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Background: Pleurectomy and decortication (PD) in malignant pleural mesothelioma has a high morbidity mostly associated with aspiration pneumonia (PNA), deep vein thrombosis (DVT), and foreign catheter sepsis. We instituted four strategies to reduce these complications and report our experience. Methods: This was a retrospective review of patients who underwent PD at the University of Pennsylvania between 2015 and 2022. Our patients underwent standard of care PD in addition to tracheostomy and gastrostomy/jejunostomy tube with therapeutic anticoagulation (AC) leading up to surgery. Measured outcomes were postoperative PNA, DVT, and sepsis. The predicted risk of those same outcomes had patients not undergone the interventions was calculated based on the American College of Surgeons (ACS) surgical risk calculator (SRC). A McNemar's test was used to determine whether the risk of having PNA, DVT and sepsis differed between the two subgroups. Results: Fifty‐five patients were included in the study. The mean age was 70 years (SD 6.2) with a mean of 21 (SD 19) pack‐years of smoking. PNA, DVT, and catheter‐related sepsis occurred in 12, four, and seven patients, respectively. Upon using the ACS SRC prediction model of the nonintervention group, PNA, DVT and catheter related sepsis was predicted to occur in 24 (paired data OR 5, 95% CI: 1.4–17.2; McNemar's test p = 0.008), 14 (paired data OR 3.5, 95% CI: 1.15–10.6; McNemar's test p = 0.03), and 17 (paired OR 3, 95% CI: 1.09–8.3; McNemar's test p = 0.04) patients, respectively. Discussion: Patients undergoing tracheostomy creation, therapeutic AC at the time of diagnosis, and gastrostomy tube placement had a reduced risk of aspiration PNA, DVT, and catheter sepsis. [ABSTRACT FROM AUTHOR]

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Introduction: In this study, we wanted to investigate the role of pleural fluid cytology, which is examined for the second and third times in malignant pleural fluid cases that cannot be diagnosed by first pleural fluid cytology. Methods: A total of 116 patients were evaluated in this retrospective study. 2nd samplings of pleural effusions were evaluated via thoracentesis in 105 patients (90.51%)with negative cytology results on the first thoracentesis attempt, and 3rd samplings were evaluated for 34 patients (29.31%). Pleural biopsy using a cope needle was performed on patients who could not be diagnosed upon pleural fluid cytology. If pleural biopsy did not yield any diagnosis, VATS (video assisted thoracoscopy) was performed, and pleural decortication was performed in some patients who could not be diagnosed with VATS. Pleural fluid cytology results suspected to be malignant were considered to be negative and the same procedure was performed as above. Results: 7 out of the 116 cases (6.03%) were found to be cytologically positive on the first thoracentesis. Out of the cases found to be negative on first attempt, 29 (26.6%) were diagnosed positive upon second attempt. 34 cases which were not diagnosed at first and second attempt underwent a third thoracentesis attempt and were evaluated cytologically. Out of the 34 cases, 11 (32%) were diagnosed in the 3rd attempt. A total of 47 cases (40.5%) were diagnosed with pleural fluid cytology. In the presence of primary lung cancer, the rate of diagnosis by 2nd fluid cytology was statistically significant compared to other types of malignancy (p<0.05). Discussion and Conclusion: In cases with negative pleural fluid cytology at the first examination, examination of fluid cytology for the second and third times should be considered with a high contribution to the diagnosis, especially in patients who are unable to apply more invasive diagnostic methods. [ABSTRACT FROM AUTHOR]

Purpose: Among non-small cell lung cancers (NSCLC), 5 years is a benchmark in cancer control and treatment, but a certain percentage of cases recur after 5 years. The long-term post-recurrence outcomes remain controversial. To examine the accurate prognostic factors associated with survival and cancer recurrence among 5-year survivors, a landmark analysis that considered competing risks was performed., Methods: Complete resection of NSCLC was performed in 2482 patients between January 2003 and December 2015. A total of 1431 patients were 5-year survivors without recurrence. A landmark time analysis was applied to the overall survival (OS) and recurrence-free survival (RFS) from 5 years after surgery, and the findings were calculated using the Kaplan-Meier method. The cumulative incidence of cause-specific death and recurrence was estimated using the cumulative incidence function, while carefully considering the competing risks., Results: Postoperative recurrence was detected in 732 patients, of whom 68 (9.3%) had recurrence after 5 years. The median follow-up period was 8.2 years. In the competing risk analysis, the independent poor prognostic factors associated with cause-specific death were age ≥ 75 years, lymph node metastasis and pleural invasion., Conclusions: Patients requiring a follow-up for > 5 years were aged ≥ 75 years and had either lymph node metastasis or pleural invasion., (© 2024. The Author(s) under exclusive licence to Springer Nature Singapore Pte Ltd.)

Background: Information regarding late recurrence after pulmonary resection for non-small cell lung cancer (NSCLC) is limited. This study aimed to analyze the risk factors for late recurrence after surgery for NSCLC in the current era., Patients and Methods: We conducted a retrospective study of patients who underwent complete resection for pathological I-III NSCLC between 2006 and 2015. Late recurrence was defined as a recurrence that met the following conditions: (1) the patient underwent chest computed tomography (CT) at or after 54 months after surgery and recurrence was not detected at that time, and (2) recurrence that occurred more than 5 years after surgery. The factors influencing late recurrence, relapse-free survival (RFS), and overall survival (OS) after surgery were analyzed., Results: A total of 1275 with 5-year relapse-free survival after surgery were enrolled in this study. The mean age of the patients was 66.4 years and 54% of the patients were men. The median interval between surgery and the latest follow-up examination was 98 months. In total, 35 patients (2.7%) experienced late recurrence and 138 patients have died thus far. The cumulative recurrence, RFS, and OS rates at 10 years were 3.9%, 84.9%, and 86.3%, respectively. A multivariate analysis revealed that pleural invasion was an independent risk factor for late recurrence. Pleural invasion was a poor prognostic factor for both RFS and OS., Conclusions: Pleural invasion was a predictor of late recurrence. Age > 67 years, preoperative serum carcinoembryonic antigen (CEA) > 5 ng/ml, non-adenocarcinoma, and pleural invasion were poor prognostic factors for RFS., (© 2024. Society of Surgical Oncology.)

Background: The role of the number of involved structures (NIS) in thymic epithelial tumors (TETs) has been investigated for inclusion in future staging systems, but large cohort results still are missing. This study aimed to analyze the prognostic role of NIS for patients included in the European Society of Thoracic Surgeons (ESTS) thymic database who underwent surgical resection., Methods: Clinical and pathologic data of patients from the ESTS thymic database who underwent surgery for TET from January 2000 to July 2019 with infiltration of surrounding structures were reviewed and analyzed. Patients' clinical data, tumor characteristics, and NIS were collected and correlated with CSS using Kaplan-Meier curves. The log-rank test was used to assess differences between subgroups. A multivariable model was built using logistic regression analysis., Results: The final analysis was performed on 303 patients. Histology showed thymoma for 216 patients (71.3%) and NET/thymic carcinoma [TC]) for 87 patients (28.7%). The most frequently infiltrated structures were the pleura (198 cases, 65.3%) and the pericardium in (185 cases, 61.1%), whereas lung was involved in 96 cases (31.7%), great vessels in 74 cases (24.4%), and the phrenic nerve in 31 cases (10.2%). Multiple structures (range, 2-7) were involved in 183 cases (60.4%). Recurrence resulted in the death of 46 patients. The CSS mortality rate was 89% at 5 years and 82% at 10 years. In the univariable analysis, the favorable prognostic factors were neoadjuvant therapy, Masaoka stage 3, absence of metastases, absence of myasthenia gravis, complete resection, thymoma histology, and no more than two NIS. Patients with more than two NIS presented with a significantly worse CSS than patients with no more than two NIS (CSS 5- and 10-year rates: 9.5% and 83.5% vs 93.2% and 91.2%, respectively; p = 0.04). The negative independent prognostic factors confirmed by the multivariable analysis were incomplete resection (hazard ratio [HR] 2.543; 95% confidence interval [CI] 1.010-6.407; p = 0.048) and more than two NIS (HR 1.395; 95% CI 1.021-1.905; p = 0.036)., Conclusions: The study showed that more than two involved structures are a negative independent prognostic factor in infiltrative thymic epithelial tumors that could be used for prognostic stratification., (© 2024. Society of Surgical Oncology.)

