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The evaluation of the use of laryngeal mask airways (LMA) as an alternative form of airway management for surgical tracheal reconstruction.A prospective case series.At a single German university hospital.Ten patients.The use of LMA for airway management in surgical reconstruction of the trachea.Ten patients with tracheal stenosis of 50% to 90% were enrolled prospectively during the study period. The airway management consisted of the insertion of an LMA. During resection and reconstruction, high-frequency jet ventilation was used. Several arterial blood gas analyses (ABG) were performed before, during, and after the tracheal resection and reconstruction. All values were presented as median and interquartile ranges or as absolute and relative values, and no emergency change to cross-field intubation was necessary. The lowest PaOThe use of LMA is an alternative option in airway management for tracheal reconstruction, even in patients with significant tracheal stenosis. Potential advantages compared to tracheal intubation are unimpaired access to the operative field and the lack of stress on the fresh anastomosis.

ZusammenfassungDurch den in Deutschland herrschenden demografischen Wandel verschiebt sich die Alterspyramide immer mehr nach oben. Als älter gilt laut WHO ein Mensch zwischen dem 61. und dem 75. Lebensjahr. Als alt werden Menschen ab 76 Jahren bezeichnet. Für die Beantwortung der Frage, ob und in welchem Ausmaß ein alter Patient aufgrund seiner Komorbiditäten thoraxchirurgisch operabel ist, gibt es bislang keine systematische Klassifizierung. In den meisten Fällen scheint für diese Entscheidung die Erfahrung und Einschätzung des Operateurs ausschlaggebend zu sein. Patienten und Methoden Die Datenanalyse erfolgte im Zeitraum von 01. 2016–01. 2018 anhand der Daten des Deutschen Thoraxregisters (Projekt-ID:2017–03), das unter der Schirmherrschaft der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) und der Deutschen Gesellschaft für Thoraxchirurgie (DGT) aufgebaut wurde. Insgesamt wurden 1357 Patienten eingeschlossen, von denen 658 ein histologisch nachgewiesenes Lungenkarzinom im Stadium I-II hatten. Diese wurden in drei Gruppen unterteilt; Gruppe I ( 75 Jahre).Wir konnten zeigen, dass Gruppe III, die der > 75-jährigen Patienten, im Wesentlichen keine erhöhten postoperativen Komplikationsraten hatten (Alle = 48,00 %; Gr. I = 40,90 %; Gr. II = 53,00 %; Gr. III = 52,90 %) und sogar bei einigen speziellen Komplikationen besser abschnitt, als die Gruppe der 65 bis ≤ 75-jährigen Patienten. (z. B. postoperative Pneumonie Gruppe II = 19,20 %, Gruppe III = 12,90 %).Die Mortalität lag bei den Patienten der Gruppen I–III, die in Zentren des Deutschen Thoraxregisters operiert wurden (Alle = 1,70 %, Gr. I = 1,90 %; Gr. II = 1,70 %; Gr. III = 1,30 %), insgesamt niedriger als im bundesdeutschen Durchschnitt (Alle = 1,99 %; Gr. I = 1,23 %; Gr. II = 2,18 %; Gr. III = 3,78 %). Insbesondere die alten Patienten der Gruppe III wiesen hierbei den größten Unterschied auf.Weiterhin konnten wir feststellen, dass im Gegensatz zu anderen deutschen Zentren und Kliniken, der größte Teil der anatomischen Resektionen in den Zentren des Deutschen Thoraxregisters minimalinvasiv per VATS (Video-assisted Thoracoscopic Surgery) durchgeführt wurde. Diskussion Auf Grundlage dieser Erhebungen stellte sich uns die Frage, ob die alten Patienten der Gruppe III (> 75jährigen) in Deutschland in der Regel einer leitliniengerechten Therapie zugeführt wurden. Zwar gibt es eine Selektion der Patienten in Gruppe III in den Zentren des Deutschen Thoraxregisters, dennoch ist unser Appell, dass nach Abwägung der individuellen Risiken und nach objektiven Kriterien auch diese Patientengruppe deutschlandweit der onkologischen Therapie der Wahl (Goldstandard) zugeführt werden sollte. Hierunter verstehen wir unbedingt die anatomische Resektion mit einem minimal invasiven Zugang per VATS. Das Risiko einer postoperativen Komplikation auf Grund des Alters darf nicht die alleinige Entscheidungsgrundlage gegen eine Resektion sein.

mp3 file (6.8 MB). In the inaugural edition of the Cancer Discovery podcast, Executive Editor Mark Landis talks with Matthew Meyerson about his paper, which describes the identification of the DDR2 kinase as a therapeutic target in squamous cell lung cancer.

XLSX file 75K, This is an excel file containing 9 sheets, one for each of the 9 supplementary tables (S1 to S9) mentioned in the main text

Supplementary Table 1 from Mutations in the DDR2 Kinase Gene Identify a Novel Therapeutic Target in Squamous Cell Lung Cancer

PDF file 234K, This is a file containing the list of supplementary tables, the list of supplementary figures, as well as the 7 supplementary figures (S1 to S7) and their correspondent legends, mentioned in the main text

Supplementary Figures 1-7 from Mutations in the DDR2 Kinase Gene Identify a Novel Therapeutic Target in Squamous Cell Lung Cancer

We discovered a novel somatic gene fusion, CD74–NRG1, by transcriptome sequencing of 25 lung adenocarcinomas of never smokers. By screening 102 lung adenocarcinomas negative for known oncogenic alterations, we found four additional fusion-positive tumors, all of which were of the invasive mucinous subtype. Mechanistically, CD74–NRG1 leads to extracellular expression of the EGF-like domain of NRG1 III-β3, thereby providing the ligand for ERBB2–ERBB3 receptor complexes. Accordingly, ERBB2 and ERBB3 expression was high in the index case, and expression of phospho-ERBB3 was specifically found in tumors bearing the fusion (P < 0.0001). Ectopic expression of CD74–NRG1 in lung cancer cell lines expressing ERBB2 and ERBB3 activated ERBB3 and the PI3K–AKT pathway, and led to increased colony formation in soft agar. Thus, CD74–NRG1 gene fusions are activating genomic alterations in invasive mucinous adenocarcinomas and may offer a therapeutic opportunity for a lung tumor subtype with, so far, no effective treatment.Significance: CD74–NRG1 fusions may represent a therapeutic opportunity for invasive mucinous lung adenocarcinomas, a tumor with no effective treatment that frequently presents with multifocal unresectable disease. Cancer Discov; 4(4); 415–22. ©2014 AACR.This article is highlighted in the In This Issue feature, p. 377

Supplementary Figure Legends 1-7 from Mutations in the DDR2 Kinase Gene Identify a Novel Therapeutic Target in Squamous Cell Lung Cancer

Supplementary Materials and Methods; Supplementary Tables S1-S3.

