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Background: Prone positioning has become a standard therapy in acute respiratory distress syndrome to improve oxygenation and decrease mortality. However, little is known about prone positioning in lung transplant recipients. This large, singe-center analysis investigated whether prone positioning improves gas exchange after lung transplantation., Methods: Clinical data of 583 patients were analyzed. Prone position was considered in case of impaired gas exchange Pao 2 /fraction of oxygen in inhaled air (<250), signs of edema after lung transplantation, and/or evidence of reperfusion injury. Patients with hemodynamic instability or active bleeding were not proned. Impact of prone positioning (n = 165) on gas exchange, early outcome and survival were determined and compared with patients in supine positioning (n = 418)., Results: Patients in prone position were younger, more likely to have interstitial lung disease, and had a higher lung allocation score. Patients were proned for a median of 19 hours (interquartile range,15-26) hours). They had significantly lower Pao 2 /fraction of oxygen in inhaled air (227 ± 96 vs 303 ± 127 mm Hg, P = .004), and lower lung compliance (24.8 ± 9.1 mL/mbar vs 29.8 ± 9.7 mL/mbar, P < .001) immediately after lung transplantation. Both values significantly improved after prone positioning for 24 hours (Pao 2 /fraction of oxygen ratio: 331 ± 91 mm Hg; lung compliance: 31.7 ± 20.2 mL/mbar). Survival at 90 days was similar between the 2 groups (93% vs 96%, P = .105)., Conclusions: Prone positioning led to a significant improvement in lung compliance and oxygenation after lung transplantation. Prospective studies are needed to confirm the benefit of prone positioning in lung transplantation., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Tracheobronchial injury is a rare but potentially life-threatening condition. Various surgical treatment options have been described for symptomatic patients with full-thickness injury. However, studies comprising a meaningful number of patients are sparse., Methods: We retrospectively analyzed all patients who received surgical repair of tracheobronchial injury between January 1999 and May 2021 at the Department of Thoracic Surgery, Medical University of Vienna. Patient characteristics, surgical variables, postoperative morbidity, and mortality were retrieved and analyzed., Results: Fifty patients with a median age of 68 years (range, 17-88) were included in the analysis. The etiologies of the iatrogenic tracheobronchial injuries were emergency intubation (48%), elective percutaneous dilatation tracheostomy (38%), or elective intubation (14%). The most common location of tracheobronchial injuries was distal third (28%) with a median length of 50 mm (range, 20-100 mm). The surgical approach was cervicotomy in 52%, thoracotomy in 38%, sternotomy in 2%, and combined approaches in 8% of cases. Moreover, intraoperative venovenous (n = 4) or venoarterial (n = 2) extracorporeal membrane oxygenation support was required in 12% of cases. Procedure-related mortality was 0%. However, as patients with tracheobronchial injury usually have severe comorbidities, the rate of patients discharged alive from the intensive care unit was only 66%. The median follow-up period of discharged patients was 5.5 months (range, 0.7-209). Airway stenosis or dehiscence was not observed in any patient., Conclusions: Surgical repair of tracheobronchial injuries can be performed safely with a low procedure-related morbidity. If possible, the less-invasive cervical access should be preferred for patients with tracheobronchial injury, even for injuries extending to the main bronchi., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Completion pneumonectomy (CP) for second primary/primary lung cancer (SPLC) and local recurrence lung cancer (LRLC) is still controversial. Although several case series on such a practice exist, the oncological benefit is under debate. The purpose of this study was to review available literatures on CP for SPLC and LRLC and evaluate postoperative and long-term outcomes., Methods: MEDLINE, SCOPUS, and Web of Science were reviewed for eligible studies in January 2021. Studies were included if they indicated outcomes of patients with lung cancer undergoing CP. Overall survival (OS) was defined as the primary endpoint; secondary endpoints included operative morbidity and 30-day mortality. Random-effects meta-analysis based on a binomial distribution was used to create pooled estimates., Results: Thirty-two eligible studies including 1157 patients were identified. These studies were uniformly retrospective reports. Pooled estimates for 3-year and 5-year