Background: Solitary fibrous tumor of the pleura (SFTP) is a rare mesenchymal tumor that arises at various sites and typically originates from the pleura. Most patients with SFTPs are asymptomatic, unless the tumor is large. Approximately 20% of SFTP cases are malignant. There are few reports on imaging diagnoses and interventional treatments of SFTP. Here, we report a case of a giant SFTP that exhibited malignant behavior and underwent successful resection after embolization of the main supply artery of the tumor.Case Presentation: We report a clinical case of a giant SFTP in a 66-year-old Chinese female patient complaining of chest tightness and cough for more than 2 months. Ten years ago, the patient had undergone a chest CT scan at a local hospital for cough. Computed tomography (CT) had revealed a mass in the right thoracic region, which was misdiagnosed as a pulmonary abscess by CT-guided biopsy. Therefore, the patient did not receive appropriate/complete treatment at that time. She was hospitalized again, because CT showed significant enlargement of the right thoracic mass, which caused her obvious symptoms of discomfort. The pathological results of CT-guided biopsy at our hospital confirmed SFTP. Considering the large size of the tumor and the rich blood supply, some of the main blood vessels were treated with embolization before surgical resection. A large tumor, about 23 cm × 16 cm × 15 cm in size, was then successfully removed by thoracic surgery. The diagnosis of malignant SFTP was confirmed by surgical pathology and immunohistochemistry.Conclusion: Imaging findings of SFTPs are not characteristic, especially when a tumor is large, the diagnosis is difficult, and the final diagnosis still depends on histological and immunohistochemical examinations. The two-stage surgical treatment described here, which involves first embolization of the main supplying artery of the large tumor and then complete surgical resection, is effective and safe for SFTPs. Whether needle biopsy or vascular embolization is performed, intervention plays a crucial role in the diagnosis and treatment of patients with SFTPs. [ABSTRACT FROM AUTHOR]

Background: Pleural biopsies for investigating the causes of pleurisy are performed through modalities including needle biopsies, local anesthetic thoracoscopic procedures, and surgery (video‐assisted thoracoscopic surgery and open thoracotomy). To date, there have been no large‐scale nationwide epidemiological studies regarding pleurisy diagnosed via surgical pleural biopsy. This study examined the epidemiology of pleurisy diagnosed via surgical pleural biopsy in a Japanese nationwide administrative database. Methods: We evaluated Japanese Diagnosis Procedure Combination data of 24 173 patients who underwent video‐assisted thoracoscopic surgery or open thoracotomy and received a diagnosis of pleurisy between April 2014 and March 2020. In addition to pleurisy diagnoses, the patients' clinical information, including age, sex, smoking status (pack‐years), dyspnea grade, length of in‐hospital stay, and comorbidities, were extracted from the dataset. Results: This study included data from 1699 patients. The most frequent causes of pleurisy were neoplastic diseases (55.9%; malignant mesothelioma 22.5%, lung cancer 15.7%, lymphoma 2.5%), followed by infectious diseases (24.0%; tuberculosis 16.2%, parapneumonic pleural effusion 3.6%, empyema 3.5%, nontuberculous mycobacteriosis 0.5%), collagen vascular diseases (2.8%; rheumatoid arthritis 1.3%, immunoglobulin G4‐related diseases 0.7%, systemic lupus erythematosus 0.3%), and paragonimiasis (0.1%). Conclusions: Neoplastic diseases, including malignant mesothelioma and lung cancer, were frequently and accurately diagnosed as pleurisy via surgical pleural biopsy. The next leading cause was infectious diseases such as mycobacterial infections. Physicians should consider performing surgical biopsy in light of the knowledge regarding the etiology of pleurisy when a definitive diagnosis cannot be made via needle pleural biopsy. [ABSTRACT FROM AUTHOR]

To carry out a dosimetric comparison and constraints feasibility proof of adjuvant radiotherapy through helical tomotherapy or volumetric modulated arc therapy (VMAT) for malignant pleural mesothelioma patients after pleurectomy/decortication. Retrospective calculations were carried out on previously acquired simulations. A whole-pleura volume with 50.4 Gy in 28 fractions was prescribed, simulating a no residual tumour situation. Calculations were carried out using an anisotropic analytical algorithm with a 2.0 mm grid. Beam-on time, planning target volume (PTV) coverage, homogeneity index and organ at risk exposure were compared. Sixteen patient plans were calculated per device. Constraints were met overall by both modalities. For helical tomotherapy and VMAT plans, median beam-on times were 13.8 (11.6–16.1) min and 6.4 (6.1–7.0) min; P = 0.006. The median left-sided radiotherapy PTV D 98 were 48.1 (48.0–48.8) Gy and 47.6 (46.5–48.3) Gy; P = 0.023. No significant difference for right-sided radiotherapy was found. PTV D 2 for left-sided radiotherapy was higher with VMAT (P = 0.014). For right-sided radiotherapy, helical tomotherapy showed higher doses (P = 0.039). No homogeneity index differences for left-sided radiotherapy (P = 1.00) and right-sided radiotherapy (P = 0.598) were seen. Significant organ at risk exposure differences were found on left-sided radiotherapy whole-lung V 20, as well as D 50 (both P = 0.008). Higher contralateral lung and ipsilateral kidney exposures were found with VMAT plans for both treatment sides. Adjuvant radiotherapy after pleurectomy/decortication in malignant pleural mesothelioma patients, with a VMAT- or helical tomotherapy-based platform, is dosimetrically feasible. Lung sparing was mostly improved with helical tomotherapy. Technique selection must be carried out according to availability and clinical criteria. • To compare helical tomotherapy and VMAT plans for adjuvant pleural mesothelioma radiotherapy. • Beam-on times are greatly shortened with VMAT. • Target coverage is equivalent with both modalities. • Overall organ at risk sparing could be slightly improved under helical tomotherapy delivery. [ABSTRACT FROM AUTHOR]

Objective: Pleural effusion (PE) is a common pathological condition that can occur during the clinical course of many diseases. This study aimed to retrospectively evaluate the clinical features and treatment results of patients with pleural fluid drainage due to PE. Methods: A retrospective analysis was performed in the study with 103 patients between January 2020 and March 2021, who had pleural drainage due to PE. The posteroanterior and lateral chest radiographs were evaluated. Results: A total of 103 patients were included in the study, with an overall mean age of 62.5 years minimum: 24, maximum: 91 years. Most patients had three or more comorbid diseases (n=53, 51.5%). The majority of patients had drainage using a pleural catheter (n=97, 94.2%). Cytological examination of the pleural fluid revealed malignancy in 5 (4.9%) patients, whereas 89 (86.4%) were discharged during follow-up, and 14 (13.6%) had mortality. In the patients who died, more fluid with exudate characteristics at a level close to statistical significance was detected. Malignant cells were detected in the pleural fluid in 10% of patients with primary malignant cases (n=50), whereas no malignant cell was found in the pleural fluid of patients without malignancy diagnosis (n=53), with a statistically significant difference between patients with and without malignancy. The total length of hospital stay was significantly higher in patients undergoing a second surgical procedure. Conclusion: Patients undergoing pleural fluid drainage had at least one systemic disease. The most common systemic disease in patients was a cardiac disease, followed by malignant disease. "No malignant cells were detected in the fluids of patients without primary malignancy," in the cytology. In addition, the rate of second pleural surgery is high in PE cases, which further prolongs the length of hospitalization of these patients. [ABSTRACT FROM AUTHOR]

