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Prioritisation of individual patients for thoracic surgeries gained importance during the current COVID-19 pandemic to ensure optimal utilisation of resources. We report a 76-year-old-male patient who presented to a tertiary care hospital in Muscat, Oman, 2020, with bilateral pulmonary metastasis. The patient underwent an urgent pulmonary metastasectomy with successful anaesthesia management in an elderly patient despite him testing positive for COVID-19 twice via real-time reverse transcription–polymerase chain reaction. At the 3-month follow-up some pulmonary abnormalities persisted but the patient was recovering well. This report discusses the rationale to perform surgery in this case and highlights the precautions taken for reducing aerosol generation during the various stages of anaesthesia.Keywords: COVID-19; Coronavirus Infections; One-Lung Ventilation; Personal Protective Equipment; Aerosols; Thoracic Surgical Procedures; Case Report; Oman.

Advances in perioperative assessment and diagnostics, together with developments in anesthetic and surgical techniques, have considerably expanded the pool of patients who may be suitable for pulmonary resection. Thoracic surgical patients frequently are perceived to be at high perioperative risk due to advanced age, level of comorbidity, and the risks associated with pulmonary resection, which predispose them to a significantly increased risk of perioperative complications, increased healthcare resource use, and costs. The definition of what is considered "fit for surgery" in thoracic surgery continually is being challenged. However, no internationally standardized definition of prohibitive risk exists. Perioperative assessment traditionally concentrates on the "three-legged stool" of pulmonary mechanical function, parenchymal function, and cardiopulmonary reserve. However, no single criterion should exclude a patient from surgery, and there are other perioperative factors in addition to the tripartite assessment that need to be considered in order to more accurately assess functional capacity and predict individual perioperative risk. In this review, the authors aim to address some of the more erudite concepts that are important in preoperative risk assessment of the patient at potentially prohibitive risk undergoing pulmonary resection for malignancy.

INTRODUCTION Nowadays the majority of the surgical procedures are video surgeries. Despite technological advances, some problems remain. The buildup of residues in front of the lens is an example of this problem. To solve it, Abreu et al. (Surg Technol Int 26:43-47, 2015) developed LacrimaSurg, which works as a lacrimal duct in the optics preventing fogging and residues buildup on it. This had 98.1% of efficiency in an experimental study. OBJECTIVE Study feasibility and safety of the device under real surgical conditions. MATERIALS AND METHODS A pilot study included 30 patients undergoing thoracic procedures using LacrimaSurg. Procedures were recorded for further analysis by investigators. The characteristics of patients (age, sex, body mass index, Charlton comorbidity index), data of environment (Temperatures variances), and data of procedures (type of surgery and duration of it) were recorded. The investigators watched the videos and recorded the residue buildup and fogging events that impaired surgeon's vision. The number of times the optics got dirty, need for further jets of crystalloid solution, and need for mechanical cleaning were collected to evaluate efficacy. Comparative serum measurements of electrolytes before and after surgery were studied. Data were organized and analyzed by simple linear correlations and t test for continuous variables and Fisher's test for categorical variables. RESULTS The use of the device allowed 97% of the procedures to be performed without interruption. No characteristics inherent to the patients or to the procedures that lead to fogging or filth of the optics were identified. There were no statistically significant differences between pre- and postoperative serum ions, and no postoperative complications related to the use of the device were observed. CONCLUSION The device was effective in preventing interruption of surgical procedures due to dirt or fogging, its use was considered safe, and did not cause postoperative complications.

Objective Minimally invasive procedures coupled with enhanced recovery pathways enable faster postoperative recovery and shorter hospitalizations. However, patients may experience unexpected concerns after return home, prompting after-hours calls. We aimed to characterize concerns prompting after-hours calls to improve discharge strategies. Methods A single-institution, retrospective review was conducted of thoracic surgical patients from 11/4/2019 to 6/14/2020. Records were reviewed and elements of patient demographics, surgical procedures, postoperative courses, reasons for calls, and outcome of calls were collected. We compared characteristics of patients who made after-hours calls to those who did not, and performed multivariable analysis to identify characteristics associated with making an after-hours call. Results During the study period, 379 patients underwent thoracic surgical procedures, among whom 88 (23.2%) initiated after-hours calls. Of these, 62 (70%) addressed patient symptoms, while 26 (30%) addressed patient questions including drain management, medications, and hospital policy questions. Patients making after-hours calls more frequently had undergone complex operations (26.1% vs 8.2%, P = 0.001), and were less likely to have received a standardized, clinician-initiated post-discharge telephone follow-up (29.5% vs 54.3%, P < 0.001). Complex operations increased likelihood of after-hours calls (OR: 3.33, 95% CI: 1.69-6.57, P < 0.001), while receipt of clinician-initiated telephone follow-up decreased likelihood of after-hours calls (OR: 0.38, 95% CI: 0.22-0.64, P < 0.001). There were no differences in emergency visits between the 2 groups (11% vs 8%, P = 0.370). Conclusions Despite efforts to optimize patient symptoms and knowledge prior to discharge, a substantial number of patients still have concerns after discharge. Many after-hours calls are related to knowledge gaps that may be addressed with improved predischarge education. Moreover, clinician-initiated telephone follow-up shows benefit in reducing after-hours calls.

