgery within 2 years after manifestation (76.7% vs 62.8%). Preoperative QMG cutoff of 26.5 identified patients with higher risk of no improvement (odds ratio 4.0; 95% CI 1.64–10.08; p = 0.02). Thymectomy efficacy was 74.5% in AChR-positive, 54.0% in MuSK-positive, and 33.0% in seronegative myasthenia gravis. Postoperative complications occurred in 4 patients (3.8%), conversion was required in 3 patients (2.9%), and no deaths or postoperative myasthenic crises were recorded. Conclusion. Preoperative stratification before thymectomy in generalized myasthenia gravis should integrate QMG score, disease time, thymoma status, and thymic morphology. QMG combined with clinical and morphological variables may be useful for predicting the expected benefit of surgery and for patient counseling.

Background : Anastomotic leakage remains one of the most severe complications after esophagectomy and is associated with an increased rate of reinterventions, prolonged hospital stay, and higher postoperative mortality. Objective : To evaluate the prognostic value of inflammatory markers in the early postoperative period in patients after subtotal esophagectomy and to develop a postoperative risk stratification model for anastomotic leakage. Materials and methods : A multicenter retrospective comparative study was conducted. The analysis included 325 patients with morphologically verified malignant tumors of the esophagus and/or esophagogastric junction who underwent subtotal esophagectomy using the Ivor Lewis or McKeown approach. Clinical, anamnestic, tumor-related, intraoperative, and laboratory parameters were analyzed. The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), prognostic nutritional index (PNI), and Creactive protein (CRP) levels were assessed preoperatively and on postoperative days 1 and 5. Results: Anastomotic leakage was diagnosed in 48 of 325 patients (14.8%). In univariate analysis, anastomotic leakage was associated with the surgical approach (Ivor Lewis/McKeown), tumor location and length, severity of dysphagia, smoking status, Charlson Comorbidity Index, blood transfusion, and anemia status. Among the laboratory parameters, the most pronounced intergroup differences were observed on postoperative day 5: patients with anastomotic leakage had higher NLR, PLR, and CRP levels and lower PNI values. The final multivariable model included PNI5 (AOR 0.863; 95% CI 0.773–0.964; p = 0.009), PLR5 (AOR 1.009; 95% CI 1.005–1.012; p < 0.001), and CRP5 (AOR 1.007; 95% CI 1.001–1.012; p = 0.013). The model demonstrated excellent discriminative performance in the study cohort (AUC = 0.922; 95% CI 0.868–0.975; p < 0.001). Conclusion: In patients after esophagectomy, CRP, PLR, and PNI on postoperative day 5 were independent predictors of anastomotic leakage. Increased CRP and PLR levels, along with decreased PNI values, were associated with a higher risk of this complication. The model based on these parameters demonstrated high discriminatory performance and may be used for early postoperative risk stratification. However, external validation in independent patient cohorts is required before clinical implementation.

BACKGROUND: A current trend in Russian pediatrics is an increase in the number of inpatient palliative care units for children and, accordingly, the number of beds and patients in this population. AIM: To identify the need for various types, forms, and techniques of surgical interventions depending on the pathology that indicates palliative care, clinical manifestations, risks of underlying disease complications, and planned procedures. METHODS: This retrospective observational study included data from 240 children with palliative status who underwent 405 different procedures between 2021 and 2025 at the G.N. Speransky Children's City Clinical Hospital No. 9. Older patients predominated (30.8%); no gender differences were found. The main group consisted of patients with cerebral palsy (40.4%), chronic (recurrent) respiratory failure (22.5%), and brain lesions (21.3%) of various etiologies. The assessment protocol included clinical, imaging, endoscopic, and laboratory methods. RESULTS: The most common procedures were gastrostomy (56.4%), tracheostomy (17.2%), thoracentesis with pleural drainage (10.3%), and fundoplication (9.1%). The number of procedures increased from 33 to 127 annually over the study period. We identified procedures aimed at improving quality of life and care conditions (75.8%), relieving (15.1%), and preventing (9.1%) complications. Elective surgery was performed in 66.9% of patients, while urgent and emergency procedures accounted for 17.5% and 15.6% of cases, respectively. Among early complications, wound suppuration predominated (1.7%); late complications included "bumper" syndrome and gastrostomy anchor failure in 3 (1.3%) patients. No procedure-related deaths occurred. CONCLUSION: Comprehensive palliative care for children was successfully implemented in a multidisciplinary children's hospital, where the surgical component is focused on preventing or alleviating suffering, improving quality of life for the child, family comfort, and working conditions for medical staff. With interdisciplinary agreement among specialists and a constructive approach from the patient's family, surgical interventions effectively and safely improve the quality of life of terminally ill children, alleviate suffering, and improve working conditions for medical staff.