Background: The role of surgery in pleural mesothelioma remains controversial. It may be appropriate in highly selected patients as part of a multimodality treatment including chemotherapy. Recent years have seen a shift from extrapleural pleuropneumonectomy toward extended pleurectomy/decortication. The most optimal sequence of surgery and chemotherapy remains unknown., Methods: EORTC-1205-LCG was a multicentric, noncomparative phase 2 trial, 1:1 randomising between immediate (arm A) and deferred surgery (arm B), followed or preceded by chemotherapy. Eligible patients (Eastern Cooperative Oncology Group 0-1) had treatment-naïve, borderline resectable T1-3 N0-1 M0 mesothelioma of any histology. Primary outcome was rate of success at 20 weeks, a composite end-point including 1) successfully completing both treatments within 20 weeks; 2) being alive with no signs of progressive disease; and 3) no residual grade 3-4 toxicity. Secondary end-points were toxicity, overall survival, progression-free survival and process indicators of surgical quality., Findings: 69 patients were included in this trial. 56 (81%) patients completed three cycles of chemotherapy and 58 (84%) patients underwent surgery. Of the 64 patients in the primary analysis, 21 out of 30 patients in arm A (70.0%; 80% CI 56.8-81.0%) and 17 out of 34 patients (50.0%; 80% CI 37.8-62.2%) in arm B reached the statistical end-point for rate of success. Median progression-free survival and overall survival were 10.8 (95% CI 8.5-17.2) months and 27.1 (95% CI 22.6-64.3) months in arm A, and 8.0 (95% CI 7.2-21.9) months and 33.8 (95% CI 23.8-44.6) months in arm B. Macroscopic complete resection was obtained in 82.8% of patients. 30- and 90-day mortality were both 1.7%. No new safety signals were found, but treatment-related morbidity was high., Interpretation: EORTC 1205 did not succeed in selecting a preferred sequence of pre- or post-operative chemotherapy. Either procedure is feasible with a low mortality, albeit consistent morbidity. A shared informed decision between surgeon and patient remains essential., Competing Interests: Conflict of interest: The authors have no potential conflicts of interest to disclose., (Copyright ©The authors 2024.)

Background: Extended pleurectomy decortication for complete macroscopic resection for pleural mesothelioma has never been evaluated in a randomised trial. The aim of this study was to compare outcomes after extended pleurectomy decortication plus chemotherapy versus chemotherapy alone., Methods: MARS 2 was a phase 3, national, multicentre, open-label, parallel two-group, pragmatic, superiority randomised controlled trial conducted in the UK. The trial took place across 26 hospitals (21 recruiting only, one surgical only, and four recruiting and surgical). Following two cycles of chemotherapy, eligible participants with pleural mesothelioma were randomly assigned (1:1) to surgery and chemotherapy or chemotherapy alone using a secure web-based system. Individuals aged 16 years or older with resectable pleural mesothelioma and adequate organ and lung function were eligible for inclusion. Participants in the chemotherapy only group received two to four further cycles of chemotherapy, and participants in the surgery and chemotherapy group received pleurectomy decortication or extended pleurectomy decortication, followed by two to four further cycles of chemotherapy. It was not possible to mask allocation because the intervention was a major surgical procedure. The primary outcome was overall survival, defined as time from randomisation to death from any cause. Analyses were done on the intention-to-treat population for all outcomes, unless specified. This study is registered with ClinicalTrials.gov, NCT02040272, and is closed to new participants., Findings: Between June 19, 2015, and Jan 21, 2021, of 1030 assessed for eligibility, 335 participants were randomly assigned (169 to surgery and chemotherapy, and 166 to chemotherapy alone). 291 (87%) participants were men and 44 (13%) women, and 288 (86%) were diagnosed with epithelioid mesothelioma. At a median follow-up of 22·4 months (IQR 11·3-30·8), median survival was shorter in the surgery and chemotherapy group (19·3 months [IQR 10·0-33·7]) than in the chemotherapy alone group (24·8 months [IQR 12·6-37·4]), and the difference in restricted mean survival time at 2 years was -1·9 months (95% CI -3·4 to -0·3, p=0·019). There were 318 serious adverse events (grade ≥3) in the surgery group and 169 in the chemotherapy group (incidence rate ratio 3·6 [95% CI 2·3 to 5·5], p<0·0001), with increased incidence of cardiac (30 vs 12; 3·01 [1·13 to 8·02]) and respiratory (84 vs 34; 2·62 [1·58 to 4·33]) disorders, infection (124 vs 53; 2·13 [1·36 to 3·33]), and additional surgical or medical procedures (15 vs eight; 2·41 [1·04 to 5·57]) in the surgery group., Interpretation: Extended pleurectomy decortication was associated with worse survival to 2 years, and more serious adverse events for individuals with resectable pleural mesothelioma, compared with chemotherapy alone., Funding: National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (15/188/31), Cancer Research UK Feasibility Studies Project Grant (A15895)., Competing Interests: Declaration of interests EL reports grants from Boehringer Ingelheim, Medela, Johnson & Johnson/Ethicon, Covidien/Medtronic, Guardant Health, Takeda, Lilly Oncology, and Bayer, paid to his institution, his company, or personally; consulting fees from BeiGene, Roche, and BMS; honoraria from Medela; two patents (P52435GB and P57988GB) issued to Imperial Innovations; and being founder of My Cancer Companion, Healthcare Companion. SP reports consulting fees from AnHeart Therapeutics, Amgen, AstraZeneca, Bayer, Blueprint, BMS, Boehringer Ingelheim, Ellipses, EQRx, Daiichi Sankyo, GSK, Guardant Health, IO Biotech, Janssen, Lilly, Merck Serono, Mirati, MSD, Novocure, Novartis, PharmaMar, Roche, Takeda, Pfizer, Pierre Fabre, and Turning Point Therapeutics; honoraria from AstraZeneca, Bayer, Guardant Health, Janssen, Merck Serono, Roche, and Takeda; fees for expert testimony from Roche and Merck Serono; support for meeting attendance from Janssen, Roche, and Gilead; and being a member of the British Thoracic Oncology Group, ALK Positive UK, Lung Cancer Europe, Ruth Strauss Foundation, Mesothelioma Applied Research Foundation, and ETOP-IBCSG Partners Foundation Board. NT reports honoraria from BMS. DF reports grants from Astex Therapeutics, Boehringer Ingelheim, Bayer Oncology, Bergen Bio, GSK, MSD, Owkin, Roche, and RS Oncology paid to his institution; consulting fees from MSD, Cambridge Clinical Laboratories, and RS Oncology; honoraria from BMS, BI, MSD, Ikena, and Owkin; and meeting support from RS Oncology and MSD, all paid to Thoracic Oncology Services where he is director. RCR reports research funding from Cancer Research UK, Asthma and Lung UK, June Hancock Mesothelioma Research Fund, Mick Knighton Mesothelioma Research Fund, and Mesobank; and participation on an advisory board for the UK Lung Cancer Coalition. PT reports honoraria from AstraZeneca. LC-S reports support for meeting attendance from Lilly. RC reports honoraria from AstraZeneca, MSD, Takeda, Janssen, Roche, and GSK; support for meeting attendance from Takeda and Janssen; participation on advisory boards for GSK, Takeda, Janssen, Pharmamar, and Amgen; and stock options with TCC and Supportive Care UK. YS reports honoraria from Amgen, AstraZeneca, AbbVie, BMS, MSD, Lilly, Roche, and Takeda; and support for meeting attendance from Takeda and Roche. ZT reports honoraria from AstraZeneca. RS reports honoraria and support for meeting attendance from Lilly and BMS. EF reports membership of the National Lung Cancer and Mesothelioma Clinical Experts Group and Northern Cancer Alliance Targeted Lung Health Check Clinical Lead. All other authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Competing Interests: FG reports consulting fees and support for attending meetings or travel from MSD, Novocure, Bristol Myers Squibb, Boehringer Ingelheim, PharmaMar, Novartis, and Pierre Fabre; payment or honoraria for lectures, presentations, speakers' bureaus, manuscript writing, or educational events from Novocure; and participation on a data safety monitoring board or advisory board for MSD, Novocure, Bristol Myers Squibb, PharmaMar, Novartis, and Pierre Fabre. LC reports support for attending meetings or travel from Pierre Fabre. AC-F reports payment or honoraria for lectures, presentations, speakers' bureaus, manuscript writing, or educational events from Amgen, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Daichii Sankyo, Foundation Medicine, Janssen, Medscape, MSD, Roche/Genentech, and Takeda; support for attending meetings or travel from Amgen; being President of the Lung Working Group for the Swiss Society for Clinical Cancer Research; and receipt of institutional grants and research support from Amgen, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, MSD, and Roche/Genentech.

