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This study aimed to use a new special inventory for lung surgery patients to evaluate postoperative symptoms and functional status and to identify factors that may affect these after uniportal video-assisted thoracoscopic surgery (VATS). In this single-center longitudinal cohort observational study, we used a new scale, the perioperative symptom assessment for lung surgery (PSA-Lung), to evaluate the recovery from symptoms and the functional status of patients undergoing uniportal VATS. We divided patients into two groups, according to patients’ symptom scores, and compared the clinical characteristics between the two groups under each item. Then, we conducted a qualitative interview regarding coughing in postoperative week 4. Exactly 104 patients were enrolled in this study. The two highest-scoring patient-reported outcome (PRO) items were “shortness of breath” and “coughing” in the fourth week after surgery. Thirty-one patients reported that “coughing” severely influenced their lives in postoperative week 4. Using the PSA-Lung inventory, we found that “shortness of breath” was the worst symptom in postoperative week 4. Although “coughing” was not the most important symptom in the early postoperative period, it affected some patients’ lives in postoperative week 4. Therefore, further research is required to determine the optimal cut-off point for coughing.

We sought to evaluate the role of robotic-assisted lung surgery on hospital volume using difference in difference (DID). We propose hospital adoption of robotic thoracic technology increases total volume of specific procedures as compared to non-robotic hospitals.The 2010-2015 Florida Agency for Health Care Administration dataset was queried for open, video-assisted thoracoscopic, and robotic-assisted thoracic surgeries. Incident Rate Ratios (IRR) from DID analysis determined the significance of robotic technology. For each technique, length of stay and elements of charges were compared to determine statistical significance.A total of 28,484 lung resection procedures performed at 162 hospitals, 65 of which had robotic capabilities were included. Robotic hospitals experienced an 85% increase in total lung surgical volume (IRR 1.85, p-value0.001). This increase in volume was consistent for each lung resection procedure separately.Hospital adoption of robotic technology significantly increases the overall lung surgical volume for select lung resection procedures.

BackgroundPatients undergoing surgery for early stage non-small cell lung cancer (NSCLC) may be at high risk for postoperative mortality. Access to stereotactic body radiation therapy (SBRT) may facilitate more appropriate patient selection for surgery.Research questionIs postoperative mortality associated with early stage NSCLC lower at facilities with higher use of SBRT?Study design and methodsPatients with early stage NSCLC reported to the National Cancer Database between 2004 and 2015 were included. Use of SBRT was defined by each facility's SBRT experience (in years) and SBRT to surgery volume ratios. Multivariate logistic regression was used to test for the associations between SBRT use and postoperative mortality.ResultsThe study cohort consisted of 202,542 patients who underwent surgical resection of cT1-T2N0M0 NSCLC tumors. The 90-day postoperative mortality rate declined during the study period from 4.6%to 2.6%(P< .001), the proportion of facilities that used SBRT increased from 4.6%to 77.5%(P< .001), and the proportion of patients treated with SBRT increased from 0.7%to 15.4%(P< .001). On multivariate analysis, lower 90-day postoperative mortality rates were observed at facilities with > 6 years of SBRT experience (OR, 0.84; 95% CI, 0.76-0.94; P= .003) and SBRT to surgery volume ratios of more than 17%(OR, 0.85; 95% CI, 0.79-0.92; P< .001). Ninety-day mortality also was associated with surgical volume, region, year, age, sex, and race, among other covariates. Interaction testing between these covariates showed negative results.InterpretationPatients who underwent resection for early stage NSCLC at facilities with higher SBRT use showed lower rates of postoperative mortality. These findings suggest that the availability and use of SBRT may improve the selection of patients for surgery who are predicted to be at high risk of postoperative mortality.

Background Unilateral vocal fold paralysis (UVFP) caused by lung surgery is associated with prolonged hospital stay and increased postoperative comorbidities. We evaluated lung surgery-related UVFP and compared its characteristics with UVFP caused by esophageal and thyroid surgeries, as the most common surgical causes of UVFP. We also evaluated the outcomes of intracordal hyaluronate injection laryngoplasty in these patients. Study design A retrospective case series study. Material and methods Patients with surgery-related UVFP were evaluated by quantitative laryngeal electromyography, videolaryngostroboscopy, voice acoustic analysis, Voice Outcome Survey (VOS) questionnaire, and Short Form-36 Health Survey (SF-36) quality-of-life questionnaire. Data for the lung, esophageal, and thyroid surgery groups were compared and changes in outcome measurements induced by hyaluronate injection were compared among the three groups. Results A total of 141 patients were recruited, including 21, 46, and 74 in the lung, esophageal, and thyroid surgery groups, respectively. Compared with the other two groups, lung surgery patients had predominantly left-sided UVFP, less involvement of the external branch of the superior laryngeal nerve, and higher jitter. Most outcome measurements improved in all three groups after office-based hyaluronate injection, with the greatest improvement in jitter in the lung surgery group. Conclusions Lung surgery-related UVFP showed a distinct disease presentation, and patients' voice parameters and quality of life recovered dramatically after office-based hyaluronate injection. We recommend evaluation of lung surgery-related UVFP and early intervention, such as office-based hyaluronate injection, to improve patients' voice function and quality of life.

Background: Although various methods are already used to calculate predicted postoperative forced expiratory volume in 1 second (FEV₁) based on preoperative FEV₁ in lung surgery, the predicted postoperative FEV₁ is not always the same as the actual postoperative FEV₁. Observed postoperative FEV₁ values are usually the same or higher than the predicted postoperative FEV₁. To overcome this issue, we investigated the relationship between the number of resected lung segments and the discordance of preoperative and postoperative FEV₁ values. Methods: From September 2014 to May 2020, the data of all patients who underwent anatomical lung resection by video-assisted thoracoscopic surgery (VATS) were gathered and analyzed retrospectively. We investigated the association between the number of resected segments and the differential FEV₁ (a measure of the discrepancy between the predicted and observed postoperative FEV₁) using the t-test and linear regression. Results: Information on 238 patients who underwent VATS anatomical lung resection at Kyung Hee University Hospital at Gangdong and by DH. Kim for benign and malignant disease was collected. After applying the exclusion criteria, 114 patients were included in the final analysis. In the multiple linear regression model, the number of resected segments showed a positive correlation with the differential FEV₁ (Pearson r=0.384, p

Background: Predicting postoperative lung function after pneumonectomy is essential. We retrospectively compared postoperative lung function to predicted postoperative lung function based on computed tomography (CT) volumetry and perfusion scintigraphy in patients who underwent pneumonectomy. Methods: Predicted postoperative lung function was calculated based on perfusion scintigraphy and CT volumetry. The predicted function was compared to the postoperative lung function in terms of forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV₁), using 4 parameters: FVC, FVC%, FEV₁, and FEV₁%. Results: The correlations between postoperative function and predicted function based on CT volumetry were r=0.632 (p=0.003) for FVC% and r=0.728 (p

Lung resections are associated with a variety of potential postoperative complications. Not surprisingly, pulmonary complications are most frequent after lung surgery. Cardiac and thromboembolic complications are also important. It is essential that surgeons anticipate the possibility of these complications and take preventative measures whenever possible. When complications do occur, prompt recognition and treatment is required to assure optimal patient outcomes.

