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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.

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.

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.

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.

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.

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.

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

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.

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.

There is increasing international interest in the use of video-assisted thoracoscopic procedures (VATS) with spontaneous respiration in the treatment of elderly and multimorbid patients. Data on the application and acceptance in Germany are not yet available.Germany-wide, online-based survey among the departments of thoracic surgery registered at the German Society of Thoracic Surgeons (DGT) on the application of VATS in local anaesthesia (LA).101 of 157 hospitals responded (64%). 42% of the respondents perform non-intubated VATS (NIVATS), 31% VATS in LA. Reasons not to perform VATS in LA are lack of experience (51%), doubts about feasibility (29%) and missing indications (24%). Among the performing clinics, the most frequent procedures are pleural catheterisation (94%), pleural biopsy (87%) and pleurodesis (87%). 42% of the clinics perform wedge resections and 10% also anatomical resections in LA. Main target groups are multimorbid patients (77%), elderly patients (65%), patients with anxiety about general anaesthesia (55%) and patients with pre-existing lung diseases (52%). In 97% of the departments, sedation is performed by anaesthesiologists. The main technical difficulties mentioned are impaired view of the surgical field (39%), hypercapnia (29%) and panic attacks (23%). Pain is of minor importance (3%).About one third of the participating departments already perform VATS in LA; others have plans to introduce the method. The majority of respondents regard multimorbid, elderly and lung patients as the main target groups, as fewer inflammatory, respiratory and neurological complications are expected.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.Deutschlandweite, onlinebasierte Umfrage an den bei der Deutschen Gesellschaft für Thoraxchirurgie (DGT) registrierten thoraxchirurgischen Abteilungen zur Anwendung der VATS in Lokalanästhesie (LA).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%).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.

Background Anterior chest wall resection for oncological purposes is usually combined with a form of reconstruction. Most surgeons are convinced that ventrally located defects more than 4 to 5 cm require adequate reconstruction to minimize the risk of lung herniation and respiratory distress through paradox motion. We describe our in-house results of ventral chest wall reconstruction using polypropylene mesh without the use of metallic or biological implants regardless of the extent of chest wall resection. Methods Patient selection involved ventral chest wall resection and reconstruction by polypropylene mesh for all indications such as primary tumors, metastasis, or infiltration by lung cancer from January 2008 to December 2016. Primary end point was the difference between both sides. Secondary end points were postoperative complications such as infection, surgical revision, and pulmonary complications. Results Forty-five cases of isolated anterior reconstruction could be identified. In 34 cases, postoperative computed tomography scan of the thorax was available. Fifteen males and 19 females with a median age of 70.5 years were operated. The evaluation of maximum hemithorax diameter between operated and nonoperated sides was documented in centimeters, and the difference was documented in percentage. The mean percentage difference was 11.1% (minimum: 0.3, maximum: 44.4). In one case, wound infection with positive culture could not be treated conservatively and required operative revision and removal of the polypropylene mesh. Conclusion Polypropylene mesh, though not rigid, can safely be used for anterior chest wall reconstruction.

During the last few years, hyperthermic intrathoracic chemotherapy (HITOC) has been performed in several departments for thoracic surgery in Germany. The objective of this expert recommendation is to provide elementary recommendations for a standardised HITOC treatment, which are based on clinical experiences and research data.Between October and December 2018, a group of experts for thoracic surgery in five departments of thoracic surgery developed recommendations for the HITOC procedure in Germany. These experts were selected by the latest national survey for HITOC and had the most clinical experience with HITOC. All recommendations are based on clinical experience, the experts' research data and recent literature.All recommendations were evaluated by all participating departments in one consensus survey. Finally, a total of six main conclusions including a total of 17 recommendations were developed. For each recommendation, the strength of the consensus is presented in percentages. 100% agreement was established for nomenclature, technique, the chemotherapeutic agent, the perioperative management, the safety measures and the indications for HITOC. All experts recommended cisplatin as the first choice chemotherapeutic agent for HITOC. The dosage of cisplatin is specified in mg/mThese expert recommendations provide a standardised and consistent implementation of the HITOC procedure. On this basis, postoperative complications associated to HITOC should be reduced and comparison of the results should be improved.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.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.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/mDiese 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.