Introduction: Extrapleural pneumonectomy (EPP) and extended pleurectomy/decortication (ePD) are surgical cytoreductive techniques aimed at achieving macroscopic resection in malignant pleural tumours such as pleural mesothelioma, non-mesothelioma pleural malignancies such as thymoma and sarcoma, and rarely for pleural tuberculosis, in a more limited fashion. Despite extensive studies on both surgical techniques and consequences, a significant knowledge gap remains regarding how best to approach the perioperative anaesthesia challenges for EPP and ePD.It is unknown if the risk stratification processes for such surgeries are standardised or what types of functional and dynamic cardiac and pulmonary tests are employed preoperatively to assist in the perioperative risk stratification. Further, it is unknown whether the types of anaesthesia and analgesia techniques employed, and the types of haemodynamic monitoring tools used, impact on outcomes. It is also unknown whether individualised haemodynamic protocols are used to guide the rational use of fluids, vasoactive drugs and inotropes.Finally, there is a dearth of evidence regarding how best to monitor these patients postoperatively or what the most effective enhanced recovery protocols are to best mitigate postoperative complications and accelerate hospital discharge. To increase our knowledge of the perioperative and anaesthetic treatment for patients undergoing EPP/ePD, this scoping review attempts to synthesise the literature and identify these knowledge gaps., Methods and Analysis: This scoping review will be conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Review Protocols methodology. Electronic databases, OVID Medline, EMBASE and the Cochrane Library, will be systematically searched for relevant literature corresponding to EPP or ePD and perioperative or anaesthetic management. Data will be analysed and summarised descriptively and organised according to the three perioperative stages: preoperative, intraoperative and postoperative factors in clinical care., Ethics and Dissemination: Ethics approval was not required. The findings will be disseminated through professional networks, conference presentations and publications in scientific journals., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Extended pleurectomy-decortication is a cytoreductive surgical treatment for malignant pleural mesothelioma. Prolonged air leak remains a major postoperative challenge, lengthening hospital stay and increasing morbidity. In this video report, we present a stepwise approach for visceral decortication and introduce the concept of aerostasis by construction of an artificial neopleura. Our results suggest that improved aerostasis results in shortened air leak duration., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Recent prospective trials have demonstrated the noninferiority of segmentectomy to lobectomy in the surgical management of early non-small cell lung cancer (NSCLC). It remains unknown, however, whether segmentectomy is sufficient for treating small tumors with visceral pleural invasion (VPI), a known indicator of aggressive disease biology and poor prognosis in NSCLC., Methods: Patients in the National Cancer Database (2010-2020) with cT1a-bN0M0 NSCLC and VPI and additional high-risk features who underwent segmentectomy or lobectomy were identified for analysis. Only patients with no comorbidities were included in this analysis to reduce selection bias. Overall survival of patients who underwent segmentectomy vs lobectomy was evaluated using multivariable-adjusted Cox proportional hazards and propensity score- matched analyses. Short-term and pathologic outcomes were also evaluated., Results: Of the 2568 patients with cT1a-bN0M0 NSCLC and VPI included in our overall cohort, 178 (7%) underwent segmentectomy and 2390 (93%) underwent lobectomy. No significant differences were found in the 5-year overall survival between patients undergoing segmentectomy vs lobectomy in multivariable-adjusted and propensity score-matched analyses (adjusted hazard ratio, 0.91 [95% CI, 0.55-1.51], P = .72; 86% [95% CI, 75%-92%] vs 76% [95% CI, 65%-84%], P = .15, respectively). There were also no differences in surgical margin positivity, 30-day readmission, and 30- and 90-day mortality between patients undergoing either surgical approach., Conclusions: In this national analysis, no differences were found in survival or in short-term outcomes between patients undergoing segmentectomy vs lobectomy for early-stage NSCLC with VPI. Our findings suggest that if VPI is detected after segmentectomy for cT1a-bN0M0 tumors, completion lobectomy is unlikely to confer an additional survival advantage., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: To evaluate optimal settings of probe size, freezing time, and distance to the pleura that influence the size and quality of biopsy specimens during transbronchial lung cryobiopsies in ESPD., Methods: We prospectively recruited 17 patients undergoing lung transplantation. We created a nonperfused ex vivo bronchoscopy setting to perform multiple cryobiopsies with different probe sizes (1.7, 1.9, and 2.4 mm), freezing times (3, 5, 7, 10, 20, 30 seconds), and probe distance from pleura (5, 10, and 20 mm). Alveolated pulmonary parenchyma area≥50% in histology was considered a good quality biopsy, with a minimum procedural artifact. We used logistic regression to identify independent parameters as risk factors for histologic adequacy., Results: A total of 545 cryobiopsies were obtained from 34 explanted lungs after pneumonectomy for lung transplantation. The mean maximum diameter of the specimen achieved with the 1.7 probe was larger (13.5 mm) than those obtained with 1.9 and 2.4 mm probes (11.3 and 10.7 mm, P= 0.07). More pleural macroscopic damage and pleural tissue in histology occurred with the 2.4 mm probe ( P <0.001). There was no difference in the quality of specimens between the different freezing times and the distance from the pleura., Conclusions: Freezing time and distance from the pleura did not affect the histologic quality for diagnosing ESPD in severely damaged lungs. Smaller cryoprobe size did not negatively affect sample adequacy., Competing Interests: Disclosure: M.L. is the Chief Medical Officer of Endocision Inc. The remaining authors declare no conflict of interest or other disclosures., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Peritoneal mesothelial cysts have been reported under various terms, including benign cystic mesothelioma, usually in the form of case reports/series, whereas extraperitoneal cases are rarely reported. Our objective was to report the detailed characteristics of cystic lesions of the serosal cavities.Methods: We retrospectively examined the clinicopathologic findings of a series of mesothelial cystic lesions (n = 79).Results: Most cases (n = 68, 86%) concerned the peritoneum, whereas 11 (14%) concerned the pericardium. No pleural cases were found. A total of 51 (64.5%) lesions were solitary, whereas 28 (35.5%) were multiple. Peritoneal lesions harbored a plump eosinophilic mesothelium and a loose connective stroma, whereas pericardial lesions showed a cuboidal/flattened mesothelium, collagenous stroma, intense inflammation, and other tissue types, like adipose and muscle tissue. Solitary peritoneal lesions are usually extrapelvic and found in older patients incidentally during other surgeries, whereas multiple lesions are found in younger patients and usually in the pelvis. The lesions show a benign clinical course with rare recurrences but no malignant transformation.Conclusions: Most mesothelial cysts are peritoneal and rarely pericardial. Peritoneal cysts differ from pericardial cysts. Peritoneal solitary lesions differ from multiple lesions, also suggesting their pathogenetic differences. [ABSTRACT FROM AUTHOR]