Background Postoperative air leaks are a common complication after lung surgery. They are associated with prolonged hospital stay, increased postoperative pain and treatment costs. The treatment of prolonged air leaks remains controversial. Several treatments have been proposed including different types of sealants, chemical pleurodesis, or early surgical intervention. The aim of this review was to analyze the impact of autologous blood pleurodesis in a systematic way. Methods A systematic review of the literature was conducted until July 2020. Studies with more than five adult patients undergoing lung resections were included. Studies in patients receiving blood pleurodesis for pneumothorax were excluded. The search strategy included proper combinations of the MeSH terms “air leak”, “blood transfusion” and “lung surgery”. Results Ten studies with a total of 198 patients were included in the analysis. The pooled success rate for sealing the air leak within 48 h of the blood pleurodesis was 83.7% (95% CI: 75.7; 90.3). The pooled incidence of the post‐interventional empyema was 1.5%, with a pooled incidence of post‐interventional fever of 8.6%. Conclusions Current evidence supports the idea that autologous blood pleurodesis leads to a faster healing of postoperative air leaks than conservative treatment. The complication rate is very low. Formal recommendations on how to perform the procedure are not possible with the current evidence. A randomized controlled trial in the modern era is necessary to confirm the benefits., A systematic literature review was conducted until July 2020 to detect the success rate of autologous blood pleurodesis in healing prolonged air leaks. Ten studies with a total of 198 patients were included in the meta‐analysis. The pooled success rate for sealing the air leak within 48 h of the blood pleurodesis was 83.7% (95% CI: 75.7; 90.3). The pooled incidence of the post‐interventional empyema was 1.5%.

Introduction: The new coronavirus, SARS-CoV-2, provokes infection with different clinical presentation. It involves an asymptomatic condition, mild variants with fever and dry cough to severe pneumonia, adynamia and respiratory failure with lethal outcome. The fibrotic lung tissue after the inflammatory process is a background for development of a secondary pneumothorax. Although it rarely causes lethal outcomes in COVID-19 patients, pneumothorax requires early diagnosis and adequate treatment to prevent any complications and decrease mortality rate. Aim: The aim of this study was to analyse the results of surgical treatment of hospitalized COVID-19 patients with pneumothorax in terms of demographic data, concomitant diseases, complications, and outcome. Materials and methods: Longitudinal prospective study was carried out with 26 patients with pneumothorax as a result of SARS-CoV-2 infection. They were treated at the Intensive Care Unit of the Infectious Disease Clinic and at the Second Clinic of Surgery, St George University Hospital in Plovdiv over a 6-month period from September 2020 to February 2021. Results: Seventeen of the patients were men and nine – women. Twenty-four of all patients underwent thoracentesis and two of them had a video-assisted thoracoscopy. The mean age of the studied patients with pneumothorax and COVID-19 was 66.77±12.61 years, which shows that it is the patients of advanced age with concomitant diseases that are at a higher risk of serious complications and adverse outcome. Of the hospitalized 1245 patients with COVID-19, 385 (30.92%) passed away. Of all hospitalized patients with SARS-CoV-2, 26 (2.08%) developed pneumothorax. Sixteen of them (62%) passed away. The possibility of a lethal outcome for intubated patients increased more than twice. Conclusions: The pneumothorax as a complication of COVID-19 carries high mortality and severely worsens the prognosis for these patients.

The technique for bronchial stump suturing following lung resection which is currently applied in the Department of Thoracic Surgery at the University Hospitals Leuven, Belgium owes its name to the Dutch surgeon Dr. Klinkenbergh (1891-1985). A true pioneer of cardiothoracic surgery in Europe, Dr. Klinkenbergh dedicated himself to the surgical treatment of pulmonary tuberculosis. His work was praised by his peers for his precision and the reasoning behind every gesture. The Klinkenbergh technique consists in performing two running sutures which cross each other 'in the same manner as the laces of a shoe' to close the bronchus, limiting the occurrence of broncho-pleural fistulas. In our experience with more than 100 patients in the last 5 years (2016-2020) who underwent open pneumonectomy for benign or malignant disease, less than 2% developed post-operative broncho-pleural fistulas. ispartof: ACTA CHIRURGICA BELGICA vol:121 issue:6 pages:449-454 ispartof: location:England status: published

BACKGROUND In this study, we describe our experience regarding the implementation of early enhanced recovery after lung surgery. We achieved early ambulation within 1 hour after extubation mainly by minimally invasive surgery combined with fast-track thoracic anesthesia. METHODS We retrospectively analyzed the clinical outcomes of early enhanced recovery in 211 patients who underwent lung resection using miniport video-assisted thoracic surgery (VATS) by a multidisciplinary team in a single institution in the period from August 2018 to August 2019. RESULTS Out of the 211 patients, 178 achieved early ambulation 1 hour after extubation. The mean age of patients in the early ambulation group was 58.6±10.8 years, and 69 men and 109 women were included. The anesthesia time (100.8±26.6 minutes), extubation time (10±2.1 minutes), and operating time (71.1±25.3 minutes) were lower in the early ambulation group (P=0.001, P

Zusammenfassung Hintergrund Ziel dieser Arbeitsgruppe der Deutschen Gesellschaft für Thoraxchirurgie (DGT) war die Erarbeitung eines Expertenkonsensus basierend auf dem Delphi-Verfahren zur Definition von „Gewebehandling“ (Behandlung von und Umgang mit Geweben) und Darstellung des intraoperativen Umgangs mit bestimmten anatomischen Strukturen bei thoraxchirurgischen Eingriffen. Material und Methoden Eingeladene Experten (Fachärzte für Thoraxchirurgie; n = 93) bearbeiteten 2 aufeinanderfolgende elektronische Delphi-Fragerunden zu 4 Schwerpunkten: Durchtrennung von Lungenparenchym, Präparation/Durchtrennung von Lungengefäßen, Angioplastik/Gefäßanastomosen und Bronchusabsetzung/-plastik/-anastomose. Als Konsens wurde eine Übereinstimmung in ≥ 75% festgelegt. Bei der anschließenden Expertenkonferenz wurden die Ergebnisse der Delphi-Umfragen diskutiert und mittels TED-Abstimmung versucht, Konsens zu erzielen. Ergebnisse In der 1. Fragerunde wurden jeweils 66 (71%) und in der 2. Fragerunde jeweils 33 (35%) Antworten gegeben. Strittige Fragen wurden durch eine finale Abstimmung bei der Expertenkonferenz (54 Teilnehmer; im Durchschnitt 55% Beteiligung) erneut diskutiert. Die Definition des Begriffs „Gewebehandling“ beinhaltet alle Verfahren zur Präparation, Durchtrennung, Versiegelung und Rekonstruktion von verschiedenen körpereigenen Geweben im Rahmen von thoraxchirurgischen Eingriffen (100% Konsens). Ebenso wurde der Begriff der „angioplastischen Erweiterung“ mit einem Konsens von 97% definiert. Ein Konsens wurde zudem bei der Technik zur Durchtrennung des Lungenparenchyms mittels Klammernahtgeräten, der erforderlichen Deckung von Anastomosen und des Bronchusstumpfes, insbesondere nach einer Vorbehandlung, erreicht (> 75%). Schlussfolgerung Dieser Expertenkonsens definiert erstmalig den Begriff des Gewebehandlings in der Thoraxchirurgie. Des Weiteren führte dieser Delphi-Prozess zu einer umfassenden aktuellen Bestandsaufnahme unterschiedlicher intraoperativer Vorgehensweisen in der deutschen Thoraxchirurgie mit daraus abgeleiteten konsentierten Empfehlungen für das Gewebehandling an Lungenparenchym, -gefäßen und Bronchialstrukturen.