Purpose: Blood-based surrogate markers would be attractive biomarkers for early detection, diagnosis, prognosis, and prediction of therapeutic outcome in cancer. Disease-associated gene expression signatures in peripheral blood mononuclear cells (PBMC) have been described for several cancer types. However, RNA-stabilized whole blood–based technologies would be clinically more applicable and robust. We evaluated the applicability of whole blood–based gene expression profiling for the detection of non–small cell lung cancer (NSCLC).Experimental Design: Expression profiles were generated from PAXgene-stabilized blood samples from three independent groups consisting of NSCLC cases and controls (n = 77, 54, and 102), using the Illumina WG6-VS2 system.Results: Several genes are consistently differentially expressed in whole blood of NSCLC patients and controls. These expression profiles were used to build a diagnostic classifier for NSCLC, which was validated in an independent validation set of NSCLC patients (stages I–IV) and hospital-based controls. The area under the receiver operator curve was calculated to be 0.824 (P < 0.001). In a further independent dataset of stage I NSCLC patients and healthy controls the AUC was 0.977 (P < 0.001). Specificity of the classifier was validated by permutation analysis in both validation cohorts. Genes within the classifier are enriched in immune-associated genes and show specificity for NSCLC.Conclusions: Our results show that gene expression profiles of whole blood allow for detection of manifest NSCLC. These results prompt further development of gene expression–based biomarker tests in peripheral blood for the diagnosis and early detection of NSCLC. Clin Cancer Res; 17(10); 3360–7. ©2011 AACR.

OBJECTIVESThe objective of this single-centre, open, randomized control trial was to compare the patients’ satisfaction with local anaesthesia (LA) or general anaesthesia (GA) for video-assisted thoracoscopy.METHODSPatients with indication for video-assisted thoracoscopy pleural management, mediastinal biopsies or lung wedge resections were randomized for LA or GA. LA was administered along with no or mild sedation and no airway devices maintaining spontaneous breathing, and GA was administered along with double-lumen tube and one-lung ventilation. The primary end point was anaesthesia-related satisfaction according to psychometrically validated questionnaires. Patients not willing to be randomized could attend based on their desired anaesthesia, forming the preference arm.RESULTSFifty patients were allocated to LA and 57 patients to GA. Age, smoking habits and lung function were similarly distributed in both groups. There was no significant difference between the 2 groups with regard to patient satisfaction with anaesthesiology care (median 2.75 vs 2.75, P = 0.74), general perioperative care (2.50 vs 2.50, P = 0.57), recovery after surgery (2.00 vs 2.00, P = 0.16, 3-point Likert scales). Surgeons and anaesthesiologists alike were less satisfied with feasibility (P CONCLUSIONSPatients were equally satisfied with both types of anaesthesia, regardless of whether the type of anaesthesia was randomized or deliberately chosen. LA is as safe as GA but correlated with shorter length of stay. Almost all patients of the preference arm chose LA. Considering the benefits of LA, it should be offered to patients as an equivalent alternative to GA whenever medically appropriate and feasible.

Resistance to MET inhibition occurs inevitably in MET-dependent non-small cell lung cancer and the underlying mechanisms are insufficiently understood. We describe resistance mechanisms in patients with MET exon 14 skipping mutation (METΔPre- and post-treatment biopsies were analysed by NGS (next generation sequencing), digital droplet PCR (polymerase chain reaction), and FISH (fluorescense in situ hybridization). A patient-derived xenograft model was generated in one case.Of 26 patients with MET tyrosine kinase inhibitor treatment, eight had paired pre- and post-treatment biopsies (Three with MET amplification, three with METΔResistance to MET inhibition is heterogeneous with on- and off-target mechanisms occurring regardless of the initial MET aberration. Switching therapy between different types of kinase inhibitors can lead to repeated responses in cases with second-site mutations. Controlled clinical trials in this setting with larger patient numbers are needed, as evidence to date is limited to preclinical data and case series.

Background: Flexible bronchoscopy (FB) in analgosedation causes alveolar hypoventilation and hypercapnia, the more so if patients suffer from COPD. Nonetheless, neither is capnometry part of standard monitoring nor is there evidence on how long patients should be monitored after sedation. Objectives: We investigated the impact of COPD on hypercapnia during FB with endobronchial ultrasound (EBUS) in sedation and how the periprocedural monitoring should be adapted. Methods: Two cohorts of consecutive patients – with advanced and without COPD – with the indication for FB with EBUS-guided transbronchial needle aspiration in analgosedation received continuous transcutaneous capnometry (ptcCO2) before, during, and for 60 min after the sedation with midazolam and alfentanil. Main Results: Forty-six patients with advanced COPD and 44 without COPD were included. The mean examination time was 26 ± 9 min. Patients with advanced COPD had a higher peak ptcCO2 (53.7 ± 7.1 vs. 46.8 ± 4.8 mm Hg, p < 0.001) and mean ptcCO2 (49.5 ± 6.8 vs. 44.0 ± 4.4 mm Hg, p < 0.001). Thirty-six percent of all patients reached the maximum hypercapnia after FB in the recovery room (8 ± 11 min). Patients with COPD needed more time to recover to normocapnia (22 ± 24 vs. 7 ± 11 min, p < 0.001). They needed a nasopharyngeal tube more often (28 vs. 11%, p < 0.001). All patients recovered from hypercapnia within 60 min after FB. No intermittent ventilation manoeuvres were needed. Conclusion: A relevant proportion of patients reached their peak-pCO2 after the end of intervention. We recommend using capnometry at least for patients with known COPD. Flexible EBUS in analgosedation can be safely performed in patients with advanced COPD. For patients with advanced COPD, a postprocedural observation time of 60 min was sufficient.

Background and objectives It is unclear how much additional perioperative risk a sleeve lobectomy could pose in comparison to lobectomy. The objective of this analysis was to compare the complication rate, 30-day mortality, and overall survival between lobectomy and sleeve lobectomy without prior neoadjuvant treatment in non-small-cell lung cancer (NSCLC). Methods This is a retrospective study using our prospective database for quality assurance in our hospital. Inclusion criteria for our study was a completed lobectomy or sleeve lobectomy for primary treatment of NSCLC. Results In 506 patients, the tumor was treated by means of standard lobectomy. In 252 patients with central tumor localization, sleeve lobectomy was performed. Postoperative complications occurred in n:148 (29.24%) patients of the lobectomy group and in n = 76 (30.15%) of the sleeve group. The mortality rate difference between the two groups was statistically significant and favored the lobectomy group (0.78% vs. 4.76%, p = .007). Five year survival was 69.97% for the lobectomy and 65.59% for the sleeve group (p = .829). Conclusion Sleeve lobectomy for primary surgical treatment of NSCLC has comparable perioperative complications with lobectomy. Sleeve lobectomy does not seem to negatively influence survival. Postoperative mortality was higher in the sleeve group.