A woman in her 30s, non-smoker, presented at the emergency department two times because of spontaneous pneumothorax. The first episode was treated with small bore catheter drainage, while during the second episode-occurring only 1 week later-thoracoscopic talcage was attempted. The postoperative course was characterised by slow clinical and radiological resolution, and recurrence 3 days after discharge. Eventually, multiportal video-assisted thoracoscopic exploration identified an interfissural solid mass. Resection and further work-up revealed the diagnosis of 'low-risk' solitary fibrous tumour (SFT) stage pT1N0M0. The interdisciplinary tumour board advised no adjuvant therapy. A CT thorax was scheduled in 1 year for follow-up. The patient was discharged without complications and has had no recurrences of pneumothorax at 6 months of follow-up. This report shows that SFT can easily be missed on initial presentation and should be considered in the differential diagnosis of pneumothorax, especially when frequently recurring., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Development of mesothelioma is associated with asbestos exposure. Common presentations are with pleural-based plaques invading the chest wall and/or pleural effusion on chest imaging. The intent of this case report is to describe a rare presentation of mesothelioma, which presented atypically as a large tension pneumothorax. A 93-year-old male presented with a history of dyspnea that started after a coughing episode. On physical examination he was hemodynamically stable, but was hypoxic requiring 2L of supplemental oxygen. Computed tomography of the chest revealed a large right tension pneumothorax. A chest tube was placed and connected to suction (-20cmH 2 0), but he continued to have an unresolving air leak over the following 2-week period. Upon video-assisted thoracotomy there were no blebs or adhesions seen. Right apical wedge resection and talc pleurodesis were performed. Pathologic examination revealed an atypical mesothelial cell proliferation with minimal, focal invasion into the pulmonary parenchyma. Tumor spread along the visceral pleura was thought to be the underlying cause of the pneumothorax. The surgical margins were uninvolved by the tumor, and the patient was later discharged home in stable condition. This was a rare presentation of what could best be described as minimally invasive mesothelioma arising in a background of probable mesothelioma in situ, which presented atypically as a large tension pneumothorax. This case highlighted the importance of establishing a pathologic diagnosis from pleural effusion cytology and/or pleural biopsy in persons presenting with spontaneous pneumothorax, and the difficulty in confirming a pathologic diagnosis of early mesothelial neoplasia., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Intrathoracic esophagogastric anastomosis following minimally invasive Ivor-Lewis esophagectomy is a technically demanding surgical technique that can result in serious intrathoracic infections when anastomotic leakage occurs. Herein, we report a novel side-overlap esophagogastric anastomosis with pleural closure for esophagogastric junction cancer., Methods: The 3 key points of our novel technique were the following: (1) overlap esophagogastric anastomosis and closure of the entry hole were all performed using a linear stapler; (2) the pleura was closed to separate the anastomotic site from the thoracic cavity; and (3) the mediastinal drain was inserted transhiatally from the abdominal cavity., Results: This modified anastomosis procedure was performed on 8 consecutive patients at our institution. The median overall/thoracoscopic operating time and estimated blood loss were 652.5/241.5 min and 89 mL, respectively. No mortality or serious postoperative complications occurred, and the median postoperative hospital stay was 22 days (range, 17 to 37 d)., Conclusion: This novel thoracoscopic overlap esophagogastric reconstruction procedure with pleural closure is safe and feasible., Competing Interests: The author declares no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Aim: data study on the results of treatment of acute non-specific purulent-destructive pleura diseases with the purpose of further improvement of its results on the basis of improvement of diagnostics, identification of factors of disease prognosis and by implementing differential tactics of surgical treatment with the use of minimally invasive interventions., Patients and Methods: Materials and Methods: We have studied modern literary sources on the topic of current trends in the treatment of acute pleural empyema and its complications. The studied material is summarized and presented in the form of a literature review in this article., Conclusion: Conclusions: These issues cannot be considered to be completely solved and require further study. Everything mentioned above dictates the search of new effective methods of the treatment of the mentioned pathology and proves the relevance of the theme. The outlined information highlights the necessity of improvement of surgical tactics in patients with pleural empyema.

Background: The internal mammary artery is the vessel of choice for myocardial revascularisation during coronary artery bypass grafting (CABG). Although it is possible to harvest the left internal mammary artery (LIMA) without opening the left pleura, pleurotomy is usually performed to provide adequate exposure and allow the placement of the LIMA medial to the upper lobe, preventing any undue tension on the mammary pedicle. However, the intact pleura technique may have a lower risk of postoperative pulmonary complications. We aimed to study the effects of both procedures on pulmonary function and the incidence of complications.Method: One hundred patients with ischaemic heart disease indicated for CABG were included and divided into two groups. The closed pleural technique group included 50 patients with preservation of the pleural integrity during mammary harvesting. The open pleural procedure group included 50 patients without preservation of pleural integrity. Spirometry was done pre- and postoperatively in both groups and postoperative pulmonary complications in both groups were recorded and analysed.Results: Internal mammary harvesting with preservation of pleural integrity during CABG in patients in the closed pleural procedure group showed significant improvement in forced expiratory volume in the first second (FEV1%), forced vital capacity (FVC%), and FEV1/FVC compared with the corresponding values in patients in the open pleural procedure group, on day 5 postoperatively, at discharge, and at day 30. There were fewer complications in preservation of pleural integrity with regard to lung atelectasis and pleural effusion, which were significantly lower in patients in the open pleural procedure group.Conclusions: Preservation of pleural integrity has beneficial effects on pulmonary function and has fewer associated pulmonary complications. [ABSTRACT FROM AUTHOR]

Background: Primary Spontaneous Pneumothorax (PSP) is considered an absolute and definitive contraindication for scuba diving and professional flying, unless bilateral surgical pleurectomy is performed. Only then is there a sufficiently low risk of recurrence to allow a waiver for flying and/or diving.Case Presentation: A young fit male patient who suffered a PSP 6 years ago, and underwent an uncomplicated videoscopic surgical pleurectomy, presented with a complete collapse of the lung on the initial PSP side. Microscopic examination of biopsies showed a slightly inflamed tissue but otherwise normal mesothelial cells, compatible with newly formed pleura.Conclusions: Even with pleurectomy, in this patient, residual mesothelial cells seem to have had the capacity to create a completely new pleura and pleural space. The most appropriate surgical technique for prevention of PSP may still be debated. [ABSTRACT FROM AUTHOR]

The management of late-stage empyema thoracis requires surgical intervention. We performed a retrospective descriptive analysis of open pleural decortication for late stage empyema thoracis in 55 children (age ≤ 15 years; median age = 6 years; age range = 1-15 years; 40 [72.7%] boys) over 42 months. The median time to thoracotomy from the onset of symptoms was 24 days, and the median duration of hospital stay before and after surgery was 15 and 4 days, respectively. Three (5.5%) patients had necrotising pneumonia, requiring debridement; 4 (7.3%) patients had superficial surgical site infection; 12 (21.8%) patients had perioperative pus culture positive for bacteria; and 3 (5.5%) patients had tubercular aetiology. There was no operative mortality. At median follow-up of 18 months, all patients are in good general health. Open pleural decortication leads to rapid resolution of symptoms and reduces hospital stay in paediatric late-stage empyema thoracis. [ABSTRACT FROM AUTHOR]

Introduction: Parietal pleurectomy with bullectomy has been established as an effective method for preventing the recurrence of primary spontaneous pneumothorax (PSP). Our center introduced enhanced technical measures in uniportal thoracoscopic parietal pleurectomy with bullectomy for patients with PSP, aiming to document our initial experience and assess the procedure's effectiveness in preventing the recurrence of PSP., Methods: We analyzed the clinical data of 86 patients with PSP who underwent the improved uniportal thoracoscopic parietal pleurectomy with bullectomy between July 2019 and August 2022. During the procedure, the parietal pleura above the second intercostal space was stripped but not removed. Instead, it was retained in the thoracic cavity using a piece of pedunculated pleura. Subsequently, the stumps of the lung were covered by the preserved parietal pleura., Results: The results of the study showed that the mean operative time was 59.87 ± 16.93 min, and the postoperative drainage duration averaged 3.94 ± 2.17 days. The mean intraoperative blood loss was 24.33 ± 48.91 ml, and the mean postoperative drainage volume was 289.00 ± 170.03 ml. Prolonged air leakage for more than 5 days was observed in five patients (5.81%), but no other postoperative complications were recorded. During the follow-up, one patient (1.16%) experienced a recurrence of pneumothorax., Conclusions: The perioperative results of bullectomy with the improved pleurectomy technique are deemed satisfactory. The various technical steps attempted at our center are found to be feasible and safe, and they may contribute to reducing the rates of recurrence in PSP., (© 2023 The Authors. The Clinical Respiratory Journal published by John Wiley & Sons Ltd.)