Background Decreasing the length of stay after thoracic surgery provides both clinical and financial benefits to both the patient and the clinical system. Since 2017, our institution has seen advancements in the care of patients undergoing thoracic surgery after utilising our protocol Enhanced Recovery After Thoracic Surgery (ERATS). Methods The protocol we implemented is comprehensive, including the patient’s pain management, thoracostomy tube drainage, physical therapy and rehabilitation, ventilator support and pulmonary care, as well as other features of preoperative, intraoperative, and postoperative care. In a retrospective review, we compared the overall length of stay prior to the protocol implementation to the length of stay after initiating the changes. Results We identified a median decrease of 2 days (from 6 days to 4 days) following the implementation of this protocol for all types of thoracic surgical procedures (p Conclusions Upon implementation of the ERATS protocol, we appreciated a decrease in the length of stay of thoracic surgery patients at our institution.

The aim of this retrospective study was to investigate the implementation of measures to prevent perioperative COVID-19 in thoracic surgery during the first wave of the COVID-19 pandemic 2020 allowing a continued surgical treatment of patients. The implemented preventive measures in patient management of the thoracic surgery department of the Asklepios Lung Clinic Munich-Gauting, Germany were retrospectively analyzed. Postoperative COVID-19 incidence before and after implementation of preventive measures was investigated. Patients admitted for thoracic surgical procedures between March and May 2020 were included in the study. Patient characteristics were analyzed. For the early detection of putative postoperative COVID-19 symptoms, typical post-discharge symptomatology of thoracic surgery patients was compared to non-surgical patients hospitalized for COVID-19. Thirty-five surgical procedures and fifty-seven surgical procedures were performed before and after implementation of the preventive measures, respectively. Three patients undergoing thoracic surgery before implementation of preventive measures developed a COVID-19 pneumonia post-discharge. After implementation of preventive measures, no postoperative COVID-19 cases were identified. Fever, dyspnea, dry cough and diarrhea were significantly more prevalent in COVID-19 patients compared to normally recovering thoracic surgery patients, while anosmia, phlegm, low energy levels, body ache and nausea were similarly frequent in both groups. Based on the lessons learned during the first pandemic wave, we here provide a blueprint for successful easily implementable preventive measures minimizing SARS-CoV-2 transmission to thoracic surgery patients perioperatively. While symptoms of COVID-19 and the normal postoperative course of thoracic surgery patients substantially overlap, we found dyspnea, fever, cough, and diarrhea significantly more prevalent in COVID-19 patients than in normally recovering thoracic surgery patients. These symptoms should trigger further diagnostic testing for postoperative COVID-19 in thoracic surgery patients. Ziel dieser retrospektiven Studie war die Untersuchung von Maßnahmen zur Prävention perioperativer COVID-19-Erkrankungen bei fortgesetztem Vollbetrieb der Thoraxchirurgie während der ersten Welle der COVID-19-Pandemie 2020. Es erfolgte eine retrospektive Analyse von eingesetzten Präventionsmaßnahmen in der Abteilung für Thoraxchirurgie der Asklepios Lungenklinik München-Gauting. Hierzu wurde die Inzidenz postoperativer COVID-19-Erkrankungen vor und nach der Einführung der Präventionsmaßnahmen ausgewertet. Patienten mit thoraxchirurgischen Operationen zwischen März und Mai 2020 wurden in die Studie eingeschlossen. Durch den Vergleich der postoperativen Symptome thoraxchirurgischer Patienten mit Symptomen von COVID-19-Patienten wurden spezifische Symptome zur Früherkennung der postoperativen COVID-19-Erkrankung identifiziert. Vor Einführung der Präventionsmaßnahmen erfolgten 35 thoraxchirurgische Operationen innerhalb von 22 Tagen während hoher COVID-19-Prävalenz im Einzugsgebiet der Klinik. Nach Einführung der Präventionsmaßnahmen erfolgten 57 thoraxchirurgische Eingriffe innerhalb von 54 Tagen. Vor Umsetzung der Präventionsmaßnahmen entwickelten 3 Patienten postoperativ eine COVID-19-Pneumonie. Nach Umsetzung zeigte sich kein postoperativer COVID-19-Fall. Fieber, Atemnot, trockener Husten und Durchfall waren bei an COVID-19 erkrankten Patienten signifikant häufiger als bei thoraxchirurgischen Patienten mit regelhaftem postoperativem Verlauf. Anosmie, Auswurf, Abgeschlagenheit, Gliederschmerzen und Übelkeit traten in beiden Gruppen ähnlich häufig auf. Basierend auf unseren Erfahrungen in der ersten Pandemiewelle bieten wir eine Blaupause für erfolgreiche, leicht umzusetzende präventive Maßnahmen zur Minimierung des Risikos für eine perioperative COVID-19-Erkrankung bei thoraxchirurgischen Patienten. Wir konnten zeigen, dass Symptome einer postoperativen COVID-19-Pneumonie teilweise schwer von klassischen postoperativen Beschwerden abgrenzbar sind. Postoperative Dyspnoe, Fieber, Husten und Diarrhöen traten jedoch signifikant häufiger bei COVID-19-Erkrankten als im postoperativen Verlauf thoraxchirurgischer Patienten auf und sollten daher differenzialdiagnostisch an eine postoperative COVID-19-Erkrankung denken lassen.