Postoperative air leak is one of the most common complications after pulmonary resection and contributes to postoperative pain, complications, and increased hospital length of stay. Several risk factors, including both patient and surgical characteristics, increase the frequency of air leaks. Appropriate intraoperative tissue handling is the most important surgical technique to reduce air leaks. Digital drainage systems have improved the management of postoperative air leak via objective data, portability, and ease of use in the outpatient setting. Several treatment strategies have been used to address prolonged air leak, including pleurodesis, blood patch, placement of endobronchial valves, and reoperative surgery.

Background Malignant peripheral nerve sheath tumors (MPNSTs) are aggressive soft tissue sarcomas which commonly arise from neurofibromatosis type 1. Lung metastases of the tumors are well-known, but intraoperative cerebral tumor embolisms of MPNSTs have not been reported in literature. Case presentation A 52-year-old female patient with neurofibromatosis type 1 underwent a right lung partial resection for lung tumors. She was extubated after adequate recovery of spontaneous breathing; however, she could not respond to verbal commands. In the intensive care unit, her neurological examination revealed conjugate eye deviation, right hemiparalysis, and aphasia. Magnetic resonance imaging revealed acute cerebral ischemia, so she underwent an endovascular thrombectomy. The histopathological diagnosis of emboli was a MPNST, which was identical with that of the resected lung tumor. Conclusion We report the first case of delayed emergence caused by a cerebral tumor embolism of MPNST during partial lung resection.

Bei Patienten mit primär resektablem Lungenkarzinom bleibt die anatomische Resektion die Therapie der Wahl. Allerdings kommen zu der etablierten Methode der Thorakotomie und Videothorakoskopie mit der Weiterentwicklung der Technik neue Methoden hinzu. Interessant ist hier insbesondere die Entwicklung der roboterassistierten Thoraxchirurgie. Die Anzahl der durch diese Technik unterstützten Lobektomien nimmt stetig zu und weitere Zentren schließen sich der roboterchirurgischen Therapie des Lungenkarzinoms an. Die roboterassistierte Thoraxchirurgie bietet einige technische Vorteile, welche die Limitationen der videoassistierten Chirurgie überwinden können. Die sichere Durchführbarkeit roboterassistierter Lobektomien konnten wiederholt gezeigt werden, wohingegen die Datenlage in Bezug auf die perioperativen Komplikationen heterogen ist. In Bezug auf die onkologischen Ergebnisse konnten bisher keine Nachteile der roboterassistierten Thoraxchirurgie gezeigt werden. Mit der Einführung neuer Robotersysteme anderer Hersteller wird die Entwicklung zukünftig wahrscheinlich noch rasanter voranschreiten und so potenziell den Anteil minimalinvasiver Operationen in der Thoraxchirurgie erhöhen. Anatomical lung resection is the standard treatment for patients with early-stage lung cancer. The conventional surgical techniques are thoracotomy and video-assisted thoracic surgery, but new methods have been added as technology has developed. The latest technological development is the robot-assisted anatomical lung resection. In this technique, a robot is used to perform an anatomical lobectomy or segmentectomy as well as lymph node dissection, as determined by oncological criteria. Comparison between the robot-assisted and video-assisted thoracic surgery is still of the greatest interest, since both minimally invasive approaches have their advantages and disadvantages. The aim of this work is to describe the development and performance of robot-assisted thoracic surgery, as well as the comparison with other surgical methods.

International audience; Introduction: In spite of increasing diffusion, Enhanced Recovery Pathways (ERP) have been scarcely assessed in large scale programs of lung cancer surgery. The aim of this study was auditing our practice. Methods: A two-step audit program was established: the first dealing with our initial ERP experience in patients undergoing non-extended anatomical segmentectomies and lobectomies, the second including all consecutive patients undergoing all kind of lung resections for NSCLC. The first step aimed at auditing results of ERP on occurrence of postoperative complications and at assessing which ERP components are associated with improved short-term outcomes. We also audited late results by assessing long-term survival of patients in the first step of our study. The second step aimed at auditing on large-scale short-term results of the ERP in a real-life setting. Results: Over a one-year period, 166 patients were included. The median number of ERP procedures per patient was three (IQR 3–4). No postoperative death occurred. The overall adverse events rate was 30%. In multivariate analyzes, the only element associated with reduced adverse postoperative events was chest tube withdrawal within POD2 (OR = 0.21, 95% CI (0.10–0.46)). The 1-, 3-, and 5-year survival rates were 97%, 86.1%, and 76.3%, respectively. In the second period, 1077 patients were included in our ERP; 11 patients died during the postoperative period or within 30 days of operation (1.02%). The overall postoperative adverse event rate was 30.3%, major complication occurring in 134 (12.4%), and minor ones in 192 (17.8%). Respiratory complications occurred in 64 (5.9%). Thoracoscore independently predicted postoperative death, the occurrence of complications (all-kind, minor, major, or respiratory ones). Conclusions: Compliance to ERP procedures and early chest tube removal are associated with reduced postoperative events in patients with lung resection surgery. In a large setting scale, ERP can be applied with satisfactory results in terms of mortality and morbidity. Thoracoscore is a useful tool in predicting mortality and postoperative adverse events.

Background There is a high incidence of venous thromboembolism (VTE) after lung resection, so it is necessary to identify the risk factors for VTE in these patients. It is also important to evaluate whether the modified Caprini score can accurately assess the risk of VTE in patients after lung resection. Methods This retrospective study included 437 patients undergoing lung resection between July 2016 and December 2017. All patients underwent lower extremities ultrasound before and after operation to determine the presence of the newly diagnosed VTE. Results Forty-seven (10.8%) of the 437 patients were diagnosed with VTE after lung surgery. Multivariate logistic regression analysis showed that age (OR, 2.04; 95% CI, 1.40-2.99), duration of operation (OR, 1.51; 95% CI, 1.08-2.12), lymphocyte count (OR, 0.28; 95% CI, 0.11-0.69), and D-dimer concentration (OR, 1.55; 95% CI, 1.22-1.97) were significantly associated with VTE in lung resection patients. The cut-off values for lymphocyte count and D-dimer concentration determined using receiver operating characteristic (ROC) curve were 1.15×109/L and 1.37 µg/mL respectively. The modified Caprini score divided the patients into three groups: low risk (0-4 points), moderate risk (5-8 points) and high risk (≥9 points), and the incidence of VTE was 12.3% (37/300), 7.5% (10/133) and 0% (0/4), respectively (P>0.05). Conclusions In this study, we identified four independent factors for VTE after lung resection patients: age, duration of operation, lymphocyte count, and D-dimer. According to the modified Caprini score, there were fewer patients in the high-risk group, and the incidence of VTE not increased with the increase of risk. Better evaluation of operation time and D-dimer may help the modified Caprini score to better assess VTE risk in these patients.

Breathing exercise training with a flow-oriented incentive spirometer (or Triflo) is important in lung expansion rehabilitation for patients with lung surgery or pulmonary injury. In this article, we propose a novel technique to estimate the volume of air inhaled and the sustained inhalation time based on video processing. The proposed technique combines a randomized circle detection algorithm to detect the three balls in Triflo tubes and a normalized cross-correlation algorithm to track these three balls that rise due to inhalation. The values of inhalation and the sustained inhalation time intervals are automatically recorded as screenshots on a personal computer for later analysis by a doctor. Three major experiments were conducted to verify the advantages of this proposed system. The first experiment evaluated the performances of both the ball detection and the tracking algorithms showing 3.68% error. The second experiment applied the proposed method implemented, so that it displays in plots the changes in the inhalation rate, as the training of a postoperative volunteer progressed. In the last experiment, a healthy subject employs Triflo to test the inhalation training format for lung volume regeneration with three levels of difficulty, to record the number of successful breathing maneuvers. When the data are displayed in rate versus time plots, a graph can help a doctor to appropriately plan the training program for the benefit of patients, because a more adaptable therapy can be realized and varying degrees of difficulty can be implemented. In addition, the patients can comfortably practice in home-based rehabilitation, seeing the improvements in the inspiratory muscle performance in computer screenshots.