OS were 50.6% (95% confidence interval [CI], 34.7%-66.5%) and 38.9% (95% CI, 32.2%-46.1%) in SPLC patients. When the SPLC was a stage I tumor, pooled 5-year OS was favorable with 60.7% (95% CI, 43.2%-75.9%). In LRLC, pooled 3-year and 5-year OS were 47.6% (95% CI, 36.1%-59.4%) and 33.8% (95% CI, 26.8%-41.5%), respectively. Pooled morbidity and 30-day mortality was reported in 38.2% (95% CI, 32.0%-44.9%), and 10.0% (95% CI, 8.1%-12.3%), respectively., Conclusions: CP for SPLC and LRLC is a challenging procedure with significant perioperative morbimortality. However, published evidence indicates good long-term survival for selected patients. Further studies are needed to identify patient subgroups which benefit most from CP., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: Dual-lumen extracorporeal membrane oxygenation (ECMO) cannulation is considered technically challenging and harbors the risk of potential life-threatening complications during cannulation. Dual-lumen cannula insertion is performed under either ultrasound or fluoroscopy guidance. Both techniques have significant disadvantages, such as examiner dependence or the necessity for transportation of the patient from the intensive care unit to the operating room., Description: Digital, mobile x-ray devices provide a novel, examiner-independent imaging modality for bedside dual-lumen ECMO cannulation., Evaluation: From November 2019 to November 2021, 23 dual-lumen cannulations were performed in 20 patients at the Department of Thoracic Surgery, Medical University of Vienna. Twelve of 23 (52.2%) were inserted in the intensive care unit using a mobile x-ray device. The remaining patients (47.8%) were cannulated in the operating room with conventional fluoroscopy guidance. In none of the procedures did cardiovascular injuries occur. Insertion site bleeding was the most common ECMO-related complication (n = 2)., Conclusions: Dual-lumen cannulation using sequential x-rays can be performed safely. Especially for infectious patients or patients who require an awake ECMO, this technique overcomes disadvantages of established imaging modalities., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Lung transplantation is an established treatment for a variety of end-stage lung diseases; however, chest wall deformities such as an asymmetric pectus excavatum are often considered a contraindication for lung transplantation. Consequently, the published experience of lung transplants and simultaneous chest wall reconstruction is limited to a few case reports. This article aims to provide a detailed description of surgical steps as well as technical challenges and pitfalls of lung transplantation with a simultaneous modified Ravitch procedure. Exemplary technical aspects will be discussed for a pediatric patient in whom such a combined procedure resulted in an excellent outcome., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Airway management during repair of laryngotracheal stenosis is demanding, and there is currently no accepted standard of care. Recently an increasing number of airway centers have started to use a laryngeal mask until the airway is surgically exposed and cross-table ventilation can be initiated. However detailed data on this approach are missing in the literature., Methods: Patients receiving laryngotracheal surgery from November 2011 until October 2018 were retrospectively included in this single-center study, except for patients who presented with a preexisting tracheostomy at time of surgery. Airway management uniformly consisted of laryngeal mask ventilation until cross-table ventilation was established. Clinical variables, perioperative complications, and airway complications were analyzed., Results: One hundred eight patients (65 women, 43 men) receiving tracheal resection (n = 50), cricotracheal resection (n = 49), or single-stage laryngotracheal reconstruction (n = 9) were included in the analysis. Of the included patients 23 (21.3%) had malignant disease and 85 (78.7%) a benign pathology. In the subgroup of patients with subglottic disease 85.1% had high-grade stenosis (Myer-Cotton III°). Airway management with a laryngeal mask was successful in all except 1 patient (99.1%). Mean pulse oximetry and mean end-tidal CO 2 during laryngeal mask ventilation was 98.7% ± 2.4% and 34.8 ± 7.6 mm Hg, respectively. At the end of surgery 95 patients (88%) were successfully weaned from the respirator using the laryngeal mask., Conclusions: The laryngeal mask as the primary airway device is feasible and safe in patients undergoing laryngotracheal surgery even in cases with high-grade stenosis., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: Preoperative assessment of benign subglottic