Background Although general anaesthesia (GA) with one-lung ventilation is the current standard of care, minor thoracoscopic surgery, i.e. treatment of pleural effusions, biopsies and small peripheral pulmonary wedge resections, can also be performed using local anaesthesia (LA), analgosedation and spontaneous breathing. Whilst the feasibility and safety of LA have been demonstrated, its impact on patient satisfaction remains unclear. Most studies evaluating patient satisfaction lack control groups or do not meet psychometric criteria. We report the design of the PASSAT trial (PAtientS’ SATisfaction in thoracic surgery – general vs. local anaesthesia), a randomised controlled trial with a non-randomised side arm. Methods Patients presenting for minor thoracoscopic surgery and physical eligibility for GA and LA are randomised to surgery under GA (control group) or LA (intervention group). Those who refuse to be randomised are asked to attend the study on the basis of their own choice of anaesthesia (preference arm) and will be analysed separately. The primary endpoint is patient satisfaction according to a psychometrically validated questionnaire; secondary endpoints are complication rates, capnometry, actual costs and cost effectiveness. The study ends after inclusion of 54 patients in each of the two randomised study groups. Discussion The PASSAT study is the first randomised controlled trial to systematically assess patients’ satisfaction depending on LA or GA. The study follows an interdisciplinary approach, and its results may also be applicable to other surgical disciplines. It is also the first cost study based on randomised samples. Comparison of the randomised and the non-randomised groups may contribute to satisfaction research. Trial registration German Clinical Trials Register, DRKS00013661. Registered on 23 March 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3190-1) contains supplementary material, which is available to authorized users.

Background: The aim of this study was to compare the perioperative outcome of patients receiving anatomic segmentectomy either by open surgery or video-assisted thoracoscopic surgery (VATS). To assess the short-term morbidity of the procedure itself, lung cancer patients in all stages as well as patients with pulmonary metastases and benign lesions scheduled for segmental resection were enrolled in this study. Methods: A retrospective analysis of prospectively collected data on 445 consecutive patients that underwent segmentectomy either by VATS (n=233) or thoracotomy (n=212) was performed. A propensity-matched analysis was conducted based on age, gender, smoking history, histology, tumor size, forced expiratory volume in 1 second (FEV1) and history of previous pulmonary resections. The matched sample included two groups of 140 patients each. Results: Both study groups were comparable with respect to age, gender, smoking history, diagnosis, tumor size, pulmonary function and history of previous pulmonary resections. VATS segmentectomy was associated with decreased length of stay (7.4 vs . 9.5 days, P vs . 5.9 days, P=0.012) and severe postoperative complications (1.4% vs . 7.1%, P=0.018). Conclusions: VATS segmentectomy is safe and effective for the treatment of benign and malignant pulmonary lesions. Compared with open thoracotomy, it is associated with shorter hospitalization time and decreased number of severe complications. The preservation of functional lung tissue, combined with a minimally invasive approach, make VATS segmentectomy highly suitable for patients with reduced pulmonary function or severe comorbidities.

Background: Single-incision laparoscopic surgery (SILS) is a variant of laparoscopic surgery, especially for diverticular disease (DD), but there are very little data comparing SILS to standard surgical procedures for DD, and most studies on DD surgery do not declare the disease stage. We compared SILS to open sigmoidectomy for DD in a stage-stratified matched-pair analysis to validate the significance of SILS. Methods: All patients with SILS or conventional sigmoidectomy for diverticulitis of a single visceral surgery department were subject to a matched-pair analysis stratified by age, sex, body mass index, previous abdominal surgery, and the stage of DD. Results: Fifty-five pairs were included. In total, 84/110 (76%) had complicated stages of DD. ASA stages were higher in the laparotomy group; the proportion of elective operations was similar (SILS 78%, open: 71%). In the SILS group, length of hospital stay (LoS; 10.2 vs. 16.7 days) and duration of intensive or intermediate care (IMC; 1.8 vs. 3.7 days) were shorter, blood transfusions were reduced (0.1 vs. 0.4 units) and less patients received opioids postoperatively (75 vs. 98%). The day of first defecation, stoma rate, and rates of morbidity and mortality were similar. Conclusions: SILS equals open sigmoidectomy regarding complications with advantages regarding pain, LoS, IMC/intensive care unit treatment, and blood transfusion.

Voltage-gated Ca2+ channels regulate cardiac automaticity, rhythmicity and excitation–contraction coupling. Whereas L-type (Cav1·2, Cav1·3) and T-type (Cav3·1, Cav3·2) channels are widely accepted for their functional relevance in the heart, the role of Cav2·3 Ca2+ channels expressing R-type currents remains to be elucidated. We have investigated heart rate dynamics in control and Cav2·3-deficient mice using implantable electrocardiogram radiotelemetry and pharmacological injection experiments. Autonomic block revealed that the intrinsic heart rate does not differ between both genotypes. Systemic administration of isoproterenol resulted in a significant reduction in interbeat interval in both genotypes. It remained unaffected after administering propranolol in Cav2·3(−|−) mice. Heart rate from isolated hearts as well as atrioventricular conduction for both genotypes differed significantly. Additionally, we identified and analysed the developmental expression of two splice variants, i.e. Cav2·3c and Cav2·3e. Using patch clamp technology, R-type currents could be detected in isolated prenatal cardiomyocytes and be related to R-type Ca2+ channels. Our results indicate that on the systemic level, the pharmacologically inducible heart rate range and heart rate reserve are impaired in Cav2·3 (−|−) mice. In addition, experiments on Langendorff perfused hearts elucidate differences in basic properties between both genotypes. Thus, Cav2·3 does not only contribute to the cardiac autonomous nervous system but also to intrinsic rhythm propagation. Copyright © 2012 John Wiley & Sons, Ltd.