Summary Background Chest X‑ray (CXR) after thoracic surgery contributes to patient discomfort and costs and is of limited therapeutic value. Lung ultrasound (LU) for pneumothorax may be an alternative to CXR, but diagnostic accuracy data are heterogeneous and biased by insufficient sonographic technique and patient selection. Reported sensitivities range from 0.21 to 1.0. We evaluated the sensitivity of LU on the first day after thoracic surgery under routine conditions. Methods We performed a prospective observational study (trial-ID DRKS00014557). Consecutive patients undergoing lung resection received standardized LU in addition to routine CXR on the first postoperative day. Ultrasound examiner and radiologist were blinded to corresponding X‑ray and ultrasound findings. CXR was used as reference to determine diagnostic test performance of ultrasound. The conformity of sonography- and routine-based therapeutic decisions was evaluated. Results A total of 68 patients were examined. The mean duration of ultrasound was 145 ± 64 s. CXR identified 23 patients with pneumothorax with a mean apex-to-cupola size of 1.5 ± 1.0 cm. Ultrasound detected 18 patients with pneumothorax. The computed sensitivity of LU was 0.48 (95% confidence interval [0.36; 0.60]). Specificity was between 0.81 and 1.0, the negative predictive value 0.76 [0.66; 0.86]. The sensitivity of CXR was 0.56 [0.44; 0.68]. Air leakage via chest tube correlated weakly with CXR (spearman’s rho = 0.26) and moderately with LU (rho = 0.43). The conformity between sonographically based recommendations and the actual therapy based on routine diagnostics was 96%. Conclusions Sensitivity of ultrasound for pneumothorax detection nearly reached CXR and resulted in equally safe patient management. Our data can serve as a pilot study for upcoming larger-scaled controlled trials.

Cervical stenosis of the trachea caused by tracheotomy, tumor or induced by inflammatory disease can be treated by resection and anastomosis with good early and long-term results. Involvement of the ring cartilage makes the procedure technical demanding and increases the risk of morbidity. We describe our technique of laryngotracheal resection and reconstruction and compare the perioperative results with standard trachea resection. Between January 2005 and September 2018, we performed 92 standard cervical tracheal resections and 50 laryngotracheal resection including 6 procedures with widening of the ring cartilage. The resections were realized by direct anastomosis using dorsal flaps and/or interposition of rib cartilage in the posterior part of the ring cartilage. In one case intraoperative tracheotomy and intralaryngeal stenting was used. Patient records have been analyzed for perioperative data retrospectively. The main cause for stenosis or defect of the trachea and operation is preceding tracheotomy. Idiopathic stenosis, tumors and subglottic stenosis in Wegener disease are less common. Healing of the anastomosis was not disturbed in any patient. In two patients, bronchoscopic resection of granulation tissue was necessary. Tracheotomy in the course of treatment for intralaryngeal swelling or recurrent nerve palsy was necessary in 3 patients including one intraoperative tracheotomy for glottic stenting. Postoperative tracheostomy was closed in all patients within 3 months. Pulmonary complications and persistent recurrent nerve palsy occurred in 4 and 2 of the patients, respectively. Two patients died of pulmonary complications. The laryngotracheal resection is a relevant part of cervical tracheal surgery. It can be performed without significant elevated morbidity and is able to restore lung function and quality of voice.

Zusammenfassung Einleitung Brustwandresektionen für die Behandlung von malignen Erkrankungen benötigen häufig eine Rekonstruktion des Defektes. Wir berichten über unsere monozentrische, 8-jährige Erfahrung in Brustwandrekonstruktion mithilfe eines monofilen Polypropylennetzes. Ziel unserer retrospektiven Analyse war die Erkennung von materialbezogenen Komplikationen und der Vergleich mit der vorhandenen Literatur. Material und Methoden Einschlusskriterium in unserer retrospektiven Kohorte war eine Brustwandvollexzision und Rekonstruktion mittels Polypropylennetzes bei hauptsächlich onkologischem Indikationsspektrum (z. B. Sarkome, Metastasen, Lungenkarzinome mit Infiltration der Brustwand) im Zeitraum Januar 2008 bis Januar 2017. Primäre Endpunkte waren materialbezogene Komplikationen: lokale Infektion, Serom, Materialmigration, Netzexplantation und Brustwandinstabilität. Sekundäre Endpunkte waren folgende postoperative Komplikationen: Pneumonie, Acute respiratory Distress Syndrome (ARDS), Nachblutung und prolongierte postoperative Beatmung (> 24 h postoperativ). Ergebnisse In einem Zeitraum von 8 Jahren wurden insgesamt 202 Brustwandresektionen in unserer Klinik durchgeführt. Davon wurden 138 Defekte mithilfe eines Polypropylennetzes rekonstruiert. Mit einer Rate von 12,3% war die Pneumonie die häufigste postoperative Komplikation. In 5,7% der Fälle entwickelte sich ein Wundserom, das die Anlage einer Redon-Sogdrainage notwendig machte. In 3 Fällen (2,1%) wurde eine lokale Wundinfektion mikrobiologisch bestätigt. In einem dieser Fälle musste das Rekonstruktionsmaterial entfernt werden. Die 30-Tage-Mortalität betrug 1,4% mit 2 postoperativen Todesfällen. Eine Materialmigration oder Brustwandinstabilität mit paradoxem Atembewegungsmuster wurden in keinem Fall dokumentiert. Fazit Die Brustwandrekonstruktion mittels Polypropylen ist eine komplikationsarme Technik. Die hier aufgezeigte niedrige Rate an lokalen Infektionen, Materialexplantationen sowie Brustkorbinstabilität kann ein hilfreicher Entscheidungsfaktor für den operierenden Thoraxchirurgen auf der Suche nach dem geeigneten Rekonstruktionsmaterial sein.

Introduction Sleeve resection is an established oncological operative treatment for centrally located tumors with reduced complications compared to pneumonectomy. In cases of neoadjuvant chemoradiotherapy, the optimal timing of surgery for bronchial anastomotic healing has not been adequately explored. Materials and methods Between 2006 and 2017, 584 tracheobronchial sleeve resections were retrospectively analyzed. We selected all patients (n = 88) after sleeve lobectomy or sleeve bilobectomy for lung cancer with fully completed neoadjuvant chemoradiotherapy. Bronchial healing was assessed by bronchoscopy on the 7th postoperative day using our earlier published classification from grades 1 to 5. Results The median interval to surgery was 50 days (interquartile range 46-53, mean 50.03 ± 3.72). Mean anastomotic grade was 2.05 ± 1.03 and in 29.5% of the patients a critical anastomosis (grade ≥3) was documented. Anastomotic healing showed optimal results (bronchoscopic grade mean value: 1.5 ± 0.70) between the 6th and 8th postchemoradiotherapy week (P = .001). All patients operated before (bronchoscopic grade mean value: 2.3 ± 1.02) or after the above period (bronchoscopic grade mean value: 2.5 ± 1.15) had an increased ratio of anastomotic healing complications. Conclusion It is safer to perform sleeve-resections for non-small cell lung cancer after neoadjuvant trimodal treatment between the 6th and 8th week of completion of chemoradiotherapy.