Backgrounds: Solitary fibrous tumor of the pleura (SFTP) is a rare thoracic tumor and usually asymptomatic. Massive SFTP may affect adjacent organs and tissues including pulmonary vasculature, bronchus and heart. A thoracotomy for massive SFTP is necessary in severe case. Therefore, it is important for anesthesiologists to understand the condition of patients with massive SFTP and develop an appropriate anesthetic management strategy. A 76-year-old woman with massive SFTP presented to our clinical center and was evaluated as requiring thoracotomy. She received multidisciplinary cooperation treatment from the radiology, cardiac, thoracic surgery and anesthetic teams. The perioperative management of anesthesiologists played a crucial role in the great prognosis of this woman., Conclusions: This case report demonstrates the importance of comprehensive and meticulous perioperative management and provides guidance to the multidisciplinary team on the potential risk and the rational treatment strategy of patients with massive SFTP during the perioperative period., (© 2023. BioMed Central Ltd., part of Springer Nature.)

In routine practice, one lung ventilation (OLV) is initiated upon pleural opening. We conducted a randomized controlled trial to compare lung collapse after preemptive OLV versus conventional OLV in thoracoscopic surgery. A total of 67 patients were enrolled (34 with conventional OLV; 33 with preemptive OLV). Preemptive OLV was conducted by closing the DLT lumen to the non‐ventilated lung immediately upon assuming the lateral position with the distal port closed to the atmosphere until pleural opening (>6 minutes in all cases). Lung collapse was assessed at 1, 5, 10, 20, 30 and 40 minutes after pleural opening using a 10‐point rating scale (10: complete collapse). The primary end point was the duration from pleural opening to satisfactory lung collapse (score of 8). Secondary end points included PaO2 and hypoxemia. The duration from pleural opening to satisfactory lung collapse was shorter in the preemptive OLV group (9.1 ± 1.2 vs. 14.1 ± 4.7 minutes, P < 0.01). PaO2 was comparable between the two groups prior to anesthetic induction (T0), and 20 (T2), 40 minutes (T3) after pleural incision, but was lower in the preemptive OLV group at zero minutes after pleural incision (T1) (457.5 ± 19.0 vs. 483.1 ± 18.1 mmHg, P < 0.01). No patients in either group developed hypoxemia. In summary, preemptive OLV expedites lung collapse during thoracoscopic surgery with minimal safety concern. [ABSTRACT FROM AUTHOR]

Closure of bronchopleural fistula remains a difficult challenge for clinicians. Although several therapeutic approaches have been proposed, the clinical results are commonly unsatisfactory. Previous reports have indicated that autologous mesenchymal stem cells (MSCs) are useful for aiding treatment of bronchopleural fistula. We report here the use of umbilical cord MSCs to effect the successful closure of a bronchopleural fistula (5 mm) in a 33-year-old woman 6 months after a lobectomy. A review of the relevant literature is included. The use of MSCs may be a promising therapeutic method for the closure of bronchopleural fistula. Randomized controlled trials with larger samples are required. [ABSTRACT FROM AUTHOR]

Purpose: We came up with a dynamic anatomical study intended to validate the safety of intercostal approach used by our center to access the upper pole of the kidney during percutaneous surgery. Materials and Methods: A total of 101 patients presenting randomly to the radiology department for CT evaluation of the abdomen and superior pelvis were involved in this study. Deep inspiration and expiration sequences in the prone position were evaluated to establish the location of the parietal pleura in relation to different anatomical landmarks. Three-dimensional reconstruction was performed to simulate the access needle course through the retroperitoneum. Results: Our data show that the position of parietal pleura is invariably higher on the right side irrespective of anatomical relation or respiratory changes. Higher position of the parietal pleura was noted in all considered landmarks upon full expiratory sequences. Using the midclavicular line as a landmark, our data show that on the right side, the parietal pleura was higher than the 10th intercostal space (ICS) in 100% of patients. Going up to the level of the ninth and eighth ICS, the pleura is higher in 89.1% and 66.3% of patients, respectively. Moreover, on the left side, the level of the parietal pleura was higher than the 11th ICS in 100% of patients. Reaching the 10th ICS, the parietal pleura still is higher in 92.07% of cases. Going up to the ninth ICS reduces the margin to 64.35% and using the eighth ICS would convey a margin of 24.7%. Conclusions: Supracostal access for percutaneous nephrolithotomy carries a risk of pulmonary complications, limiting its use worldwide. We have shown in this study that using the differences in inspiration and expiration along with the right anatomical landmarks could substantially lower the risk of complications. However, regardless of the side or landmark used, supracostal access is safe in >90% of cases. [ABSTRACT FROM AUTHOR]

Introduction: Surgical treatment of primary spontaneous pneumothorax (PSP) usually consists of bullectomy and any form of pleurodesis to reduce risk of disease recurrence. Whether pleurectomy is superior to pleural abrasion is still a matter of debate with recurrence rates especially high when performed with a video-assisted thoracoscopic (VATS) approach. Aim of this study was to compare the efficacy of the two methods in prevention of recurrence of pneumothorax in a minimally invasive setting.Materials and methods: Between 01/2005 and 12/2015, 107 patients younger than 40 years with PSP underwent VATS bullectomy and either partial pleurectomy or pleural abrasion. Medical records of patients were reviewed retrospectively.Results: Pleural abrasion was performed in 34/107 patients, 73/107 patients underwent partial pleurectomy. There were no statistically significant differences in age, sex, body mass index or smoking history at time of surgery. There was no significant difference in major postoperative complications (p = 0.3022). Nine (8.4%) patients had a recurrence of pneumothorax during follow-up. Incidence of recurrence in those undergoing pleural abrasion was significantly higher than those undergoing apical pleurectomy (8/34 vs. 1/73, p < 0.001). Surgical technique was the only factor associated with a recurrence of PSP after surgical intervention.Discussion: In our analysis, a VATS partial pleurectomy proved to be effective for prevention of recurrent PSP. Recurrence rates were low despite a minimally invasive approach and significantly lower than in the pleural abrasion group. According to these findings, VATS pleurectomy might be considered as the primary choice for surgical pleurodesis in patients with PSP. [ABSTRACT FROM AUTHOR]

Non-steroidal anti-inflammatory drugs (NSAIDs) reduced pleural adhesion in animal studies, but its effect on human had not been studied. A retrospective study was carried out for patients with solitary pulmonary nodules without a pre-operative tissue diagnosis positive for malignancy. The impact of the use of NSAIDs after stage one wedge resection was assessed by the degree of pleural adhesions encountered during second-stage, redo completion lobectomy. From April 2016 to March 2022, 50 consecutive patients meeting the inclusion criteria were included, and 44 patients were selected for analysis after exclusion (Treatment group with NSAID: N = 27; Control group without NSAID: N = 17). The preoperative characteristics and the final tumor pathologies were similar between the groups. The use of NSAID was significantly associated with lower risk of severe pleural adhesions and complete pleural symphysis (risk difference = -29%, p = 0.03). After controlling the effect of tumor size and chest drain duration, only the use of NSAID was statistically associated with the lowered risk of severe pleural adhesions and complete pleural symphysis. No statistically significant effects of NSAID on operative time (p = 0.86), blood loss (p = 0.72), and post-operative length of stay (p = 0.72) were demonstrated. In human, NSAIDs attenuated the formation of pleural adhesions after pleural disruptions. Physicians and surgeons should avoid the use of NSAIDs when pleural adhesion formation is the intended treatment outcome., (© 2023. Springer Nature Limited.)