Background We have recently witnessed incredible interest in computer-based, internet web-dependent mechanisms and artificial intelligence (AI)-dependent technique emergence in our day-to-day lives. In the recent era of COVID-19 pandemic, this nonhuman, machine-based technology has gained a lot of momentum. Main body of the abstract The supercomputers and robotics with AI technology have shown the potential to equal or even surpass human experts’ accuracy in some tasks in the future. Artificial intelligence (AI) is prompting massive data interweaving with elements from many digital sources such as medical imaging sorting, electronic health records, and transforming healthcare delivery. But in thoracic surgical and our counterpart pulmonary medical field, AI’s main applications are still for interpretation of thoracic imaging, lung histopathological slide evaluation, physiological data interpretation, and biosignal testing only. The query arises whether AI-enabled technology-based or autonomous robots could ever do or provide better thoracic surgical procedures than current surgeons but it seems like an impossibility now. Short conclusion This review article aims to provide information pertinent to the use of AI to thoracic surgical specialists. In this review article, we described AI and related terminologies, current utilisation, challenges, potential, and current need for awareness of this technology.

Increasing number of lung diseases, unfavorable environmental factors, dissemination of infectious agents in a patient's body result in increased frequency of purulent-septic complications, thereby making the study on methods of their diagnosis and treatment relevant. Aim of the work: to examine the diagnostic value of lung ultrasound (US) and spiral computed tomography (SCT) in the diagnosis of acute abscesses and in determining the tactics of surgical treatment. Materials and methods. A prospective study of 40 cases of acute lung abscesses with diagnostic value of US and SCT examination to choose a surgical method in accordance with the type of acute lung abscess. Results. Male was dominated in the study (82.5 %). The median age was 52 (43.5; 60.0) years. SCT revealed an abscess with sequestration in 9 (22.5 %) of 40 patients, which was confirmed during surgery. A false negative result was obtained in 5 (35.7 %) patients out of 14. Lung US revealed sequestration in 14 (35.0 %) patients: 2 (14.3 %) of them were false positive. Transthoracic drainage was performed in 24 (92.3 %) of 26 patients without sequestration. In 2 (7.7 %) cases – video abscessoscopy (VAS). The median length of hospital stay was 34.5 (29.0; 43.0) days for patients without sequestration and 32.0 (26.0; 35.0) – with sequestration, Р = 0.16. Conclusions. Modern radiation imaging is an effective tool for the diagnosis of lung abscess. The sensitivity and specificity of computed tomography was 64.3 % and 100.0 %, sonography – 85.7 % and 92.3 %, respectively, in the study. The concurrent use of these diagnostic methods increases their information content: sensitivity up to 100.0 %, specificity up to 92.3 %. Video abscessoscopy with sequestrectomy is an effective method of treatment and etiological diagnosis of the process, which allows achieving the length of hospital stay comparable to patients without sequestration: 32.0 (26.0; 35.0) vs 34.5 (29.0; 43.0), Р = 0.16.