The Cav2.3 voltage-gated calcium channel represents the most enigmatic of all voltage-gated calcium channels due to its pharmacological inertness and to its mixed characteristics of HVA and LVA calcium channels. Protein interaction partners of the cytosolic II-III linker of Cav2.3 contribute to calcium homeostasis by regulating the channels surface expression and activation. Specific regulation of Cav2.3 by proteins interacting with the carboxy terminal region plays an important role in exocytosis and presynaptic plasticity, linking channel function to long-term potentiation. Modulation of Cav2.3 by its interaction partners thus contributes to several physiologic processes such as signal transduction in the retina, insulin secretion and generation of rhythmic activity in the heart and in the brain.

Voltage-gated Ca(2+) channels regulate cardiac automaticity, rhythmicity and excitation-contraction coupling. Whereas L-type (Cav 1·2, Cav 1·3) and T-type (Cav 3·1, Cav 3·2) channels are widely accepted for their functional relevance in the heart, the role of Cav 2·3 Ca(2+) channels expressing R-type currents remains to be elucidated. We have investigated heart rate dynamics in control and Cav 2·3-deficient mice using implantable electrocardiogram radiotelemetry and pharmacological injection experiments. Autonomic block revealed that the intrinsic heart rate does not differ between both genotypes. Systemic administration of isoproterenol resulted in a significant reduction in interbeat interval in both genotypes. It remained unaffected after administering propranolol in Cav 2·3(-|-) mice. Heart rate from isolated hearts as well as atrioventricular conduction for both genotypes differed significantly. Additionally, we identified and analysed the developmental expression of two splice variants, i.e. Cav 2·3c and Cav 2·3e. Using patch clamp technology, R-type currents could be detected in isolated prenatal cardiomyocytes and be related to R-type Ca(2+) channels. Our results indicate that on the systemic level, the pharmacologically inducible heart rate range and heart rate reserve are impaired in Cav 2·3 (-|-) mice. In addition, experiments on Langendorff perfused hearts elucidate differences in basic properties between both genotypes. Thus, Cav 2·3 does not only contribute to the cardiac autonomous nervous system but also to intrinsic rhythm propagation.

Compared with single-incision laparoscopy, multiport laparoscopy is associated with greater risk of postoperative wound pain, infection, incisional hernias, and suboptimal cosmetic outcomes. The feasibility of minimally invasive single-incision laparoscopic surgery (SILS) for colorectal procedures is well-established, but outcome data remain limited.Patients with benign diverticular disease, Crohn's disease, or ulcerative colitis admitted to Klinikum Leverkusen, Germany, for colonic resection between July 2009 and March 2011 (n = 224) underwent single-incision laparoscopic surgery using the SILS port system. Surgeons had ≥7 years' experience in laparoscopic colon surgery but no SILS experience. Patient demographic and clinical data were collected prospectively. Pain was evaluated by using a visual analog scale (0-10). Data were analyzed by using the SPSS PASW Statistics 18 database.The majority of patients underwent sigmoid colectomy with high anterior resection (AR) or left hemicolectomy (n = 150) for diverticulitis. Our conversion rate to open surgery was 6.3 %, half in patients undergoing sigmoid colectomy with high AR or left hemicolectomy, 95 % of whom had diverticulitis. Mean operating time was 166 ± 74 (range, 40-441) min in the overall population, with shorter times for single-port transanal tumor resection (SPTTR; 89 ± 51 min; range, 40-153 min) and longer times for proctocolectomy (325 min; range, 110-441 min). Mean hospital stay was approximately 10 days, longer after abdominoperineal rectal resection or proctocolectomy (12-16 days). Most complications occurred following sigmoid colectomy with high AR or left hemicolectomy [19/25 (76 %) of early and 4/5 (80 %) of late complications, respectively]. Pain was4 on a scale of 0-10 in all cases on postoperative day 1, and typically decreased during the next 2 days.Our findings support the feasibility and tolerability of colorectal surgery, conducted by experienced laparoscopic surgeons without specific training in use of the SILS port.