Objective: Mid-point transverse process to pleura (MTP) block is a new regional analgesia technique. This study aimed to assess the perioperative analgesic effects of MTP block in children undergoing open-heart surgery., Design: A single-center, randomized, double-blinded, controlled, superiority study., Setting: At a University Children's Hospital., Participants: Fifty-two patients aged 2 to 10 years who underwent open-heart surgery., Interventions: Patients were randomized to receive either bilateral MTP block or no block (control)., Measurements and Main Results: The primary outcome was fentanyl consumption in the first postoperative 24 hours. The secondary outcomes were intraoperative fentanyl consumption, modified objective pain score (MOPS) measured at 1, 4, 8, 16, and 24 hours after extubation, and the duration of stay in the intensive care unit (ICU). The mean (SD) postoperative fentanyl consumption (µg/kg) in the first 24 hours was significantly reduced in the MTP block group (4.4 ± 1.2) compared to the control group (6.0 ± 1.4, p < 0.001). The mean (SD) intraoperative fentanyl requirement (µg/ kg) was significantly reduced in the MTP block group (9.1 ± 1.9) compared to the control group (13.0 ± 2.1, p < 0.001). The MOPS was significantly reduced in the MTP block group compared to the control group at 1, 4, 8, and 16 hours after extubation but was comparable in both groups at 24 hours. The mean (SD) duration of ICU stay (hours) was significantly reduced in the MTP block group (25.0 ± 2.9) compared to the control group (30.7 ± 4.2, p < 0.001)., Conclusions: Single-shot bilateral ultrasound-guided MTP block in children undergoing cardiac surgery reduced the mean fentanyl consumption in the first postoperative 24 hours, intraoperative fentanyl requirements, pain score at rest, time to extubation, and duration of ICU stay., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

A 70-year-old man was incidentally diagnosed with left pneumothorax. Primary surgery via the caudal thoracic cavity found severe pleural adhesions causing narrowing of the tunnel leading to the lung apex. The point of air leakage was located at the lung apex beyond the tunnel. To stop the air leakage, fibrin glue was injected to the apex via the tunnel; however, leakage reoccurred postoperatively. Considering the lung injury, a novel approach for lung apex without adhesion dissection was chosen for secondary surgery. An axillary skin incision was made at the 2nd intercostal space, and extrapleural dissection proceeded toward the apex. After the pleural space was confirmed by the movement of pleural effusion, the parietal pleura was incised, and a bulla was exposed and resected. The presented procedure to reach the apex of the lung without adhesion dissection could be an option in cases with dense and extensive pleural adhesions., (© 2023. The Author(s), under exclusive licence to The Japanese Association for Thoracic Surgery.)

The authors describe the role of the critical care nurse in the management of thoracic surgery patients to establish protocol-driven care guidelines. Topics covered include preparation for a patient's arrival, the concept of post-operative huddle, and special considerations for the critical care nurse.

Abstract: Background and Aims: Prolonged air leaks (PAL) are a common problem after pulmonary resection. PAL can be a source of significant complications. One of the treatment options is chemical pleurodesis. Material and Methods: The efficiency of three methods of treatment of PAL after lung resection was evaluated. In Iodine_ group aqueous iodine solution (lat.Tinctura Jodi) was applied intrapleurally (30 patients); in Doxycycline_group (34 patients) 200 mg of Doxycyclin was given and in Drainage_group 35 patients were applied Lidocaine solution only. Results: The group investigated was similar with regard to age [F = 0.04, P = 0.96] and the amount of air leakage (approx. 462 mL/min). The shortest drainage time and hospital stay was observed in the Iodine_group [10.57, P < 0.001]. However, this therapy was connected with strongly perceptible chest pain (P < 0.0001]). The number of case of pneumothorax recurrence was low and it was the same was seen in other methods of treatment [F = 0.87, P = 0.42]. Allergic reactions were not observed. The number of episodes of tachycardia, hypotension, dyspnea, pneumonia, subcutaneus empyema, fluid collection, emphysema, pneumothorax recurrence and number of re‐thoracotomies were statistically similar in all three methods of treatment. Conclusion: Iodine pleurodesis can be considered as one of possible treatment methods of PAL after lung resection as it showed favorable results compared with Doxycycline pleurodesis or drainage alone regarding duration of air leakage, hospitalization and pneumothorax recurrence with only slightly increased pleural pain. [ABSTRACT FROM AUTHOR]

Tension pneumothorax, a major preventable cause of battlefield death, often arises from chest trauma and is treated by needle decompression to release trapped air from the pleural cavity. Surgical simulation mannequins are often employed to train medical personnel to perform this procedure properly. Accurate reproduction of the mechanical behavior of the parietal pleura, especially in response to needle penetration, is essential to maximize the fidelity of these surgical simulators. To date, however, the design of pleura-simulating material has been largely empirical and based on subjective practitioner feel rather than on the tissue properties, which have remained unknown. In this study, we performed uniaxial extension tests on samples of cadaveric human parietal pleura. We found that the pleura was highly nonlinear and mildly anisotropic, being roughly twice as stiff in the direction parallel to the ribs vs. perpendicular to the ribs (large-strain modulus = 20.44 vs. 11.49 MPa). We also did not find significant correlations for most pleural properties with age or BMI, but it must be recognized that the age range (59 ± 9.5 yrs) and BMI range (31 ± 5.3) of the donors in our study was not what one might expect from combatants, and there could be differences for younger, lighter individuals. We found a significantly higher low-strain modulus in the diabetic donors (0.213 vs. 0.100 MPa), consistent with the general tendency of tissue to stiffen in diabetes. The nonlinearity and tensile strength should be considered in material design and selection for future surgical simulators. [ABSTRACT FROM AUTHOR]

Tension pyopneumothorax is a rare and life-threatening complication of pneumonia, lung abscess, and empyema, and immediate thoracic drainage or surgery is required. A 70-year-old man presented to another hospital 2 weeks after exacerbation of dyspnea and anorexia. Chest X-ray imaging revealed leftward deviation of the mediastinum, pleural effusion, and collapse of the right lung. The patient was referred to our hospital for surgical treatment. He underwent chest drainage immediately after the transfer. The patient's blood pressure was elevated after drainage. Chest X-ray imaging showed improvement in the mediastinal deviation, but expansion failure of the lung occurred. Debridement and parietal and visceral decortications were performed under thoracotomy. The thoracic cavity was irrigated using a pulse lavage irrigation system with 12,000 mL of saline. The patient underwent fibrinolytic therapy with intrathoracic urokinase postoperatively because of persistent high inflammatory marker levels and multilocular pleural effusion. Parvimonas micra was detected in the preoperative pleural fluid culture. He was discharged on postoperative day 22 and followed up as an outpatient afterwards. Two years have passed since the surgery, and there has been no recurrence of empyema. Decortication of the parietal and visceral pleura and irrigation using a pulse lavage irrigation system were effective., (© 2023. The Author(s).)

Background: Surgical approach is the most effective treatment for primary spontaneous pneumothorax. The two most widely adopted surgical methods are mechanical abrasion and apical pleurectomy, in addition to bullectomy. We performed a systematic review and meta-analysis to examine which technique is superior in treating primary spontaneous pneumothorax., Methods: PubMed, MEDLINE and EMBASE databases were searched for studies published between January 2000 to September 2022 comparing mechanical abrasion and apical pleurectomy for treatment of primary spontaneous pneumothorax. The primary outcome was pneumothorax recurrence. Secondary outcomes included post-operative chest tube duration, hospital length of stay, operative time and intra-operative of blood loss., Results: Eight studies were eligible for inclusion involving 1,613 patients. There was no difference in the rate of pneumothorax recurrence between pleural abrasion and pleurectomy (RR: 1.34; 95% CI: 0.94 to 1.92). However, pleural abrasion led to shorter hospital length of stay (MD: -0.25; 95% CI: -0.51 to 0.00), post-operative chest tube duration (MD: -0.30; 95% CI: -0.56 to -0.03), operative time (MD: -13.00; 95% CI -15.07 to 10.92) and less surgical blood loss (MD: -17.77; 95% CI: -24.36 to -11.18)., Conclusion: Pleural abrasion leads to less perioperative patient burden and shorter hospital length of stay without compromising the rate of pneumothorax recurrence when compared to pleurectomy. Thus, pleural abrasion is a reasonable first choice surgical procedure for management of primary spontaneous pneumothorax., (© 2023. The Author(s).)