Thoracic surgical procedures and the use of cardiac devices such as pacemakers are becoming increasingly common in the population. Therefore, dermatologists may be more likely to encounter previously implanted or discarded surgical material during a dermatological operation on the chest wall. A basic understanding of the types of wires and tunneling paths used in such procedures is essential to accurately predict the presence of these wires and effectively manage any chance encounters. Dermatologists should be aware that temporary epicardial pacemaker electrodes and pacemaker electrodes often remain in the chest wall of many patients. All patients with a history of cardiac surgery should be asked about the possible presence of temporary epicardial electrodes in their body, and if such materials are found during the operation, it is necessary to immediately stop the procedure and do not undertake further manipulations with them until the material from which it is made is determined. Specialists in cardiology and cardiothoracic surgery need to document any abandoned wire in the patient's list of problems and inform the patient about the abandoned wire so that he or she can be an important source of clinical information. Trying to pull out the remaining pacemaker electrodes is a serious risk, so dermatologist surgeons should not attempt it under any circumstances. When detecting wire material, it is necessary to determine the type and location of the material before any manipulation or pulling attempts. Once it is established that this is a non-functional, abandoned wire, it is necessary to apply the correct technique for removing it, which consists in gently pulling and securing the wire at the exit point. Accurate identification of the material is required in order not to interfere with the operation of the active device and not to abandon the operation unnecessarily. The aim of the work is to consider the implementation of dermatological operations in patients who have previously undergone cardiac surgery.

Most cases of mediastinal abscess occur as a postoperative complication of a thoracic surgical procedure or following trauma. The most common causative microorganism is Staphylococcus aureus, but it can be rarely caused by unusual microorganisms, such as Gemella species. These are relatively difficult-to-identify commensal microorganisms of the upper respiratory and gastrointestinal tracts and may cause several infections. A 66-year-old man was diagnosed with Gemella bergeri mediastinal abscess by the molecular detection of bacterial genes. He was successfully treated with penicillin antibiotic for eight weeks. To our knowledge, this is the first case report of mediastinal abscess caused by G. bergeri.

Lung cancer is a type of neoplasia with one of the highest incidences worldwide and is the largest cause of mortality due to cancer in the world today. It is classified according to its histological and biological characteristics, which will determine its treatment and prognosis. Non-small cell lung cancer accounts for 85% of the cases, and these are the cases that surgeons mostly deal with. Small cell lung cancer accounts for the remaining 15%. Surgery is the main method for treating early stage lung cancer, and lobectomy is the preferred procedure for treating primary lung cancer, while sublobar resection is an alternative for patients with poor reserve or with very small tumors. Surgeons need to be trained to use the resources and techniques available for lung resection, including less invasive approaches such as video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS), and need to be familiar with new oncological approaches, including curative, adjuvant or palliative treatments for patients with lung cancer.

Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used in patients undergoing complex thoracic surgical procedures. However, studies reporting the clinical outcomes of these patients are limited to case reports, without real consensus. Our aim was to evaluate the perioperative use of ECMO as respiratory and/or circulatory support in thoracic surgery: indications, benefits, and perioperative management. Methods: Between May 2013 and December 2018, we reviewed the clinical data of 15 patients (11 males and 4 females; mean age: 47 years old; range, 25–73 years) undergoing ECMO-assisted thoracic surgery in our hospital. Results: Of the 15 patients, 10 cases received peripheral veno-arterial (VA) ECMO and five cases received veno-venous (VV) ECMO. Indications for ECMO were pulmonary transplantation with hard-to-maintain oxygenation (n = 5), traumatic main bronchial rupture (n = 2), traumatic lung injury (n = 1), airway tumor leading to severe airway stenosis (n = 2), huge thoracic mass infiltrated vena cava (n = 5). The ECMO duration was 1–51 hours. All patients were successfully extubated and weaned from ECMO postoperatively. The main complications were hemorrhage (26.7%), infection (33.3%), acute hepatic dysfunction (33.3%), and venous thrombosis (26.7%). There was only one hospital death and postoperative one-year survival rate was 86%. Conclusion: Our experience indicates that ECMO is a feasible method for complex trachea-bronchial surgery, huge thoracic mass excision and lung transplantation, and the ECMO-related risks may be justified. With further accumulation of experience with ECMO, a more sophisticated protocol for management of critical airway or heart failure problems in thoracic surgeries can be derived.