stenosis is usually performed by endoscopy and a computed tomography scan. Both diagnostic modalities have relevant limitations and sometimes an accurate assessment of the extent of disease is challenging., Description: Based on computed tomography scans of benign glotto-subglottic stenosis and a control airway, color-coded three-dimensional (3D) models were produced using a commercially available 3D printer. The diagnostic relevance of 3D models was tested by means of a quiz., Evaluation: 52 thoracic surgeons from 4 North American and 1 European institution with different levels of experience in airway surgery were invited to test the diagnostic accuracy of 3D models against endoscopy films and computed tomography scans. 3D models were found to be superior to the other two diagnostic tools in terms of grading the extent of the stenosis and selecting the correct surgical strategy. The group of residents benefited the most from the 3D models., Conclusions: 3D models of complex glotto-subglottic airway stenosis are a useful supplement of the preoperative assessment. In addition, they can serve as a teaching tool for residents and fellows., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

A 55-year-old woman was referred to our department with a bilateral stenosis of both main bronchi starting at the level of the carina and a blind-ended pouch originating from the carina. Differential diagnosis of diffuse narrowing of the intrathoracic central airways was excluded during the diagnostic workup. Recurrent infection of the blind-ended pouch remained a possible explanation of this unusual type of stenosis. Carinal resection and reconstruction by end-to-end anastomosis of the trachea to the right main bronchus and reimplantation of the left main bronchus to the intermediate bronchus with intraoperative extracorporeal membrane oxygen support resulted in an excellent long-term outcome., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Anastomotic failure is a rare but severe complication after airway surgery. A sufficient blood supply is crucial for the healing of the anastomosis. Currently, judging the appearance of the mucosa by conventional bronchoscopy is the only available technique to monitor the anastomosis. Near-infrared imaging using indocyanine green (ICG) as an intravasal fluorescent can be used to directly assess tissue perfusion. For technical reasons, bronchoscopic ICG angiography to evaluate blood supply of airway anastomosis was unavailable in the past. We sought to investigate the technical feasibility of ICG perfusion using a newly developed bronchoscopy unit with an integrated near-infrared filter to monitor perfusion during the healing of tracheal anastomosis., Methods: Twelve patients who underwent elective airway surgery were included in this prospective, single-center feasibility study. The ICG was administered intravenously at 0.2 mg/kg body weight at three timepoints: at the end of surgery; 3 to 5 days postoperatively; and 2 months postoperatively. A custom-made bronchoscopy unit (Karl Storz, Tuttlingen, Germany) was used to assess the anastomosis with white light and additionally with near-infrared light to monitor the distribution and intensity of the fluorescence signal., Results: A total of 32 ICG fluorescence bronchoscopies were performed in our study cohort. In all measurements, a sufficient fluorescence signal was detected. A lack of perfusion was detected in all patients confined to the anastomotic suture line immediately after the operation. This malperfusion resolved gradually after 3 to 5 days and disappeared completely after 2 months. No anastomotic complication developed in our series of patients during follow-up (median 7 months)., Conclusions: To the best of our knowledge, this is the first report on ICG fluorescence bronchoscopy in the literature. It is an easy and effective method to evaluate the perfusion at the tracheal anastomosis. In the future, it might contribute to an early detection of anastomotic failure and reduce morbidity and mortality after airway surgery., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Herein we report the case of a 60-year-old female patient who developed severe respiratory failure after right-sided pneumonectomy starting 2 hours after uneventful surgery. A computed tomographic scan revealed a completely congested left lower lobe. The underlying pathomechanism of this unique finding was a kinking effect of the left lower lobe vein over the descending aorta, caused by the shifting of the heart toward the right side. Even with immediate reintubation and aggressive ventilation it was impossible to stabilize the patient and therefore an extracorporal membrane oxygenation (ECMO) had to be