Enhanced recovery programs (ERPs) aim to reduce psychological and physiological stress related to surgery, and minimize opioid use. This article describes the tenets of enhanced recovery, the guidelines for ERP in lung surgery, and the University of Virginia experience with developing and implementing a program. The impact of these strategies on short-term patient outcomes and potential long-term benefits including influence on lung cancer-specific outcomes are reviewed. The opioid crisis is of utmost importance; this article will explore how ERPs may be a mitigating factor.

Background: In the setting of the COVID-19 pandemic, the conduct of elective cancer surgery has become an issue because of the need to balance the requirement to treat patients with the possibility of transmission of the virus by asymptomatic carriers. A particular concern is the potential for viral transmission by way of aerosol which may be generated during perioperative care. There are currently no guidelines for the conduct of elective lung resection surgery in this context. Methods: A working group composed of 1 thoracic surgeon, 2 anesthesiologists and 1 critical care specialist assessed the risk for aerosol during lung resection surgery and proposed steps for mitigation. After external review, a final draft was approved by the Committee for the Governance of Perioperative and Surgical Activities of the Hôpital Maisonneuve-Rosemont, in Montreal, Canada. Results: The working group divided the risk for aerosol into 6 time-points: (1) intubation and extubation; (2) Lung isolation and patient positioning; (3) access to the chest; (4) conduct of the surgical procedure; (5) procedure termination and lung re-expansion; (6) chest drainage. Mitigating strategies were proposed for each time-point. Conclusions: The situation with COVID-19 is an opportunity to re-evaluate operating room protocols both for the purposes of this pandemic and similar situations in the future. In the context of lung resection surgery, specific time points during the procedure seem to pose specific risks for the genesis of aerosol and thus should be the focus of attention.

Context.—Transbronchial cryobiopsy is an emerging procedure to obtain lung tissue for diagnosis of interstitial lung disease and has gained popularity because it is less invasive and has a lower rate of complications compared with nonselective surgical lung biopsy.Objective.—To provide an overview of the status of the medical literature regarding transbronchial cryobiopsy.Data Sources.—A literature search was performed using PubMed search engine. The terms “cryobiopsy” or “cryoprobe” and “interstitial lung disease” or “diffuse parenchymal lung disease” or “pulmonary fibrosis” were used, with the search concluding at the end of November 2019.Conclusions.—While the diagnostic yield of transbronchial cryobiopsy is slightly lower than surgical lung biopsy, a growing amount of literature suggests that with a multidisciplinary approach cryobiopsy provides diagnostic and prognostic information approaching that of surgical lung biopsy with lower morbidity and mortality.

To evaluate the value of the improved POSSUM scoring system combined with the Clavien-Dindo classification in predicting the incidence of severe complications after thoracoscopic lung surgery and provide quantitative basis for clinical decision-making and improvement of preoperative physiological state of patients are the objectives of this study. The POSSUM scoring system was improved, the original indicators with less impact on surgery were removed, and the new indicators with greater influence were included. A new scoring system was established, and the fourth was selected from Hebei Medical University from January 2016 to December 2016. Three hundred fifteen patients underwent thoracoscopic lung surgery in hospital thoracic surgery. Summarizing their preoperative and intraoperative data and using the modified POSSUM POSSUM score, graded by Clavien-Dindo, set nonserious complications as class I group and II~V level as serious complications. The number of complications predicted by POSSUM and modified POSSUM and the number of actual serious complications were compared, and the prediction rates of the two groups were compared. A total of 167 complications occurred in 315 patients, and the number of complications was 44.1% (139/315). All patients had no death record within 30 days after surgery. Using the Clavien-Dindo classification, grade I, II, III, IV, and above complications accounted for 22.5%, 11.1%, 9.8%, and 0.6%, respectively. Sixty-eight cases of serious complications accounted for 21.6%, and 71 cases of nonserious complications accounted for 22.5%. The prediction equation of the improved POSSUM scoring system is ln(R/1 − R) = − 11.727 + (0.339 × PS) + (0.304 × OS), where R is the incidence of postoperative complications. POSSUM and the improved scoring system have predictive effects on postoperative complications, and the improved POSSUM scoring system has better predictive value than the original score. The Clavien-Dindo grading system combined with a modified POSSUM score can accurately predict the incidence of serious complications after thoracoscopic lung surgery. The sensitivity and specificity of the modified POSSUM score were higher than the POSSUM score, and the prediction of complications after VATS lung surgery was more accurate.

Background Fibrin glue effectively controls air leakage in lung surgery; however, allogenic fibrin glue cannot eliminate the risks of infection and allergy despite current sterilization methods. Autologous fibrin glue (AFG) could be a good alternative, but is not commonly used worldwide because of its limited availability and lack of evidence. Herein, we report clinical outcomes of AFG in thoracic surgery. Methods We retrospectively analyzed patients who underwent lobectomies or segmentectomies between November 2016 and September 2017 in our institution. We used two types of AFGs. One was a partially-autologous fibrin glue (PAFG), the components of which are largely autologous but which contains allogenic thrombin. The other was a completely-autologous fibrin glue (CAFG) which has no allogenic components. PAFG was used in the first half of the study period, after which CAFG was used from March 2017 onward. Patients who did not undergo AFG generation were categorized as the non-AFG group. The perioperative outcomes of the three groups were evaluated. Results A total of 207 patients underwent lung surgery, including 118 lobectomies and 89 segmentectomies. Among them, 83 patients received PAFG, 94 received CAFG, and 30 received non-AFG. The mean postoperative drainage period was within a few days in each group (PAFG vs. CAFG vs. non-AFG: 3.23±3.91 vs. 3.16±4.04 vs. 3.17±4.16 days, respectively; P=0.405), and the incidence of postoperative prolonged air leakage was within an acceptable range (PAFG vs. CAFG vs. non-AFG: 13.3% vs. 12.8% vs. 16.7%, respectively; P=0.821). Conclusions The use of AFG is clinically feasible for patients who undergo lobectomies or segmentectomies. AFGs could be a viable alternative to conventional allogenic fibrin glues.

Background . Air-leak after lung resection is a common complication occurring in 30–50 % of patients immediately after surgery. The prolonged air-leak (PAL) is a serious problem if it lasts more than 5 days after lung surgery with the reported incidence of 15 %. Despite the progress in thoracic surgery including energy-based vessel-sealing devices and digital drainage systems, there is no universal agreement on the optimal treatment of patients with prolonged air-leaks. T he aim of the study : to improve postoperative outcomes in patients with PAL by optimization of postoperative treatment algorithm. Material and methods . Treatment outcomes were analyzed in 194 patients, who underwent lobectomy for non-small cell lung cancer in 2017–2018. results. The prolonged air-leak was detected in 19 (9.8 %) patients after. The average time interval between surgery and development of this complication was 3.4 days. There was no mortality in our series. The median postoperative hospital stay was 8.7 days in patients with non-complicated postoperative period and 14.8 days in patients with PAL. Based on our own experience and practice we have developed and implemented an algorithm of the management of patients with PAL. Conclusion. The treatment of patients with PAL should be based on multidisciplinary approach providing safety of the patients after major lung resection. Each case with PAL should be discussed individually to achieve better results.