Objective. Improvement of treatment results in functionally inoperable patients with multiple pulmonary metastases. Material and methods. This study is based on the treatment outcomes of 64 patients diagnosed with multiple pulmonary metastases. Patients were divided into 2 groups: in the 1st (n=37) stereotactic radiotherapy (SRT) was performed, in the 2nd (n=27) surgical treatment (ST). All patients in the SRT group were deemed functionally inoperable. For metastases located in the peripheral zones of the lung, a total dose of 46-60 Gy with a dose per fraction of 15 Gy was delivered in 78.4% of cases. In patients with centrally located lesions, a total dose of 40-50 Gy with a dose per fraction of 8-10 Gy was administered (21.6% of patients). SRT was performed using Elekta linear accelerators with Active Breathing Control (ABC) and target position verification prior to each fraction using X-ray Volume Imaging (XVI). In the surgical group, 70.4% of patients underwent atypical resections, and 29.6% underwent anatomical resections. Results. Radiation pneumonitis grade 1 (RTOG 1) was diagnosed in 13 patients (35.1%) in the SRT group. In the ST one patient (3.7%) developed postoperative wound infection. Local recurrence following SRT was observed in 1 patients (1.6%), and in 3 patients (4.7%) after surgery. Local control (LC) in the SRT group remained stable at 96.2% over both 1- and 3-year follow-up periods. In the surgical group, LC was 100% at 1 year and declined to 76.4% at 3 years. The 1-year and 3-year overall survival (OS) rates in the SRT group were 91.6% and 57.2%, respectively, while in the surgical group they were 92.0% and 50.5%. Conclusion. The conducted analysis demonstrated that SRT and surgical resection provide comparable efficacy in achieving local control of both solitary and multiple pulmonary metastases.

Objective. To assess the incidence of postoperative hemothorax and influence of redo surgery timing on outcomes. Material and methods. A multiple-center retrospective study included 70 out of 7.796 postoperative patients who underwent redo surgery for postoperative hemothorax following lung resection between 2019 and 2024 in four specialized thoracic centers in Russia. Of these, 57 (81.4%) patients underwent anatomical resections (including 45 lobectomies), and 13 (18.6%) underwent non-anatomical wedge resections. Patients were stratified into early (<24 hours) and delayed (≥24 hours) redo surgery groups. Postoperative complications were assessed using the Thoracic Morbidity and Mortality (TMM) classification. The primary outcome was 90-day mortality. Results. The incidence of hemothorax was 1.1% after anatomical resections and 0.5% after non-anatomical resections. Ninety-day mortality was significantly lower in the early redo surgery group (12.5% vs. 36.6%, p=0.037). Early redo surgery was associated with higher rate of intraoperative identification of bleeding source (67.5% vs. 36.7%, p=0.030). The Charlson comorbidity index was significantly higher in the delayed group (p<0.001). Delayed interventions demonstrated a trend towards more severe complications and higher rates of pleural empyema. Delayed redo surgery beyond 24 hours was associated with more than threefold increase in the risk of death (OR 3.98; 95% CI 1.21–13.07). Conclusion. Early surgical intervention for postoperative hemothorax, especially within the first 24 hours, is associated with better clinical outcomes and significantly lower 90-day mortality.

Objective. To study the immediate and long-term outcomes of segmentectomy and lobectomy for malignant lung tumors. Material and methods. A retrospective study included patients with primary malignant lung tumors who underwent anatomical lung resection, including segmentectomy (335 patients) and lobectomy (1.238 patients) via thoracoscopic and open approaches between January 01, 2009 and December 31, 2022. Patients who required conversion to thoracotomy were included in the open surgery group. We enrolled 240 patients for analysis (120 after segmentectomy for non-small cell lung cancer (NSCLC) and 120 after lobectomy for NSCLC, ratio 1:1). Results. The total number of complications in thoracoscopic segmentectomies differed from lobectomy (4.2% and 9%, respectively; p=0.047). The same trend was observed for open segmentectomies and lobectomies (4.8% and 9.6%, respectively; p=0.05). Recovery of external respiratory function occurred significantly faster after thoracoscopic segmentectomies compared to thoracoscopic lobectomies. Thus, preoperative forced expiratory volumes in 1 second (FEV1) were 85% (42–120) and 89% (80–97), respectively. After 6 months and 1 year, FEV1 after thoracoscopic segmentectomy reached 80% (40–111) and 84% (42–116), after thoracoscopic lobectomy — 80% (70–90) and 82% (72–94), respectively. The same trend was observed in groups of open segmentectomy and lobectomies. Preoperative FEV1 was 79% (39–125) and 90% (43–136), after 6 months — 75% (36–117) and 82% (36–121), after 1 year — 78% (37–123) and 83% (39–130), respectively. The overall 5-year survival rates for patients with stage Ia1 and Ia2 NSCLC after thoracoscopic segmentectomy and lobectomy were 90.4% and 91.5% (p=0.940), 5-year disease-free survival rates — 83.3% and 89.4%, respectively (p=0.949). The overall 5-year survival rates for patients with stage Ia1 and Ia2 NSCLC after open segmentectomy and lobectomy were 79.7% and 83.5% (p=0.951), 5-year disease-free survival rates — 74.5% and 76.9%, respectively (p=0.457). Conclusion. Segmentectomy is associated with lower complication rate than lobectomy, and long-term outcomes are comparable to those of lobectomy in patients with NSCLC <2 cm.