Background Preoperative radiotherapy and/or chemotherapy of lung cancer in patients with locally advanced disease is an option in multimodal treatment. Sleeve lobectomy has an important part in decreasing complications and sparing lung function. We present our experience in a large cohort of patients after sleeve lobectomy with or without neoadjuvant treatment and standardized assessment of bronchial anastomotic healing. Methods The data used for this study were collected in a prospective database in our hospital. Anastomotic healing was documented by bronchoscopy on the seventh postoperative day and thereafter only when necessary, using a standardized scoring system. From 2006 to 2017, we performed 501 sleeve lobectomies representing 19% of all lung cancer resections. A total of 365 of patients had no preoperative treatment (73%), 41 had neoadjuvant chemotherapy (8%), and 95 had radiochemotherapy (19%). Results Using our scoring system of the bronchial anastomosis from 1 (excellent) to 5 (insufficient), we found the anastomosis was worse than grade 2 after no treatment, chemotherapy, or radiochemotherapy in 17%, 10%, and 30%, respectively (P = .002). The rate of anastomotic insufficiency was equally low after no pretreatment and chemotherapy (2.7% and 2.4%) and rose to 10.4% after radiotherapy (P = .002). Similarly, the risk for pulmonary complications was higher after radiochemotherapy (39%) compared with no pretreatment (29%) or chemotherapy (27%), respectively (P = .382). Conclusions Neoadjuvant radiotherapy is associated with worse wound healing of the anastomosis after sleeve lobectomy in lung cancer. There seems to be a higher risk for anastomotic insufficiency and complications.

OBJECTIVES Thoracic ultrasound is superior to chest X-ray for the detection of a pneumothorax in trauma and intensive care medicine. Data regarding its use in non-cardiac thoracic surgery are scarce and contradictory. Previous studies are heterogeneous regarding sonographic methodology and patient selection. This study aimed to evaluate the accuracy of thoracic ultrasound for pneumothorax assessment after lung resecting surgery in unselected patients. METHODS SONOR (SONOgraphy vs x-Ray) is a prospective observational trial (registry-ID DRKS00014557). A total of 123 consecutive patients with lung resecting surgery received a standardized thoracic ultrasound the same day and in addition to routine chest X-rays in erect position after removal of the chest tube. The sonographer was blinded to radiological findings and vice versa. RESULTS Sensitivity, specificity, positive and negative predictive values of ultrasound after removing the chest tube were 0.32, 0.85, 0.54, 0.69 for any pneumothorax and 1.0, 0.82, 0.19, 1.0 for pneumothorax ≥3 cm. No clinically relevant pneumothorax was missed. The agreement between sonography- and routine-based therapeutic decisions was 97%. Lung pulse was the most frequently detected sign to sonographically rule out a pneumothorax. CONCLUSIONS Postoperative thoracic ultrasound in unselected patients has a low overall sensitivity to detect a residual pneumothorax; however, its sensitivity and negative predictive values regarding clinically relevant pneumothorax are high. Test quality depends on the distinct sonographic methodology and patient selection. Anatomic differences in postsurgical and medical patients may be responsible for the contradictory results of previous trials. Studies with a larger population size are required to validate the accuracy of relevant pneumothoraces and identify appropriate selection criteria. Clinical trial registration number DRKS—German Clinical Trials Register, www.drks.de, registry-ID DRKS00014557.

Due to the demographic change prevailing in Germany, the age pyramid is shifting more and more upwards. According to the WHO, a patient over the age of 75 is considered to be old. Whether or not and to what extent an old patient can tolerate thoracic surgery purely based on his age and comorbidities remains unclear. Under most circumstances the surgeon's experience seems to be crucial in this decision. PATIENTS AND METHODS: The data analysis included data from 01. 2016-01. 2018 based on the German Thorax Register (Project ID: 2017-03), which was set up under the patronage of the German Society for Anesthesiology and Intensive Care Medicine (DGAI) and the German Society for Thoracic Surgery (DGT). A total of 1357 patients were included, 658 patients had histologically proven lung cancer stage I-II. These were divided into three groups according to their age; group I ( 65 years), group II (65- ≤ 75) years and group III ( 75 years). We were able to show that group III had essentially no increased postoperative complication rates (all = 48.00 %; group I = 40.90 %; group II = 53.00 %; group III = 52.90 %) and even performed better than group II (65 to ≤ 75) regarding pulmonary complications. (postoperative pneumonia group II = 19.20 %, group III = 12.90 %) The mortality was lowest in patients who were operated on in centers of the German Thorax Register (all = 1.70 %, group I = 1.90 %; group II = 1.70 %; group III = 1.30 %), compared to national german average. (all = 1.99 %; group I = 1.23 %; group II = 2.18 %; group III = 3.78 %) In particular, patients of group III showed the greatest difference. Furthermore, we saw that the majority of anatomical resections performed in centers of the German Thorax Register were resected by VATS (Video-assisted Thoracoscopic Surgery) as opposed to patients operated on in hospitals not affiliated with the German Thorax Register. DISCUSSION: Considering these results, the question arises whether in Germany all old patients were treated according to current guidelines. Although there is a certain selection bias in group III, operative candidates fit for surgery are operated in the centers of the German Thorax Register. Our results permit us to conclude that this group of patients should be given optimal surgical therapy when indicated. Age alone should not be the sole determining factor in decision-making regarding thoracic surgery.Durch den in Deutschland herrschenden demografischen Wandel verschiebt sich die Alterspyramide immer mehr nach oben. Als älter gilt laut WHO ein Mensch zwischen dem 61. und dem 75. Lebensjahr. Als alt werden Menschen ab 76 Jahren bezeichnet. Für die Beantwortung der Frage, ob und in welchem Ausmaß ein alter Patient aufgrund seiner Komorbiditäten thoraxchirurgisch operabel ist, gibt es bislang keine systematische Klassifizierung. In den meisten Fällen scheint für diese Entscheidung die Erfahrung und Einschätzung des Operateurs ausschlaggebend zu sein. PATIENTEN UND METHODEN: Die Datenanalyse erfolgte im Zeitraum von 01. 2016–01. 2018 anhand der Daten des Deutschen Thoraxregisters (Projekt-ID:2017–03), das unter der Schirmherrschaft der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) und der Deutschen Gesellschaft für Thoraxchirurgie (DGT) aufgebaut wurde. Insgesamt wurden 1357 Patienten eingeschlossen, von denen 658 ein histologisch nachgewiesenes Lungenkarzinom im Stadium I-II hatten. Diese wurden in drei Gruppen unterteilt; Gruppe I ( 65 Jahre), Gruppe II (65– ≤ 75 Jahre) und Gruppe III ( 75 Jahre).Wir konnten zeigen, dass Gruppe III, die der 75-jährigen Patienten, im Wesentlichen keine erhöhten postoperativen Komplikationsraten hatten (Alle = 48,00 %; Gr. I = 40,90 %; Gr. II = 53,00 %; Gr. III = 52,90 %) und sogar bei einigen speziellen Komplikationen besser abschnitt, als die Gruppe der 65 bis ≤ 75-jährigen Patienten. (z. B. postoperative Pneumonie Gruppe II = 19,20 %, Gruppe III = 12,90 %).Die Mortalität lag bei den Patienten der Gruppen I–III, die in Zentren des Deutschen Thoraxregisters operiert wurden (Alle = 1,70 %, Gr. I = 1,90 %; Gr. II = 1,70 %; Gr. III = 1,30 %), insgesamt niedriger als im bundesdeutschen Durchschnitt (Alle = 1,99 %; Gr. I = 1,23 %; Gr. II = 2,18 %; Gr. III = 3,78 %). Insbesondere die alten Patienten der Gruppe III wiesen hierbei den größten Unterschied auf.Weiterhin konnten wir feststellen, dass im Gegensatz zu anderen deutschen Zentren und Kliniken, der größte Teil der anatomischen Resektionen in den Zentren des Deutschen Thoraxregisters minimalinvasiv per VATS (Video-assisted Thoracoscopic Surgery) durchgeführt wurde. DISKUSSION: Auf Grundlage dieser Erhebungen stellte sich uns die Frage, ob die alten Patienten der Gruppe III ( 75jährigen) in Deutschland in der Regel einer leitliniengerechten Therapie zugeführt wurden. Zwar gibt es eine Selektion der Patienten in Gruppe III in den Zentren des Deutschen Thoraxregisters, dennoch ist unser Appell, dass nach Abwägung der individuellen Risiken und nach objektiven Kriterien auch diese Patientengruppe deutschlandweit der onkologischen Therapie der Wahl (Goldstandard) zugeführt werden sollte. Hierunter verstehen wir unbedingt die anatomische Resektion mit einem minimal invasiven Zugang per VATS. Das Risiko einer postoperativen Komplikation auf Grund des Alters darf nicht die alleinige Entscheidungsgrundlage gegen eine Resektion sein.