Fragestellung Die Recurrensparese in der thorakalen Chirurgie stellt mit einer Inzidenz von 1,9-32% eine ernst zu nehmende Komplikation mit weitreichenden Folgen dar. Vor allem Eingriffe am Aortenbogen und der linken Lunge stellen ein erhebliches Risiko für die Verletzung des Nervus laryngeus recurrens im Abgang aus dem Nervus vagus im aortopulmonalen Fenster dar. Die Anwendung des Neuromonitorings, wie es in der Schilddrüsenchirurgie zum Einsatz kommt, wurde bereits diskutiert und in einigen Fällen erfolgreich angewendet. Aufgrund der Notwendigkeit zur Einlungenventilation bei Lungeneingriffen, ergibt sich die Frage, ob es technisch möglich ist, das kontinuierliche Neuromonitoring über einen Doppellumentubus durchzuführen und wie hierfür die Ableitelektroden auf dem Tubus angeordnet werden sollten. Hierfür wurden Patienten mit der Indikation zur linksseitigen Thorakotomie in diese Studie eingeschlossen. Alle Patienten erhielten vor und nach der Operation eine phoniatrische Untersuchung durch die Kollegen der Hals-, Nasen-, Ohrenheilkunde zum Ausschluss einer vorbestehenden Pathologie im Bereich der Stimmlippen. Der Doppellumentubus wurde mit zwei hintereinander geklebten Elektroden proximal des trachealen Cuffs versehen und die jeweiligen Abstände dokumentiert. Im Rahmen der Operation erfolgte die kontinuierliche Stimulation des Nervus vagus vor Abgang des Nervus laryngeus recurrens. Als signifikantes Signal wurde eine Amplitude von mindestens 165µV definiert und dokumentiert, ob sich distal, proximal oder an beiden Elektroden ein Signal ableiten ließ. Ergebnisse Es wurden insgesamt 20 Patienten eingeschlossen. Es zeigten sich keine wesentlichen Unterschiede in Geschlecht, Größe und Gewicht. In 14 Fällen bestand eine maligne Erkrankung, bei 6 Patienten eine benigne Veränderung. Bei allen Patienten wurde ein Doppellumentubus verwendet, davon 18 linksläufige und 2 rechtsläufige Tuben in allen Größen von 35 bis 41Chr. Bei 18 Patienten konnte ein signifikantes Signal abgeleitet werden. Bei 14 Patienten wurde nur an der distalen Elektrode, bei 4 Patienten an beiden Elektroden ein Signal detektiert. Bei keinem der Patienten wurde nur proximal ein Signal gemessen. In keinem Fall zeigte sich während der Operation ein mildes oder schweres Ereignis im Sinne eines Amplitudenabfalls in Kombination mit einer Latenzzeitverlängerung, ein Loss-of-Signal trat nicht auf. Nachweislich kein Patient wies postoperativ eine Recurrensparese auf. Die meisten signifikanten Signale ließen sich bei einem Abstand der Elektrode zum trachealen Cuff von 10-11mm ableiten. Ab einer Distanz von 74mm zwischen trachealem Cuff und Elektrode war kein Signal nachweisbar. Diskussion Die Studie konnte die bis dato vorliegenden Untersuchung zur Anwendung des Neuromonitorings bestätigen und ziegen, dass das kontinuierliche Neuromonitoring über einen Doppellumentubus technisch durchführbar und sicher anzuwenden ist. Dabei sollte die Ableitelektrode mindestens 10mm vom trachealen Cuff, jedoch nicht weiter als 74mm entfernt liegen. Damit kann bei Verwendung nur einer Ableitelektrode diese auf Höhe der Stimmlippen positioniert werden. Unter Berücksichtigung der vorangegangenen Studien, in denen die Produkte verschiedener Hersteller von Elektroden und Doppellumentuben verwendet wurden und unserer Untersuchung, wird sich das cIONM auf die verschiedenen Materialkombinationen anwenden lassen. Limitationen liegen in der Stichprobengröße von 20 Patienten. Außerdem sollte in einer nachfolgenden Untersuchung sowohl die Elektrodenanordnung als auch die Möglichkeit zur Senkung der Recurrenspareserate überprüft werden. Schlussfolgerung Das kontinuierliche, intraoperative Neuromonitoring über den Doppellumentubus bei linksthorakalen Eingriffen als einfach anzuwendende und für den Patienten sichere Methode, bietet dem Operateur eine zusätzliche Sicherheit im Rahmen der Präparation. Insbesondere in der Therapie des Lungenkarzinoms ist die Lymphknotendissektion ein entscheidender, prognosebeeinflussender Schritt. Hierbei spielen die Lymphknoten der Level 4-6 als mediastinale Lymphknoten im aortopulmonalen Fenster eine bedeutende Rolle. Dies stellt jedoch ein hohes Risiko für die Funktion des N. laryngeus recurrens dar. Die intraoperative Echtzeit-Überwachung der Funktion durch Anwendung des kontinuierlichen Neuromonitorings kann möglicherweise zu einer deutlichen Risikoreduktion einer Recurrensparese beitragen. Neben der Lymphadenektomie der Level 4-6 in der Lungenchirurgie finden sich auch in der Herz- und Viszeralchirurgie potentielle Anwendungsgebiete. Eingriffen nahe am Aortenbogen, in der kindlichen Herzchirurgie, sowie der Ösophaguschirurgie stellen Risikoeingriffe für die Entstehung einer Recurrensparese dar. Daher sollte auch in diesem Bereich das cIONM implementiert werden.

Objective: Lung cancer is one of the deadliest cancer forms, and many of the operations are done with mini-invasive technics. OUSU is trying to focus more on mini-invasive technic: VATS. This makes it necessary to systematically go through relevant data and literature to assess cons and pros of different surgical methods: VATS, RATS, and open thoracotomy. Method: 139 patients were operated at OUSU in 2020: n=66 open UL, n=49 VATS UL, n=4 open BL and n=8 open PM. 23 articles about VATS, RATS and open thoracotomy were assessed to ascertain possible differences between findings from OUSU and other institutions. Results: OUSU had conversionrate of 19,7%; higher than in literature. Operation time was significantly lower for open thoracotomy then VATS (120±38min vs. 175±41min). Most of literature showed lack of consensus on this topic. In OUSU: amount of extracted lymph nodes and lymph node stations was significantly higher for open thoracotomy (12vs.7 and 5vs.3). This was supported by two of the articles that compared VATS and open thoracotomy. RATS was shown to extract more lymph nodes then VATS and was comparable with open thoracotomy. TNM-upstaging was comparable in OUSU (28,5% for VATS vs. 25,5% for open), and mostly happened because of changes in T-stadium. Most articles agreeded that TNM-upstaging was comparable between different technics. One showed TNM upstaging of 17%, 13% and 21% for RATS, VATS, and open thoracotomy. Conclusion: In OUSU VATS resulted in longer operation time and fewer extracted lymph nodes. It was difficult to find consensus in literature about this. It was found that most of upstaging happened because of postoperative changes in tumor size. No clear data indicated that RATS is superior to VATS.