One of the challenges in thoracic surgery is the development of chronic pain syndrome following thoracoscopic procedures due to intercostal nerve injury. The use of spaces beneath the costal arch and subxiphoidally for placing “large” thoracoports is presented as an alternative approach to avoid this complication. Objective. To evaluate the immediate outcomes of thoracoscopic anatomical lung resections for malignant neoplasms performed via a subxiphoid approach. Material and Methods. The subxiphoid approach group included six patients, with a mean age of 67±5 years. Four surgical procedures in the form of lobectomy were performed for primary peripheral non-small cell lung cancer at stages IA3 and IB. Two segmentectomy procedures were conducted for solitary secondary lesions. The comparison group consisted of six patients aged 61±5 years, operated on using a multiport intercostal thoracoscopic technique for primary malignant lung tumors in the form of lobectomy. Results. The operative time in the subxiphoid approach group was 235±13 minutes, compared to 170±15 minutes in the comparison group. Blood loss volume was 125±15 ml and 75±15 ml, respectively. The postoperative period was uneventful in both groups. The mean hospital stay was 6.5±1.5 days in the subxiphoid group and 7.5±1.5 days in the comparison group. Pain intensity measured on the Visual Analogue Scale, (VAS) in the subxiphoid group was: day 1 — 3.5 points, day 3 — 2.5 points, discharge day — 1.5 points. In comparison, the intercostal multiport thoracoscopy group scored: day 1 — 4.5 points, day 3 — 3.5 points, discharge day — 2.5 points. Conclusion. The subxiphoid approach can be used for anatomical lung resection without compromising efficacy or safety. Performing thoracoscopic anatomical lung resections using a subxiphoid approach results in reduced postoperative pain compared to the traditional intercostal thoracoscopic approach.

The aim of the study was to systematize current data on the use of human epididymis protein 4 (HE4) as a tumor-associated marker for lung cancer (LC) diagnosis, prognosis of treatment response, and monitoring of this category of patients. Material and Methods . A search and analysis of available Russian and Englishlanguage sources was performed in the RSCI and PubMed databases using keywords “lung cancer” and “HE4”. The review includes 44 papers published between 2006 and 2024. Results . HE4 is involved in gynecological cancer progression, but its role in the development of LC remains poorly studied despite its high expression in tumor tissue. Modern studies demonstrate that diagnostic characteristics of serum HE4 are comparable to or slightly superior to other markers used in the diagnosis of LC (CYFRA21-1, CEA, NSE, ProGRP, etc.). Several studies report that the HE4 serum level can serve as a predictor of response to chemotherapy and the duration of the relapse-free interval in LC. Some studies indicate the feasibility of HE4 as a marker for monitoring patients for early detection of lung cancer relapse. The indicators of the diagnostic and prognostic signifcance of serum HE4 vary signifcantly in different studies due to the heterogeneity of the included groups, differences in the reference values and methods for assessing the HE4 levels. This does not allow us to adopt a unifed diagnostic algorithm for using HE4. Conclusion . The accumulated data indicate the feasibility of using HE4 as a tumor-associated marker in LC. However, some aspects that are important for the practical application of HE4 remain unclear. Thus, the introduction of this marker into clinical practice requires further systematic and in-depth studies.

BACKGROUND: Sublobar lung resections in children include wedge (nonanatomic) resection and anatomic segmentectomy. Segmentectomy is used less frequently due to its technical complexity and the lack of objective patient selection criteria. This study aims to address this gap. The authors evaluated whether patient-specific 3D models can standardize preoperative anatomical assessment and thereby support selection of the optimal extent of resection in pediatric patients. AIM: This study aimed to determine the impact of preoperative 3D modeling on surgical strategy and outcomes in minimally invasive lung resections in children and to identify anatomical and clinical predictors of the extent of resection. METHODS: The study included 32 children (0–17 years) who underwent minimally invasive lung resection for congenital malformations or benign neoplasms (2020–2025). Patients were divided into a 3D modeling group (n = 16) and a standard computed tomography–based planning group (n = 16). Outcomes assessed included type of resection, complications, operative time, and concordance between planned and performed resection. Stepwise logistic regression was used to identify predictors of the extent of resection. In an additional analysis, patients were stratified by type of resection (wedge resection, segmentectomy, lobectomy). Quantitative parameters derived from 3D models—such as lesion-to-lobe volume ratio, zoning, and number of involved segments—were used to refine surgical planning algorithms. RESULTS: 3D-based planning significantly increased the likelihood of performing segmentectomy (odds ratio ≈ 25; p = 0.001), while maintaining high concordance between planned and performed procedures without increasing complication rates. The most significant quantitative predictor of resection extent was the lesion-to-lobe volume ratio (optimal threshold 0.205; AUC = 0.922). The type of resection was also associated with age, number of affected segments, and anatomical location. CONCLUSION: 3D modeling facilitated more frequent use of segmentectomy without increasing complications. The lesion-to-lobe volume ratio and anatomical factors may be used to guide selection of resection type. Incorporation of quantitative 3D parameters may improve the quality of preoperative planning in pediatric lung resections.