Background Unilateral diaphragmatic paralysis or paresis (UDP) in adults is an often overlooked disease which relevantly impairs the patient's lung function and quality of life. Particularly in idiopathic UDP, there is no evidence for conservative therapy and only little evidence for surgical therapy. Methods The method involves retrospective single-center analysis of patients with UDP persistent for at least 1 year who were operated by diaphragmatic resection, plication, and augmentation with a polypropylene mesh. The patients were tested for lung and diaphragmatic function, six-minute walk test (6MWT), and blood gas analysis before, 3 and 12 months after surgery. Results In total, 85 patients received surgery for UDP. The most frequent reasons for UDP were idiopathic (67%), iatrogenic (mainly cardiac and cervical spine surgery; 24%), and trauma (9%). The mean operation time was 84 ± 24 minutes, the length of hospital stay 8.4 ± 3.9 days, chest tubes were removed after 11.7 ± 4.1 days. Overall morbidity was 42%, mortality 0%. Forced expiratory volume in one second (FEV1) in supine position improved by 12.4% absolute, vital capacity by 11.8% absolute, and sniff nasal inspiratory pressure by 1.4 kPa 12 months after surgery (p Conclusion Surgical therapy for UDP is highly effective in the long term. The superiority over conservative treatments needs to be evaluated prospectively with standardized physiotherapeutic protocols. FEV1 in supine position and 6MWT are easy to perform tests and represent statistically and patient-relevant outcomes.

Background Patients undergoing bronchoscopy in spontaneous breathing are prone to hypoxaemia and hypercapnia. Sedation, airway obstruction, and lung diseases impair respiration and gas exchange. The restitution of normal respiration takes place in the recovery room. Nonetheless, there is no evidence on the necessary observation time. We systematically reviewed current guidelines on bronchoscopy regarding sedation, monitoring and recovery. Methods This review was registered at the PROSPERO database (CRD42020197476). MEDLINE and awmf.org were double-searched for official guidelines, recommendation or consensus statements on bronchoscopy from 2010 to 2020. The PICO-process focussed on adults (Patients), bronchoscopy with maintained spontaneous breathing (Interventions), and recommendations regarding the intra- and postprocedural monitoring and sedation (O). The guideline quality was graded. A catalogue of 54 questions was answered. Strength of recommendation and evidence levels were recorded for each recommendation. Results Six guidelines on general bronchoscopy and three expert statements on special bronchoscopic procedures were identified. Four guidelines were evidence-based. Most guidelines recommend sedation to improve the patient’s tolerance. Midazolam combined with an opioid is preferred. The standard monitoring consists of non-invasive blood pressure, and pulse oximetry, furthermore electrocardiogram in cardiac patients. Only one guideline discusses hypercapnia and capnometry, but without consensus. Two guidelines discuss a recovery time of two hours, but a recommendation was not given because of lack of evidence. Conclusion Evidence for most issues is low to moderate. Lung-diseased patients are not represented by current guidelines. Capnometry and recovery time lack evidence. More primary research in these fields is needed so that future guidelines may address these issues, too.

Zusammenfassung Einleitung Videothorakoskopische Eingriffe (VATS) bei erhaltener Spontanatmung erfahren vor dem Hintergrund älterer und multimorbider Patienten international eine zunehmende Verbreitung. Daten zur Anwendung und Akzeptanz in Deutschland liegen bisher nicht vor. Methode Deutschlandweite, onlinebasierte Umfrage an den bei der Deutschen Gesellschaft für Thoraxchirurgie (DGT) registrierten thoraxchirurgischen Abteilungen zur Anwendung der VATS in Lokalanästhesie (LA). Ergebnisse 101 von 157 angeschriebenen Kliniken haben geantwortet (64%). 42% der Befragten führen Non-intubated VATS (NIVATS) durch, 31% VATS in LA. Gründe, VATS in LA nicht durchzuführen, sind mangelnde Erfahrung (51%), Zweifel an der Durchführbarkeit (29%) und fehlende Indikationen (24%). Unter den durchführenden Kliniken sind die häufigsten Prozeduren Anlage von Pleuraverweilkathetern (94%), Pleuraprobeexzisionen (87%) und Pleurodesen (87%). 42% der Kliniken führen Keilresektionen und 10% auch anatomische Resektionen in LA durch. Hauptzielgruppen sind multimorbide Patienten (77%), ältere Patienten (65%), Patienten mit Angst vor einer Allgemeinanästhesie (55%) und mit vorbestehenden Lungenerkrankungen (52%). In 97% der Kliniken führt die Anästhesie die Sedierung durch. Als technische Schwierigkeiten werden vor allem mangelnde Übersicht (39%), Hyperkapnie (29%) und Panikattacken (23%) genannt. Schmerzen spielen eine untergeordnete Rolle (3%). Diskussion Rund ⅓ der befragen Kliniken führt bereits VATS in LA durch, weitere haben Pläne zur Einführung der Methode. Die Mehrheit der Befragten sieht als Hauptzielgruppen multimorbide, ältere und lungenerkrankte Patienten, weil sie weniger inflammatorische, respiratorische und neurologische Komplikationen erwartet.