Background Evaluation of the diagnostic value of routine chest tube tip culture for detection of postoperative infection after surgery for noninfectious lung disease. Methods Included subjects were patients who underwent lung surgery between January 1st 2013 and January 1st 2018 in University Medical Centre Utrecht and of whom a chest tube tip was cultured. Postoperative outcomes included pneumonia, surgical site infection, and empyema within 30 days after surgery. Univariable analysis for diagnostic accuracy of chest tube tip culture results predicting these postoperative outcomes was performed, as well as multivariable analysis using penalized firth logistic regression. Results Patients developed one or more postoperative infections in 42 out of 210 (20%) lung surgeries. Pneumonia, surgical site infection, and empyema were found in 36 (17%), 8 (4%), and 2 (1%) cases respectively. Chest tube tip culture had a sensitivity of 31%, a specificity of 83%, a positive predictive value of 32%, and a negative predictive value of 83% for postoperative infections. In the subgroup of patients who did not have evidence of postoperative infection at the time of chest tube removal, the drain tip culture’s positive and negative predictive value changed to 18% and 92% respectively. Adding additional variables to chest tube tip culture in a prediction model resulting in only limited improvement in diagnostic performance. Conclusions We found insufficient diagnostic performance to support the practice of routine chest tube tip culture after surgery for noninfectious lung disease. Therefore, routine chest tube tip culture is not advisable and should be omitted to unburden the healthcare process and prevent low value care together with extra costs.

Background: Current treatment guidelines for stage IV non-small cell lung cancer (NSCLC) with brain metastases recommend brain treatments, including surgical resection and radiotherapy (RT), in addition to resection of the primary lung tumor. Here, we investigate the less-studied impact of treatment sequence on the overall survival.Methods: The National Cancer Database was queried for NSCLC patients with brain metastases who underwent surgical resection of the primary lung tumor (n = 776). Kaplan-Meier survival curves with log-rank test and propensity score stratified Cox regression with Wald test were used to evaluate the associations between various treatment plans and overall survival (OS).Results: Compared to patients who did not receive any brain treatment (median OS = 6.05 months), significantly better survival was observed for those who received brain surgery plus RT (median OS = 26.25 months, p < 0.0001) and for those who received brain RT alone (median OS = 14.49 months, p < 0.001). Patients who received one upfront brain treatment (surgery or RT) before lung surgery were associated with better survival than those who received lung surgery first (p < 0.05). The best survival outcome (median OS 27.1 months) was associated with the sequence of brain surgery plus postoperative brain RT followed by lung surgery.Conclusions: This study shows the value of performing upfront brain treatments followed by primary lung tumor resection for NSCLC patients with brain metastases, especially the procedure of brain surgery plus postoperative brain RT followed by lung surgery.

Background: Thoracic surgery is a recommended treatment option for non-small cell lung cancer patients. An important part of a patient’s therapy, which helps to prevent postoperative complications and improve quality of life, is pulmonary rehabilitation (PR). The aim of this study was to assess whether the implementation of physical activity has an influence on forced oscillation technique (FOT) values in patients after thoracic surgery due to lung cancer. Methods: In this observational study, we enrolled 54 patients after thoracic surgery due to lung cancer, 49 patients with idiopathic interstitial fibrosis (IPF), and 54 patients with chronic obstructive pulmonary disease/asthma–COPD overlap (COPD/ACO). All patients were subjected to three weeks of in-hospital PR and assessed at the baseline as well as after completing PR by FOT, spirometry, grip strength measurement, and the 6-min walk test (6MWT). Results: We observed differences between FOT values under the influence of physical activity in studied groups, mostly between patients after thoracic surgery and COPD/ACO patients; however, no significant improvement after completing PR among FOT parameters was noticed in any group of patients. Improvements in the 6MWT distance, left hand strength, and right hand strength after PR were noticed (p < 0.001, 0.002, and 0.012, respectively). Conclusions: Three weeks of pulmonary rehabilitation had no impact on FOT values in patients after thoracic surgery due to lung cancer. Instead, we observed improvements in the 6MWT distance and the strength of both hands. Similarly, no FOT changes were observed in IPF and COPD/ACO patients after completing PR.

The lungs are a common site of metastases from malignant tumors. Their removal with a minimal but safe tissue margin is essential for the long-term survival of patients. The aim of this study was to evaluate the usefulness of a 1940 nm thulium-doped fiber laser (TDFL) and a 1470 nm diode laser (DL) in a pig model of lung surgery that involved the incision and excision of lung tissue. Histopathological analysis was performed on days 0 and 7 after surgery. Neither TDFL nor DL caused significant perioperative or postoperative bleeding. Histological analysis revealed the presence of carbonized necrotic tissue, mixed fibrin–cellular exudate in the superficial zone of thermal damage and bands of deeper thermal changes. The mean total width of thermal damage on day 0 was 499.46 ± 61.44 and 937.39 ± 109.65 µm for TDFL and DL, respectively. On day 7, cell activation and repair processes were visible. The total width of thermal damage was 2615.74 ± 487.17 µm for TDFL vs. 6500.34 ±1118.02 µm for DL. The superficial zone of thermal damage was narrower for TDFL on both days 0 and 7. The results confirm the effectiveness of both types of laser in cutting and providing hemostasis in the lungs. TDFL caused less thermal damage to the lung parenchyma than DL.

BackgroundFatigue and long work hours of surgeons attracts increasing concerns in recent years. In clinical practice, most patients prefer to receiving surgery in the morning. So, we aimed to explore whether starting time is associated with perioperative outcomes and hospital cost for elective lung surgery. MethodsA retrospective study was conducted on elective lung surgery patients between September 2019-November 2019. Patients were divided into “early start group” if surgery started before 4pm while “late start group” was after 4pm. Perioperative outcomes and total hospital costs were compared between two groups. Besides, multivariable logistic regression analysis was performed for further analysis.ResultsA total of 398 patients were finally enrolled for analysis in this study. Of all the cases, 295 patients were divided into early start group while 103 patients belonged to late start group. There were no differences in postoperative hospital duration, operation time, complication incidence and total hospital cost. In multivariable logistic regression analysis, surgery start late was still found not to be a risk factor.ConclusionIn elective lung surgery, perioperative outcomes and cost were all similar between early start and late start surgery, it was not necessary to worry about surgery order for these patients.

The growing unmet demand for suitable organ donors increases each year. Despite relative contraindications for thoracic organ donation after previous cardiac surgery, experienced programmes and surgeons can successfully utilise the lungs from select donors who have undergone prior cardiac surgery. This is the first reported case of double lung en bloc procurement from a donor who had a previous arterial switch operation as an infant.

BackgroundDetermining benign and malignant nodules before surgery is very difficult when managing patients with pulmonary nodules, which further makes it difficult to choose an appropriate treatment. This study aimed to develop a lung cancer risk prediction model for predicting the nature of the nodule in patients’ lungs and deciding whether to perform a surgical intervention.MethodsThis retrospective study included patients with pulmonary nodules who underwent lobectomy or sublobectomy at Tianjin Medical University General Hospital between 2017 and 2020. All subjects were further divided into training and validation sets. Multivariable logistic regression models with backward selection based on the Akaike information criterion were used to identify independent predictors and develop prediction models.ResultsTo build and validate the model, 503 and 260 malignant and benign nodules were used. Covariates predicting lung cancer in the current model included female sex, age, smoking history, nodule type (pure ground-glass and part-solid), nodule diameter, lobulation, margin (smooth, or spiculated), calcification, intranodular vascularity, pleural indentation, and carcinoembryonic antigen. The final model of this study showed excellent discrimination and calibration with a concordance index (C-index) of 0.914 (0.890–0.939). In an independent sample used for validation, the C-index for the current model was 0.876 (0.825–0.927) compared with 0.644 (0.559–0.728) and 0.681 (0.605–0.757) for the Mayo and Brock models. The decision curve analysis showed that the current model had higher discriminatory power for malignancy than the Mayo and the Brock models.ConclusionsThe current model can be used in estimating the probability of lung cancer in nodules requiring surgical intervention. It may reduce unnecessary procedures for benign nodules and prompt diagnosis and treatment of malignant nodules.