The left lung usually has an oblique fissure that divides it into superior and inferior lobes. Some variants in the lobar fissure are well known, but the knowledge of certain uncommon variants will enhance our anatomical understanding and proper identification of the bronchopulmonary segments. Several imaging techniques have been used to describe anatomical variations of the lung, but studies that utilize dissections as tools for understanding lobar variations were limited. In this report, we described an incomplete horizontal fissure, bifurcated accessory fissure, incomplete superior and middle lobes, and fibrous condensation of the left lung pulmonary pleura observed during dissection. The knowledge of these anatomical variations will be useful in surgical segmental resection and lobectomy, and for accurate interpretations of medical diagnostic images. [ABSTRACT FROM AUTHOR]

Purpose: Malignant pleural effusion (MPE) is a disabling condition caused in most instances by far-advanced cancer. The treatment is palliative and should ideally be minimally invasive. The aim of this retrospective study was to evaluate the effectiveness of implantation of a permanent PleurX catheter in the treatment of recurrent MPE in patients with terminal cancer disease. Patients and methods: Eighteen consecutive patients with terminal cancer and MPE, who had a permanent PleurX catheter implanted in the period from February 2014 to August 2015, were retrospectively evaluated. Medical records were reviewed for data on procedures and patients. Results: Twenty-two PleurX catheters were implanted in the pleural cavity of 18 patients. The technical success rate was 100%. All patients had relief of symptoms. Catheter patency was 91%. Six patients experienced minor adverse events (AEs) and two patients experienced moderate-tosevere AEs. The median survival time for the 14 patients who died during follow-up was 45 days. Conclusion: Implantation of a permanent PleurX catheter is a safe procedure with a high success rate and only few AEs. The procedure has the potential to serve as an effective procedure for palliation of recurrent MPE in terminal cancer patients. [ABSTRACT FROM AUTHOR]

The article presents a case study of a retained piece of glass in pleural cavity of a 16-year-old male who suffered from a penetrating chest injury. It states that the patient underwent seven chest X-rays, and he returned to the emergency department with severe chest pain, another chest- X-ray showed a radiopaque foreign body. He was taken to the operating room for removal of the foreign body.

Regional anesthetic techniques have gradually revolutionized the perioperative analgesia in breast surgeries. Recently, midpoint transverse process to pleura block has been described and found to provide excellent opioid-sparing analgesia. We performed the block in a novel out-of-plane technique to decrease the patient-needle interaction time and at the same time achieving good analgesia. The immediate postoperative Numeric Pain Rating Scale score was 0/10 both at rest and on movement, and patient reported a score of 5/10 after 12 h, which get subsided with single dose of nonopioid analgesic. [ABSTRACT FROM AUTHOR]

The article discusses a case of a patient who suffered blunt thoracic injury and underwent ligation for the treatment of bilateral chylothoraces. Topics mentioned include the symptoms experienced by the patient after involving in motor vehicle accident, the complications associated with chylothorax, the mortality rates of chylothoraces, the results of the pleural fluid analysis, and the conservative management given to the patient.

Objectives: The rates of postoperative mortality and morbidity are high in patients with malignant pleural mesothelioma (MPM). Therefore, it is important to identify variables that increase the risk of postoperative complications. Pleural thickness has recently been identified as a prognostic indicator in patients with MPM. The aim of this study was to investigate clinical variables, including pleural thickness, that contribute to postoperative complications in patients with MPM., Patients and Methods: A total of 47 patients who underwent surgical excision of MPM between 2005 and 2021 were enrolled in this study. Correlations between postoperative complications within 90 days of surgery and preoperative clinical factors were investigated., Results: A total of 27 patients underwent extrapleural pneumonectomy (EPP), and the remaining 20 underwent pleurectomy/decortication (P/D). Macroscopic complete resections were obtained in all but three patients. Of the 47 patients, 23 (49%) experienced postoperative complications of grade 3 or worse. The major complication in patients with EPP was respiratory failure (n = 6), whereas the major complication in patients with P/D was prolonged air leakage (n = 7). Univariate logistic regression analysis found a correlation between postoperative complications and age, surgical side, and pleural thickness, while multivariate logistic regression analysis found surgical side (p = 0.04, 95% Cl 1.10-21.71, OR 4.90) and pleural thickness (p = 0.03, 95% Cl 1.21-23.00, OR 5.26) to significantly influence the occurrence of postoperative complications., Conclusions: Pleural thickness has a significant effect on the occurrence of postoperative complications. Patients with thick pleura on the right side are at greater risk of postoperative complications., (© 2022. Society of Surgical Oncology.)

Background: Primary spontaneous pneumothorax occasionally relapses, even after bullectomy; therefore, coverage of the bullectomy staple line for pleural reinforcement is common in Japan. However, the appropriate covering materials have not yet been determined., Methods: This was a longitudinal prospective cohort study. Data were available for patients aged < 40 years with primary spontaneous pneumothorax who underwent their first thoracoscopic bullectomy between July 2015 and June 2021. We used oxidized regenerated cellulose (ORC) sheets from July 2015 to June 2018, and polyglycolic acid (PGA) sheets from July 2018 to June 2021. The postoperative recurrence-free survival rate was evaluated. The characteristics of the recurrent cases (radiographic, intraoperative, and pathological findings) were also evaluated. The extent of pleural adhesions was classified into the following three groups: none, medium, or extensive., Results: A total of 187 patients were included in the study. There were 92 and 95 participants in the ORC and PGA sheet groups, respectively. The postoperative recurrence-free survival rates were significantly higher in the PGA sheet group than in the ORC sheet group (ORC group vs. PGA group, 82.9% vs. 95.4%, p = 0.031). In recurrent cases, there was a significant difference in terms of pleural adhesion (0.0% [12 of 12, none] vs. 100.0% [four of four, extensive], p < 0.001)., Conclusions: Compared with ORC sheets, PGA sheets are an effective material for preventing early recurrence of primary spontaneous pneumothorax. Strong local pleural adhesions potentially contribute to decreasing recurrence., (© 2023. The Author(s).)

Percutaneous or transbronchial markings are performed to localize pulmonary nodules preoperatively. We present a novel intraoperative procedure that utilizes virtual thoracoscopic imaging-assisted pleural marking. In this procedure, a virtual thoracoscopic image is created preoperatively, and the coordinates of the pleural point above the tumor are determined. The pleural marker is intraoperatively placed on the coordinates, and dye is transferred to the visceral pleura with two lung ventilations. We present the specific procedures and countermeasures for cases when nodules are not palpable. Additionally, we present a comparison between the various methods of preoperative marking and this method.

Background: Pleurodesis performed either by pleurectomy or pleural abrasion is recommended in the approach to primary spontaneous pneumothorax to avoid recurrence. However, the efficacy of parietal pleural abrasion in producing pleurodesis is questioned. This study aims to determine the efficacy of apical abrasion alone, abrasion plus fibrin sealant application, and pleurectomy in producing pleurodesis in rabbits.Methods: Rabbits were subjected to video-assisted thoracic surgery alone (control) or to video-assisted thoracic surgery with apical gauze abrasion, abrasion plus fibrin sealant instillation, or apical pleurectomy. Blood samples were collected preoperatively and 48 h and 28 days postoperatively to measure total leukocytes (white blood cell count), neutrophil counts, and serum interleukin (IL)-8 levels. After 28 days the animals were sacrificed for macroscopic evaluation of the degree of apical pleurodesis and microscopic evaluation of local pleural fibrosis and collagen deposition.Results: White blood cell and neutrophil counts were similar in all groups, whereas the serum IL-8 level peaked at 48 h in all groups and decreased after 28 days, except in the pleurectomy group. After 28 days the abrasion plus fibrin sealant and pleurectomy groups had significantly more pleural adhesions, pleural fibrosis, and collagen deposition than the abrasion alone group, mainly due to thick mature fibers.Conclusions: Abrasion with local fibrin sealant instillation is as effective as pleurectomy in producing pleurodesis in rabbits. Apical pleurectomy elicits a more persistent elevation of serum IL-8 levels than apical abrasion alone or abrasion plus fibrin adhesive instillation. [ABSTRACT FROM AUTHOR]