Zusammenfassung Hintergrund Die hypertherme intrathorakale Chemotherapie (HITOC) wird bereits seit einigen Jahren in mehreren thoraxchirurgischen Kliniken angewendet. Diese Expertenempfehlung soll nun basierend auf der klinischen Erfahrung und der vorhandenen Literatur grundlegende Empfehlungen für eine standardisierte Durchführung der HITOC liefern. Material und Methode Im Zeitraum von Oktober bis Dezember 2018 wurden Empfehlungen zur Anwendung der HITOC in Deutschland durch eine Gruppe von Experten aus 5 thoraxchirurgischen Kliniken erarbeitet. Die Auswahl der Experten mit den meisten Operationen mit HITOC erfolgte anhand einer deutschlandweiten HITOC-Umfrage aus dem Jahr 2017. Die Empfehlungen basieren auf den klinischen Erfahrungen sowie wissenschaftlichen Arbeiten bzw. Daten der einzelnen Kliniken und einer aktuellen Literaturrecherche zur HITOC. Ergebnis Die Empfehlungen wurden durch alle 5 teilnehmenden Kliniken in einer Konsensusumfrage bewertet. Hieraus ergaben sich 6 Schwerpunkte mit insgesamt 17 Empfehlungen. Bei jeder Empfehlung wurde eine Konsensstärke in Prozent berechnet. Eine 100%ige Konsensstärke wurde bei der Nomenklatur (HITOC), der technischen Durchführung, dem Chemotherapeutikum, dem perioperativen Management, den Schutzmaßnahmen und den Indikationen erreicht. Als Basis-Chemotherapeutikum für die HITOC wird von allen Experten Cisplatin empfohlen, da hier die meisten klinischen Erfahrungen und Daten vorliegen. Die Dosierung von Cisplatin wird in mg/m2 Körperoberfläche (KOF) angegeben und sollte zwischen 150 und 175 mg/m2 KOF betragen. Die zusätzliche Angabe des Perfusionsvolumens (ca. 4 – 5 l) scheint für den intrathorakalen Konzentrationsgradienten eine Rolle zu spielen und sollte mit beachtet werden. Schlussfolgerung Diese Expertenempfehlungen zeigen eine standardisierte und einheitliche Durchführung der HITOC. Hierdurch sollen postoperative Komplikationen durch die HITOC vermindert und eine bessere Vergleichbarkeit der Ergebnisse ermöglicht werden.

Zusammenfassung Einleitung Zervikale Tracheastenosen als Folge von Tracheotomien oder Tumoren sowie idiopathischer Genese können in der Regel durch eine Tracheaquerresektion unterhalb des Ringknorpels dauerhaft geheilt werden. Im Falle einer Beteiligung des Ringknorpels erhöhen sich die Komplexität und das Risiko des Eingriffs. Wir berichten über die Technik der laryngotrachealen Resektion und Rekonstruktion und vergleichen in unserem eigenen Patientengut die Ergebnisse der zervikalen Tracheaquerresektion und der laryngotrachealen Resektion in Bezug auf ihre perioperativen Ergebnisse. Patienten und Methode In unserer Klinik wurden im Zeitraum von 01/2005 bis 12/2015 über 800 Tracheaeingriffe durchgeführt. Davon waren 111 zervikale Trachearesektionen mit 76 Tracheaquerresektionen und 35 laryngotracheale Resektionen. Die Resektion erfolgte immer mit primärer Anastomose ohne Anlage eines intraoperativen Tracheostomas oder einer intralaryngealen Schiene. Die perioperativen Daten wurden retrospektiv aus den Patientenakten erhoben. Ergebnisse Bei der Indikationsstellung überwiegt in beiden Gruppen die Stenose oder Defektbildung nach Tracheotomie, gefolgt von idiopathischer Stenose, Tumoren und Morbus Wegener. Es traten keine Wundheilungsstörungen an der Anastomose auf. Postoperative Tracheotomien waren mit 3 bzw. 2 Eingriffen nach Tracheaquer- bzw. laryngotrachealer Resektion selten notwendig. Pulmonale Komplikationen und die N. recurrens-Parese waren mit 5/4 und 2/2 Fällen in beiden Gruppen ähnlich häufig. Kein Patient musste mit einem definitiven Tracheostoma weiterleben. Es verstarb jeweils ein Patient im postoperativen Verlauf. Somit ergab sich kein signifikanter Unterschied in der Komplikationsrate zwischen den beiden Gruppen. Schlussfolgerung Die laryngotracheale Resektion ist ein relevanter Bestandteil der zervikalen Trachearesektion. Sie kann ohne signifikant erhöhte Morbidität durchgeführt werden und erhält so die pulmonale und Stimmfunktion des Patienten auch bei komplexen Stenosen mit Beteiligung des unteren Kehlkopfes.

Background The few existing studies on the accuracy of lung ultrasound in the detection of a postoperative pneumothorax after thoracic surgery differ in the sonographic technique and the inclusion criteria. Several conditions are considered unfavourable in the sonographic examination of the lung. We aim to test these conditions for their impact on the diagnostic accuracy of lung ultrasound. Methods We compared lung ultrasound and chest roentgenograms for the detection of a pneumothorax after lung-resecting surgery in two prospective trials (register ID DRKS00014557 and DRKS00020216). The ultrasound examiners and radiologists were blinded towards the corresponding findings. We performed posthoc subgroup analyses to determine the influence of various patient or surgery related conditions on the sensitivity and specificity of ultrasound in the detection of pneumothorax. Results We performed 340 examinations in 208 patients. The covariates were age, gender, body mass index, smoking status, severity of chronic obstructive pulmonary disease, previous ipsilateral operation or irradiation, thoracotomy, postoperative skin emphysema, indwelling chest tube and X-ray in supine position. In univariate analysis, an indwelling chest-tube was associated with a higher sensitivity (58%, p = 0.04), and a postoperative subcutaneous emphysema with a lower specificity (73% vs. 88%, p = 0.02). None of the other subgroups differed in sensitivity or specificity from the total population . Conclusions Most of the patient- or surgery related conditions usually considered unfavourable for lung ultrasound did not impair the sensitivity or specificity of lung ultrasound. Further studies should not excluce patients with these conditions, but test the accuracy under routine conditions. Trial registration DRKS, DRKS00014557, registered 06/09/2018, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00014557 and DRKS00020216, registered 03/12/2019, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00020216

Background: Diaphragmatic paralysis is a rare disorder and has multidisciplinary underlying conditions. Therefore, treatment options are sparse and even though there is a lack of information about the long-term effects, the number of surgical procedures rises continuously. Therefore, validations of the treatment options are urgently needed to avoid unnecessary procedures. Aims: The current study was aimed at developing the Diaphragmatic Paralysis Questionnaire (DPQ) as a specific tool to assess HRQL in patients with diaphragmatic paralysis. Methods: Potential topics for item development were listed as agreed by an expert panel of physician regularly diagnosing and treating patients with diaphragmatic paralysis. Topics were rated by patients who were untreated (N = 11) or who had already received diaphragmatic plication (N = 9). Items were built based on the relevant topics as rated by the patients. Items were rated on a 5-point-Likert-Scale ranging from “completely untrue” (1 point) to “always true” (5 points). The origin questionnaire was developed in German and was finally translated and transculturally adapted into different languages. Results: 20 patients were assessed for eligibility and all patients completed the protocol and were included in the final analysis. Out of 43 topics 21 topics were finally rated >/=0 and were subject for item building. Therefore, 51.2% of the items were not included into the final DPQ. Conclusion: The DPQ is a novel specific tool for the assessment of HRQL in patients suffering from diaphragm paralysis. The final version was professionally translated and will be available free of charge for scientific purposes.