Objective The prevalence of patients with concomitant heart and lung lesions requiring surgical intervention is increasing. Simultaneous cardiac surgery and pulmonary resection avoids the need for a second operation. However, there are concerns regarding the potentially increased mortality and complication rates of simultaneous surgery and the adequacy of lung exposure during heart surgery. Therefore, we performed a meta-analysis to evaluate the perioperative mortality and complication rates of combined heart surgery and lung tumor resection. Methods A comprehensive literature search was performed in July 2020. The PubMed, Embase, and Web of Science databases were searched to identify studies that reported the perioperative outcomes of combined heart surgery and lung tumor resection. Two reviewers independently screened the studies, extracted data, and assessed the risk of bias of included studies. Pooled proportions and 95% confidence intervals (95% CI) were calculated by R version 3.6.1 using the meta package. Results A total of 536 patients from 29 studies were included. Overall, the pooled proportion of operative mortality was 0.01 (95% CI: 0.00, 0.03) and the pooled proportion of postoperative complications was 0.40 (95% CI: 0.24, 0.57) for patients who underwent combined cardiothoracic surgery. Subgroup analysis by lung pathology revealed that, for patients with lung cancer, the pooled proportion of anatomical lung resection was 0.99 (95% CI: 0.95, 1.00) and the pooled proportion of systematic lymph node dissection or sampling was 1.00 (95% CI: 1.00, 1.00). Subgroup analysis by heart surgery procedure found that the pooled proportion of postoperative complications of patients who underwent coronary artery bypass grafting (CABG) patients using the off-pump method was 0.17 (95% CI: 0.01, 0.43), while the pooled proportion of complications after CABG using the on-pump method was 0.61 (95% CI: 0.38, 0.82). Conclusion Combined heart surgery and lung tumor resection had a low mortality rate and an acceptable complication rate. Subgroup analyses revealed that most patients with lung cancer underwent uncompromised anatomical resection and mediastinal lymph node sampling or dissection during combined cardiothoracic surgery, and showed off-pump CABG may reduce the complication rate compared with on-pump CABG. Further researches are still needed to verify these findings.

Covid-19 has touched all corners of the globe and impacted our lives in more ways than one. Thoracic surgeons are frontliners impacted in both our professional and personal capacities. In this commentary we discuss the impact that Covid-19 has had on thoracic surgery as a practice highlighting the discrepant impact upon developed and developing countries, the state of affairs of the “new normal” that we live in and the challenges ahead as we transition from pandemic living to endemic living alongside Covid-19. We need to evolve as the virus does and keep abreast of the latest developments to continue providing excellent care to our patients. While the challenges brought about by the Covid-19 pandemic are unprecedented in this generation, it can bring forth tremendous opportunities for us to redefine excellence in thoracic surgery service delivery in this endemic times.

Our department has a database of thoracic gunshot wounds (GSWs), which has cataloged these injury patterns over the past five decades. Prevailing wisdom on the management of these injuries suggested operative treatment beyond tube thoracostomy is not commonly required. It was our clinical impression that the operative treatment required beyond chest tube placement has greatly increased over the past several decades, whereas the operative management of cardiac GSWs seemed to be increasingly infrequent events. To test these observations, we analyzed the treatment of GSWs to the chest and heart in four distinct time periods, categorized as “historical” (1973–1975 and 1988–1990) and “modern” (2005–2007 and 2015–2017). There was a significant increase in emergent thoracotomy, delayed thoracic operations, overall operative interventions, and pulmonary resections from the historical period to the modern era. There was a decline in cardiac injuries treated, whereas the number of injuries remained constant. Mortality was unchanged between the early and later periods. Operative treatment beyond tube thoracostomy was much more prevalent for noncardiac thoracic GSWs in the past two decades than in the prior decades, whereas the number of cardiac wounds treated decreased by half.

Background No consensus regarding the best post-operative treatment option for air leak has been established. In this study, we evaluate the use of intra-pleural fresh frozen plasma (FFP) as a promising treatment method. Methods Treatment for a sustained air leak (3 days) was warranted in approximately 12% of the lung surgeries at our institution. Fifty-two patients were treated with FFP by application of 250 mL daily. The patients were divided into two cohorts: cohort 1 consisted of 35 patients undergoing anatomical lung resections and cohort 2 consisted of 17 patients after miscellaneous types of lung surgery. Successfulness of the procedure as well as the potential influential factors was evaluated statistically and validated by a bootstrapping. Area under receiver operating characteristic curve was used to establish a cut-off value of the predictor. Results In the first cohort, air leakage was successfully treated in 28 (80%), while in seven (20%) it was still present after third treatment with FFP. The success rate in cohort 2 was 76.5%. The only covariate which appeared to remain significant in both cohorts was flow as displayed on the digital suction device prior to application of FFP. Flow ≤375 mL/min was indicative of successful aerostasis. Conclusion Intra-pleural instillation of FFP seems to be a feasible method for the treatment of post-operative air leakage. Although the optimum strategy regarding its application as well as its limitations is yet to be established, an absence of complications or undesirable events makes this (off label) method a safe and promising alternative to existing options.

A chest tube is traditionally placed to drain pleural effusions in order to maintain the pressure balance of the thorax after pneumectomy and at the same time observe possible hemorrhage, air or lymphatic leakage (1-3). Even though the rapid progress of the chest tube management along with the advances in surgical technologies and ideas in lung surgery, much controversy still exists on size and type of chest tube, criteria for chest tube removal after surgery over these years (1,4,5). What’s more, chest tube placement postoperatively increases chest pain and analgesic dosage and even extends the length of hospital stay, and most importantly affects patients’ early motivation and postoperative rehabilitation.

ObjectivesOrganization and governance of national healthcare might play an important role in decision-making and outcomes in patients with lung cancer. Both Denmark and the Netherlands have a high level of healthcare but a different financial coverage, governance and level of centralization. By using both national databases we analyzed the consequences of these differences on patterns of care and outcomes with a focus on morbidity, mortality and clinical staging.Materials and methodsGeneral numbers on both healthcare systems were requested. All patients who had surgery for lung cancer from 2013 to 2016 were included. Mortality, morbidity and clinical staging were analyzed for patients with NSCLC without metastases, only one operation and no neo-adjuvant therapy.ResultsIn 2016 annual budget as share of gross national product was 10.4% for both countries. In Denmark 4 hospitals performed lung surgery in 2016, compared to 43 hospitals in the Netherlands. We included 4030 Danish and 8286 Dutch patients. In the subgroup 30-day mortality was 1.5% in Denmark compared to 1.9% in the Netherlands. The percentage of patients with a complicated course was 24.4% and 34.8% respectively (p ConclusionSurgery for lung cancer is at a high level in both countries, reflected by low mortality-rates. Centralization has been implemented successfully in Denmark, which might explain the lower rate of patients with a complicated post-operative course, although different definitions preclude firm conclusions. In both countries correct clinical staging of lung cancer remains a challenge.