Laparoscopic cholecystectomy (LC) is nowadays the standard method for cholecystectomy. Recently, surgeons attempt to introduce even less-invasive surgical procedures, such as single-port LC or LC through natural orifice transluminal endoscopic surgery (NOTES). The number of studies showing the feasibility of these techniques increased during the last years, but specific complications that correlated with these new techniques are still not apparent. Here, we report on a case with an unusual complication, iatrogenic right diaphragm injury in single-port LC. A 72-year-old man underwent single-port LC because of symptomatic cholecystolithiasis. During the operation, the long rigid straight forceps holding the fundus of the gallbladder slipped off toward the right diaphragm and caused a 1-cm full-thickness diaphragmatic tear. Laparoscopic suture repair was performed, and the patient recovered uneventfully. In using long forceps in single-port LC or transvaginal NOTES-LC, reticulating and bent instruments may avoid this unusual but possible complication in these operations.

Purpose Diaphragmatic hernias (DHs) are divided into congenital and acquired hernias, most of which are congenital. Among acquired DHs, up to 80% are left-sided, only a few iatrogenic DHs have been reported, and bilateral hernias are extremely rare. For diagnostic reasons, many DHs are overlooked by ultrasonography or X-ray and are only recognized at a later stage when complications occur. Methods In 2009, we performed three partial diaphragm replacements in our clinic for repairing DHs using a PERMACOL™ implant. Results As all patients had uneventful postoperative courses and the clinical outcomes were very good, we present one special case of a 65-year-old male with a giant iatrogenic bilateral DH with an enterothorax. Conclusion We see a good indication for diaphragm replacements by using a PERMACOL™ implant for fixing especially DHs with huge hernial gaps and in cases with fragile tissue.

A 62 year-old patient with therapy-refractory pouchitis after proctocolectomy for ulcerative colitis was admitted with hematochezia and abdominal discomfort. A malignant melanoma (MM) was found after repeated biopsies of the pouch. Complete staging revealed no evidence for distant metastases and the patient underwent abdominoperineal pouch resection. Six weeks later, the patient was readmitted because of severe general deterioration and diffuse metastatic spread to the liver was found. The patient died of hepatorenal syndrome shortly thereafter. Patients with inflammatory bowel disease are at increased risk of developing cancer, including rarities such as MM. Our experience stresses the importance of repeated biopsies in therapy-refractory pouchitis.

Acute abdomen is a common and often complicated condition inthe emergency department. Etiology may vary from harmless toextremely severe causes, any of which can present the samenonspecific symptoms. Impalement or penetrating injuries of thelower genital tract are rare and frequently related to unusual sexualhabits [2]. Evaluating the mechanism of trauma may be difficult aspatients are often unwilling or unable to provide the necessaryinformation.An 18-year-old woman presented at the emergency departmentwith sudden and severe lower abdominal pain in the early morning.Initial history did not reveal trauma or previous illness.Physical examination showed a tense abdomen with diffuseguarding and rare bowel sounds. Laboratory evaluation showed awhite blood cell count of 25.7/nL and C-reactive protein of 84 mg/L.Urinalysis exhibited 150 Ery/μL, 100 leukocytes/μL, and a negativepregnancytest. Abdominal ultrasound was normal but X-rayrevealedair in the peritoneal cavity.Laparoscopy was performed for suspected gastrointestinal perfo-ration. Turbid and blood-stained perihepatic fluid was found andhyperemia of the parietal peritoneum was suggestive of earlyperitonitis. No perforation was found in the upper abdomen. In therectovaginal pouch there was a 4-cm wide laceration through thevagina vault, with transvaginal loss of carbon dioxide gas.Following irrigation with 5 liters of warm saline, repair wasperformed laparoscopically with a continuous PDS II suture (3-0,Lahodny) and fixed with two resorbable clips. Intravenous cephazolin(3×2 g) and metronidazole (2×500 mg) were administered to thepatient for 7 days. Review of the gynecologic history revealed forcefulsexual intercourse as the cause of the injury. The patient's recoveryfrom surgery was uneventful.Impalement injuries of the vagina are seldom described in theliteratureandincludesevereinjuriesoftherectum,bladder,peritoneal,duodenum, diaphragm, and lung [1–3].The most common symptom in women with vaginal impale-ment injury is vaginal bleeding after coitus with no history ofcongenital abnormalities, gynecologic operation, pregnancy, orbirth [4]. Careful gynecologic history is necessary and should beaccompanied by vaginal examination and ultrasound or radiogra-phy when indicated.Vaginal bleeding as the classical symptom was absent in thepresent case and the clinical aspect was that of an acute abdomenwith diffuse peritonitis. In such cases, full evaluation may lead tolaparoscopy.Conflict of interestNo conflicts of interest exist.References