Chest wall resection for malignant tumours is usually combined with reconstruction of the bony defect. We analysed our single centre, 8-year, experience using polypropylene mesh for chest wall reconstruction. The goal of our retrospective study was to identify material-related complications and to compare them with the existing literature.The inclusion criterion in our retrospective cohort was a full-thickness chest wall excision and reconstruction using a polypropylene mesh with a mainly oncological indication spectrum (e.g. sarcomas, metastases, lung carcinomas with infiltration of the chest wall) in the period from January 2008 to January 2017. Primary endpoints were material-related complications: local infection, seroma, material migration, mesh explantation and chest wall instability. Secondary endpoints were the following postoperative complications: pneumonia, acute respiratory distress syndrome (ARDS), postoperative bleeding and prolonged postoperative ventilation ( 24 h postoperatively).A total of 202 chest wall resections were performed in our clinic over a period of 8 years. Of these, 138 defects were reconstructed using a polypropylene mesh. Pneumonia was the most common postoperative complication at a rate of 12.3%. In 5.7% of the cases, a wound seroma developed that made it necessary to insert a Redon suction drain. Local wound infection was confirmed microbiologically in three cases (2.1%). In one of these cases, the reconstruction material had to be removed. The 30-day mortality rate was 1.4% with two postoperative deaths. Material migration or chest wall instability with a paradoxical pattern of breathing movement were not documented.Chest wall reconstruction using polypropylene mesh is a technique with low material-related complication rate. The low rate of local infections, material explantation, and chest instability documented in our cohort can be a helpful decision factor for the operating thoracic surgeon looking for the appropriate reconstruction material.Brustwandresektionen für die Behandlung von malignen Erkrankungen benötigen häufig eine Rekonstruktion des Defektes. Wir berichten über unsere monozentrische, 8-jährige Erfahrung in Brustwandrekonstruktion mithilfe eines monofilen Polypropylennetzes. Ziel unserer retrospektiven Analyse war die Erkennung von materialbezogenen Komplikationen und der Vergleich mit der vorhandenen Literatur.Einschlusskriterium in unserer retrospektiven Kohorte war eine Brustwandvollexzision und Rekonstruktion mittels Polypropylennetzes bei hauptsächlich onkologischem Indikationsspektrum (z. B. Sarkome, Metastasen, Lungenkarzinome mit Infiltration der Brustwand) im Zeitraum Januar 2008 bis Januar 2017. Primäre Endpunkte waren materialbezogene Komplikationen: lokale Infektion, Serom, Materialmigration, Netzexplantation und Brustwandinstabilität. Sekundäre Endpunkte waren folgende postoperative Komplikationen: Pneumonie, Acute respiratory Distress Syndrome (ARDS), Nachblutung und prolongierte postoperative Beatmung ( 24 h postoperativ).In einem Zeitraum von 8 Jahren wurden insgesamt 202 Brustwandresektionen in unserer Klinik durchgeführt. Davon wurden 138 Defekte mithilfe eines Polypropylennetzes rekonstruiert. Mit einer Rate von 12,3% war die Pneumonie die häufigste postoperative Komplikation. In 5,7% der Fälle entwickelte sich ein Wundserom, das die Anlage einer Redon-Sogdrainage notwendig machte. In 3 Fällen (2,1%) wurde eine lokale Wundinfektion mikrobiologisch bestätigt. In einem dieser Fälle musste das Rekonstruktionsmaterial entfernt werden. Die 30-Tage-Mortalität betrug 1,4% mit 2 postoperativen Todesfällen. Eine Materialmigration oder Brustwandinstabilität mit paradoxem Atembewegungsmuster wurden in keinem Fall dokumentiert.Die Brustwandrekonstruktion mittels Polypropylen ist eine komplikationsarme Technik. Die hier aufgezeigte niedrige Rate an lokalen Infektionen, Materialexplantationen sowie Brustkorbinstabilität kann ein hilfreicher Entscheidungsfaktor für den operierenden Thoraxchirurgen auf der Suche nach dem geeigneten Rekonstruktionsmaterial sein.

OBJECTIVES Measurement tools of health-related quality of life (HRQL) that are specific for the underlying disorder are inevitably needed to assess HRQL changes following specific treatment strategies. The aim of the current study was to develop a questionnaire assessing HRQL in patients with unilateral diaphragmatic paresis. METHODS Firstly, topics of health impairments covering physical, psychological, social and functional aspects were predefined by a physician expert panel to ensure face validity. Secondly, all predefined topics were rated by a patient group with unilateral diaphragmatic paresis (untreated: n = 11; postoperative: n = 9) using a 5-point Likert scale ranging from ‘not relevant at all’ (−2) to ‘absolutely relevant’ (+2) to guarantee content validity. Thirdly, only relevant topics (0 to +2) were used for item development, while non-relevant items ( RESULTS In total, 20 patients rated a total of 43 topics covering a broad spectrum of health impairment. 21 were considered as relevant for item development. Items are answered on a 5-point Likert scale ranging from ‘completely untrue’ (−2) to ‘always true’ (+2). The Diaphragmatic Paralysis Questionnaire (DPQ) Summary Score ranges from 0 (worst HRQL) to 100 (best HRQL). Finally, the German DPQ was professionally translated and transculturally adapted into English, Italian, Dutch, French, Greek and Spanish, using translation/back-translation procedures. CONCLUSIONS The DPQ is the first diseases-specific HRQL measure developed for patients with diaphragmatic paresis. In addition, the DPQ is available in 7 languages free of charge for non-profit purposes. Clinical trial registration German clinical trials register: DRKS00017056

Background In thoracic surgery, utilization of extracorporeal membrane oxygenation (ECMO) is mainly established for patients undergoing lung transplantation. The aim of our study was to summarize our single-center experience with intraoperative use of veno-venous- or veno-arterial-ECMO in patients undergoing complex lung surgery involving the main carina, or the left atrium or the descending aorta. Methods A total of 24 patients underwent combined complex lung, carinal, aortal, or left atrial resections. In cases of carinal resection, percutaneous veno-venous, jugular–femoral cannulation was considered suitable. For combined resection of lung and descending aorta, a percutaneous femoral veno-arterial cannulation was used. In cases of extended left atrial resection, a percutaneous jugular–femoral veno-venous-arterial cannulation was favored. Results Procedures were divided into three groups: carinal resections and reconstruction (n = 8), resections of the descending aorta and left lung (n = 7), resections of lung and left atrium (n = 9). No intraoperative complications occurred. Overall 30-day mortality was 25%. A complete resection was achieved in 18 patients. Median survival was 12 months. One- and 5-year survival were 48.1 and 22.7%, respectively. Conclusion The present study shows that intraoperative use of ECMO for extended carinal, aortic, or atrial resections is feasible with minimal intraoperative complications allowing surgeons increased operating-field safety. Perioperative mortality is high, but this is rather an attribute of local extended disease and patient comorbidities.

In Germany, 10,000 cases of spontaneous pneumothorax are treated inpatient every year. The German Society for Thoracic Surgery, in co-operation with the German Society for Pulmonology, the German Radiological Society, and the German Society of Internal Medicine has developed an S3 guideline on spontaneous pneumothorax and post-interventional pneumothorax moderated by the German Association of Scientific Medical Societies. Method: Based on the source guideline of the British Thoracic Society (2010) for spontaneous pneumothorax, a literature search on spontaneous pneumothorax was carried out from 2008 onwards, for post-interventional pneumothorax from 1960 onwards. Evidence levels according to the Oxford Center for Evidence-Based Medicine (2011) were assigned to the relevant studies found. Recommendations according to grade (A: “we recommend”/“we do not recommend,” B: “we suggest”/“we do not suggest”) were determined in 3 consensus conferences by the nominal group process. Results: The algorithms for primary and secondary pneumothorax differ in the indication for CT scan as well as in the indication for chest drainage application and video-assisted thoracic surgery. Indication for surgery is recommended individually taking into account the risk of recurrence, life circumstances, patient preferences, and procedure risks. For some forms of secondary pneumothorax, a reserved indication for surgery is recommended. Therapy of post-interventional spontaneous pneumothorax is similar to that of primary spontaneous pneumothorax. Discussion: The recommendations of the S3 Guideline provide assistance in managing spontaneous pneumothorax and post-interventional pneumothorax. Whether this will affect existing deviant diagnostic and therapeutic measures will be demonstrated by future epidemiological studies.