Background. Air leakage is a common postoperative complication in pulmonary surgery, and surgical sealants have been developed to prevent or reduce the incidence of air leaks. In this study, we evaluated the efficacy of cross-linked gelatin glue (gelatin plus glutaraldehyde) in canine lung surgery models. Methods. Pulmonary fistulas and injuries were created in dogs and sealed with gelatin glue, fibrin glue, or fibrin glue with a polyglycolic acid (PGA) sheet. Seal-breaking pressures were measured in the fistula model, and pleural adhesions were assessed 28 days postoperatively in the lung injury model. Results. The seal-breaking pressures for canine cadaver and living lung surgeries (; the maximum pressures were 80 and 40 cm H₂O) were respectively: gelatin glue, 77 ± 6 and 32.3 ± 8.9cm H₂O; fibrin glue using spray, 39.2 ± 9.3 and 32 ± 6cm H₂O; fibrin glue using the rub-and-soak method, 35 ± 13.4 and 40 ± 0 cm H₂O; and fibrin glue with a PGA sheet, 55.5 ± 18.2 and 39 ± 2cm H₂O. In the lung injury model, there were no chest wall adhesions in the gelatin and fibrin glue alone groups, while strong adhesions were observed when treated with fibrin glue with a PGA sheet. Conclusions. Gelatin glue's sealing effect was superior to that of fibrin glue while preventing postoperative pleural adhesions. These findings suggest that gelatin glue may be effective as a surgical sealant or anti-adhesion materialin lung surgery.

Resume Introduction L’avenement des techniques minimalement invasives a permis une ouverture plus large des indications chirurgicales avec notamment des patients plus âges et presentant un nombre plus important de comorbidites. Le taux de complications postoperatoire est cependant reste stable. Etat des connaissances On les definit comme une variation par rapport au deroule habituel. Elles surviennent dans 30 % des interventions mais restent majoritairement mineures. La mortalite globale d’apres les series disponibles est estimee entre 2 % et 3 %. On distingue ainsi : (1) les complications precoces survenant dans les 24 premiere heures, regroupant les complications chirurgicales « classiques » ainsi que d’autres plus specifiques a cette chirurgie d’organe ; (2) les complications survenant lors de l’hospitalisation (au cours des 3 premiers mois) comprennent les evenements infectieux avec une preponderance des pneumopathies, des infections sur site operatoire, des complications bronchiques, pleurales ou cardiologiques ; (3) les complications tardives dominees par les douleurs chroniques. La lobectomie reste l’intervention standard, que nous prenons comme modele pour la description des complications. La pneumonectomie represente une chirurgie a part notamment dans sa gestion peri- et postoperatoire. Conclusion La chirurgie d’exerese majeure a beneficie des progres des voies minimalement invasives et des circuits de rehabilitation precoces. On note l’apparition cependant de nouvelles complications specifiques a ces voies d’abord.

Aim of this study was to elucidate an alteration of quality of life (QOL) score before and after video-assisted thoracoscopic surgery (VATS) for non-small cell lung cancer (NSCLC) patients using the 5-level EuroQol-5D questionnaire (EQ-5D-5L). We also investigated how the preoperative QOL scores affected the postoperative clinical outcome prospectively. Between July 2018 and December 2018, 24 consecutive NSCLC patients who underwent VATS were recruited. The EQ-5D-5L for Japanese was used with face-to-face interviews to estimate the utility values of QOL. QOL scores were significantly declined after surgery (0.81 ± 0.19 vs. 0.74 ± 0.11: P = 0.049). The levels of EQ-5D-5L questionnaire were not significantly different before and after surgery except Q4 (pain control). The levels of Q4 were significantly worsened after surgery (1.33 ± 0.56 vs. 1.88 ± 0.61, P

Xianhui Kang,1,* Xiaodong Tang,1,* Yang Yu,1 Fangping Bao,1 Shuyuan Gan,1 Wei Zheng,1 Jian Zhang,2 Shengmei Zhu1 1Department of Anesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China; 2Department of Anesthesiology, The Third People’s Hospital of Chengdu, Chengdu, Sichuan, China *These authors contributed equally to this work Purpose: This retrospective cohort study aimed to investigate the association between intraoperative dexmedetomidine infusion and emergence agitation (EA), and recovery profiles after lung surgery in adult patients. It was hypothesized that dexmedetomidine was associated with reduced EA and improved recovery profiles. Patients and methods: A single-center chart review was conducted on elective lung surgeries in adults between January and December 2016. The primary outcome was the incidence of EA in postanesthesia care units (PACUs). The secondary outcomes included rescue analgesia, shivering, time to extubation, residual sedation, postoperative pulmonary events, duration of PACU stay, length of hospital stay, and intraoperative hemodynamic changes. Univariate and multivariate regression analyses were used to analyze data. Results: Among 2,468 patients, 814 received an intraoperative dexmedetomidine infusion. Intraoperative dexmedetomidine infusion was associated with a lower incidence of EA (10.9% vs 15.0%; adjusted OR, 0.67; 95% CI, 0.51–0.87; P=0.003), rescue analgesia (7.6% vs 12.2%; adjusted OR, 0.63; 95% CI, 0.47–0.86; P=0.003), shivering (4.2% vs 6.6%; adjusted OR, 0.58; 95% CI, 0.38–0.88; P=0.010), and intraoperative bradycardia (18.6% vs 12.6%; adjusted OR, 1.51; 95% CI, 1.19–1.92; P=0.001). No differences were observed in residual sedation, duration of PACU stay, postoperative pulmonary events, and length of hospital stay between the groups. Conclusion: This retrospective study suggested that intraoperative dexmedetomidine infusion was associated with a lower incidence of EA, rescue analgesia, and shivering in adults after lung surgery. Intraoperative bradycardia was the main side effect. Keywords: dexmedetomidine, emergence agitation, intraoperative administration, lung surgery, recovery profiles

There has been evidence of an association between patient outcomes and the number of surgeries performed at a hospital. To our knowledge, there are no Australian data on hospital cancer surgery volumes and patient outcomes. We evaluated the relationship between hospital non-small cell lung cancer (NSCLC) surgery volume and patient outcomes in Victoria.Patients with a primary diagnosis of NSCLC between 2008 and 2014 were identified in the Victorian Cancer Registry (n = 15,369), 3,420 (22%) of whom had lung cancer surgery. Primary outcome was death within 90 days of surgery and secondary outcomes included overall survival, use of postoperative ventilation and ≥24hours spent in ICU. Hospital volume was measured as the average number of lung surgeries performed per year, with quartiles Q1: 1-17, Q2: 18-34, Q3: 35-58 and Q4: 59 + .57% (1,941/3,420) lung cancer patients underwent lobectomy, 38% (1,299/3,420) sub-lobar resection and 5% (180/3,420) pneumonectomy. The overall 90-day mortality after lung surgery was 3.5%, and was 2.6% and 4.5% for patients undergoing lobectomy and sub-lobar resection respectively. There was no difference in 90-day mortality and overall survival between low- and high-volume centres regardless of procedure. Patients operated on in lower volume centres had more admissions to ICU ≥24hours (Q1. 55% vs. Q4. 11%, p-trend0.001). A higher proportion of patients attending private hospitals (19%) had an ASA score of 4 compared with patients attending a public hospital (9%).We observed no evidence of survival differences between lung cancer patients attending low- and high-volume hospitals for cancer surgery. A higher proportion of patients had an ICU admission ≥24hours in lower volume centres and there are a higher proportion of patients with an ASA score of 4 in private hospitals compared to public hospitals.