implanted. The ECMO support and right-lateral and prone positioning of the patient markedly improved oxygenation. After a stabilization period of 2 days the ECMO could be removed and the patient was extubated on the ninth postoperative day. To the best of our knowledge, this is the first reported case of a unilobar edema caused by a transiently impaired venous drainage after pneumonectomy. The combination of immediate ECMO support together with right-lateral and prone positioning resulted in restoration and stabilization of the patient's cardiorespiratory function., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The human lung is considered a nonsterile organ, and surgical interventions therefore take place in a more or less contaminated operating field. Nevertheless, infectious complications of the pleural cavity are low after major lung resections. Antimicrobial peptides (AMPs) are part of the innate immunity and display a broad capacity to kill pathogens. We hypothesized that the pleural space must have a high natural antimicrobial barrier and that AMPs might effectively protect the pleural cavity., Methods: Pleural effusions were collected after lung operations. Antimicrobial activity of the fluids against gram-positive and gram-negative pathogens was analyzed by microdilution assays. AMPs were determined by enzyme-linked immunosorbent assay (ELISA), polymerase chain reaction (PCR), and immunohistochemical analysis. The impact of proinflammatory triggers on AMP release from pleural mesothelial cells was evaluated., Results: Antimicrobial activity assays revealed high bactericidal properties of postoperative pleural drainage fluids. They effectively killed gram-negative pathogens (Escherichia coli, Pseudomonas aeruginosa) as well as gram-positive pathogens (Staphylococcus aureus, Streptococcus pneumoniae, and Streptococcus pyogenes). A variety of AMPs was detected at constantly high concentrations in the pleural fluids. They mainly derived from leukocytes and pleural epithelium. Although proinflammatory cytokine levels were elevated in the postoperative pleural fluids, AMP expression could not be augmented by Toll-like receptor (TLR) triggering or by the proinflammatory cytokines interleukin (IL)-1β and tumor necrosis factor (TNF)α., Conclusions: We provide the first evidence of a high abundance of AMPs in postoperative pleural fluids. Our findings might explain the broad protection against infectious complications of the pleural space after major lung operations., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Pulmonary benign metastasizing leiomyomatosis (BML) is a rare smooth-muscle cell disorder of the lung. Most BML lesions stay constant in size for a long time. The prevailing treatment option is primary excision of the nodules or if unresectable, long-time hormone therapy. Herein, we present a case of BML in which a wait-and-see strategy after diagnosis was decided. Fourteen years later a routine chest roentgenogram revealed multiple bi-lobar BML lesions with a giant cyst filling the whole left lung cavity. We conclude that a wait-and-see procedure for BML is feasible, but primary resection of the BML tumor masses is preferable to avoid complications as described in our case.

Background: The secretion of heat shock protein (HSP) 27, HSP60, HSP70, HSP90alpha, 20S proteasome, and their correlations to proinflammatory cytokine interleukin-6 is unknown in patients undergoing on-pump versus off-pump coronary artery bypass graft (CABG) operation., Methods: Forty patients were included in this explorative study (on- versus off-pump CABG, each n = 20). Serum samples were obtained before and 30 minutes, 60 minutes, and 24 hours after CABG operation. Enzyme-linked immunosorbent assay technique was utilized to determine soluble HSP27, 60, 70, and 90alpha, 20S proteasome, and levels of interleukin-6., Results: Serum levels of HSP are increased in patients undergoing on-pump CABG operation as compared with off-pump CABG technique. These differences were highly significant for HSP27, 70, and 90alpha at 60 minutes after initiation of cardiopulmonary bypass (all, p < 0.001). Concentrations of soluble 20S proteasome were increased 24 hours after operation in on- and off-pump CABG patients (p < 0.001) and correlated significantly with the serum content of HSP 27, 70, and 90alpha at 60 minutes after initiation of cardiopulmonary bypass (p < 0.001). No correlation was found when comparing interleukin-6 levels with intravascular leakage of HSP and 20S proteasome after CABG operation., Conclusions: We conclude from our data that the innate immune system is activated owing to spillage of known immune modulatory and apoptosis-associated proteins after CABG operation.