Background Supraglottic airway devices (SADs) may have advantages over endotracheal intubation for tracheal resection and reconstruction in cases of severe and proximally located subglottic stenosis. This retrospective case series examines the feasibility of using SADs as a novel approach to airway management in tracheal resections. Methods All patients who were managed with SADs for cervical tracheal resection and reconstruction during the study period (2010-2015) in our university hospital were included.To examine the feasibility of airway management with SADs for tracheal resection, medical records were obtained from our institution's electronic database and reviewed. Results SADs were used in 10 patients who had extensive tracheal stenosis and a high prevalence of severe comorbidities. SAD insertion and subsequent positive pressure ventilation were successful in all patients, although 1 patient with preoperative respiratory failure had persistent hypercarbia. During the phase of resection and reconstruction, high-frequency jet ventilation was used to ensure adequate oxygenation. There were no intraoperative complications related to anesthetic management, apart from transient hypercarbia during and after jet ventilation. Most patients (n = 6; 60%) had an uneventful postoperative course. In this high-risk cohort, postoperative complications (ie, vocal cord edema, postoperative hemorrhage, pneumonia) occurred in 4 patients (40%). Conclusions This retrospective case series demonstrates the feasibility of using supraglottic airways alongside high-frequency jet ventilation for airway management in at least some cases of cervical tracheal resection and reconstruction. However, the small number of cases examined limits conclusions regarding indications, contraindications, and periprocedural safety.

Zusammenfassung Einführung Nicht kleinzellige Lungenkarzinome (engl. non-small cell lung cancer = NSCLC) im Stadium III und ihre mögliche multimodale Therapie stellen eine Herausforderung für die behandelnden Onkologen, Thoraxchirurgen und Strahlentherapeuten dar. Ziel dieser retrospektiven Studie war die Analyse und Evaluation des Therapiealgorithmus unserer Klinik bei Patienten mit NSCLC im Stadium III (intention to treat). Es sollte ermittelt werden, ob sich ein aggressives Therapieregime mit primärer trimodaler Therapie (Hochdosisradiochemotherapie und Resektion) unabhängig von einem „multilevel“-N2- oder „single-level“-N3-Status: Diese Resultate wurden anschließend mit einem historischen Kollektiv unserer Patienten verglichen, die eine alleinige simultane Radio-/Chemotherapie erhielten (= bimodale Therapie). Material und Methoden 156 Patienten wurden in dem Erhebungszeitraum mit einem NSCLC Stadium III diagnostiziert und einer trimodalen Therapie zugeführt. Das mediane Alter war 71 Jahre, 103 Patienten (60%) waren männlich, 53 (34%) waren weiblich. In der Gruppe mit bimodaler Therapie konnten 102 Patienten ausgewertet werden. Ergebnisse Nach radiologischem Restaging und Überprüfung der funktionellen Resektabilität konnten 90 Patienten (57,7%) aus der trimodalen Therapiegruppe einer sekundären Resektion zugeführt werden. Hierbei wurden 37 (41,1%) Lobektomien/Bilobektomien, 37 (41,1%) Sleeve-Lobektomien, 13 (14,4%) Pneumonektomien und 3 (3,3%) Segmentektomien (bei schwerer lungenfunktioneller Einschränkung) durchgeführt. Das mediane Überleben in der trimodalen Therapiegruppe betrug 535 Tage, in der bimodalen Therapiegruppe hingegen 388 Tage, der Unterschied war statistisch nicht signifikant (p = 0,1377). Abschließend wurde eine Analyse der 5-Jahres-Überlebensrate nach tatsächlicher Therapie durchgeführt („as-treated trimodally“ vs. „as-treated bimodally“). Hier betrug das mediane Überleben 807 Tage für Patienten, die eine trimodale Therapie erhielten, 427 Tage für Patienten die eine bimodale Therapie erhielten. Schlussfolgerung Eine hochdosierte neoadjuvante Radiochemotherapie gefolgt von einer sekundären Resektion stellt weiterhin eine wertvolle Option für selektionierte Patienten in der Behandlung des NSCLC im Stadium III dar. Diese retrospektive Analyse konnte jedoch einen statistisch signifikanten Überlebensvorteil für die „intention-to-treat-trimodally“-Patienten nicht nachweisen.

ZusammenfassungDie Erhebung klinischer Behandlungsdaten in Registerdatenbanken hat seit Jahren einen hohen Stellenwert in der Versorgungsforschung. Hierdurch kann bspw. eine kritische Prüfung der Sicherheit, Wirksamkeit und Wirtschaftlichkeit klinischer Behandlungskonzepte an großen Untersuchungskollektiven erfolgen. Die erhobenen Erkenntnisse aus der Registerforschung entsprechen der tatsächlichen Patientenklientel und dem Versorgungsalltag der teilnehmenden Kliniken. Sie sind nicht durch strenge Einschlusskriterien oder realitätsferne Rahmenbedingungen klinischer prospektiver Studien beschränkt. Durch die Implementierung des Deutschen Thoraxregisters wurde erstmalig die Möglichkeit geschaffen, die interdisziplinäre Betreuung (Thoraxchirurgie, Anästhesiologie, Intensivmedizin, Schmerztherapie) von Patienten mit operativen Eingriffen am Thorax ganzheitlich in einer Datenbank zu erfassen und auszuwerten. Unter der Schirmherrschaft der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) und der Deutschen Gesellschaft für Thoraxchirurgie (DGT) wurde ein ursprünglich rein thoraxchirurgisches Register des Klinikums der Universität Witten/Herdecke-Köln in enger Kooperation mit dem Universitätsklinikum Freiburg erweitert. Nach Ausarbeitung eines umfangreichen Datenschutzkonzepts und Abschluss der Pilotphase wurde das Deutsche Thoraxregister als erstes perioperatives, interdisziplinäres Behandlungsregister im Januar 2016 offiziell implementiert. Neben der reinen Registerforschung, profitieren die teilnehmenden Kliniken vor allem durch die „benchmarking“-Funktionen. Das „benchmarking“, also der Vergleich der Behandlungsqualität verschiedener Kliniken, erlaubt es, individuelle Profile, Stärken und Schwächen im nationalen Vergleich zu identifizieren und eigene Fortschritte über mehrere Jahre zu verfolgen. Das Eingabe- und Benchmarkportal ist jederzeit online verfügbar (www.thoraxregister.de). Seit Oktober 2016 wurde das Teilnehmerspektrum erweitert, sodass sämtliche Kliniken mit mindestens 50 thoraxchirurgischen Eingriffen im Jahr teilnahmeberechtigt sind.