Objective Enhanced recovery after surgery (ERAS) with a pre-emptive pain management program has been shown to decrease opioid prescriptions after thoracic surgery. We sought to determine which patient or procedural factors were associated with the need for prescription opioid medications after thoracic surgical procedures. Methods We performed a retrospective analysis of a postoperative pain survey at the time of follow-up in combination with procedural and patient characteristic data. We then performed univariate and multivariate logistic regression to determine factors associated with prescription opioids use. Results Two hundred twenty-eight patients completed questionnaires at a median of 37 days after surgery. Most patients received minimally invasive surgery (n = 213, 93%) with the 2 most common types of operations being foregut (n = 92, 40%) and pulmonary resection (n = 80, 35%). Thirty-nine percent of patients (n = 89) were taking chronic pain medications preoperatively, with 15% on chronic opioids medication (n = 33). After surgery, 166 patients (72%) did not take opioids at home. Multivariate analysis showed any chronic opioid medications before surgery (odds ratio, 28.8; 95% confidence interval, 9.13-90.8, P Conclusions ERAS with pre-emptive pain management was associated with patients avoiding opioid prescriptions during recovery. The patient factor of preoperative opioid pain medication(s) and younger age is a significant factor for the patient needing opioids at home after surgery instead of procedural factors. Patient characteristics should be considered when tailoring the patient's pain management after thoracic surgical procedures.

In the last five years, surgeons have applied endoscopic transforaminal surgical techniques mastered in the lumbar spine to the treatment of thoracic pathology. The aim of this systematic review was to collate the available literature to determine the place and efficacy of full endoscopic approaches used in the treatment of thoracic disc prolapse and stenosis. An electronic literature search of PubMed, Embase, the Cochrane database and Google Scholar was performed as suggested by the Preferred Reporting Items for Systematic Review and Meta-analysis statements. Included were any full-text articles referring to full endoscopic thoracic surgical procedures in any language. We identified 17 patient series, one cohort study and 13 case reports with single or of up to three patients. Although the majority included disc pathology, 11 papers related cord compression in a proportion of cases to ossification of the ligamentum flavum or posterior longitudinal ligament. Two studies described the treatment of discitis and one reported the use of endoscopy for tumour resection. Where reported, excellent or good outcomes were achieved for full endoscopic procedures in a mean of 81% of patients (range 46–100%) with a complication rate of 8% (range 0–15%), comparing favourably with rates reported after open discectomy (anterior, posterolateral and thoracoscopic) or by endoscopic tubular assisted approaches. Twenty-one of the 31 author groups reported use of local anaesthesia plus sedation rather than general anaesthesia, providing ‘self-neuromonitoring’ by allowing patients to respond to cord and/or nerve stimuli.Cite this article: EFORT Open Rev 2021;6:50-60. DOI: 10.1302/2058-5241.6.200080

Purpose of review Perioperative transesophageal echocardiography (TEE) is most often employed during cardiac surgery. This review will summarize some of the recent findings relevant to TEE utilization during thoracic surgical procedures. Recent findings Hemodynamic monitoring is a key component of goal-directed fluid therapy, which is also becoming more common for management of thoracic surgical procedures. Although usually not required for the anesthetic management of common thoracic surgeries, TEE is frequently used during lung transplantation and pulmonary thromboendarterectomy. Few clinical studies support current practice patterns, and most recommendations are based on expert opinion. Summary Currently, routine use of TEE in thoracic surgery is often limited to specific high-risk patients and/or procedures. As in other perioperative settings, TEE may be utilized to elucidate the cause of acute hemodynamic instability without apparent cause. Contraindications to TEE still apply and have to be taken into consideration before performing a TEE on a thoracic surgical patient.

OBJECTIVES We reviewed the incidence of coronavirus disease 2019 cases and the postoperative outcomes of patients who had thoracic surgery during the beginning and at the highest point of transmission in our community. METHODS We retrospectively reviewed patients who had undergone elective thoracic surgery from 12 February 2020 to 30 April 2020 and were symptomatic or tested positive for severe acute respiratory syndrome coronavirus 2 infection within 14 days after surgery, with a focus on their complications and potential deaths. RESULTS Out of 101 surgical procedures, including 57 primary oncological resections, 6 lung transplants and 18 emergency procedures, only 5 cases of coronavirus disease 2019 were identified, 3 in the immediate postoperative period and 2 as outpatients. All 5 patients had cancer; the median age was 64 years. The main virus-related symptom was fever (80%), and the median onset of coronavirus disease 2019 was 3 days. Although 80% of the patients who had positive test results for severe acute respiratory syndrome coronavirus 2 required in-hospital care, none of them were considered severe or critical and none died. CONCLUSIONS These results indicate that, in properly selected cases, with short preoperative in-hospital stays, strict isolation and infection control protocols, managed by a dedicated multidisciplinary team, a surgical procedure could be performed with a relatively low risk for the patient., Since the outbreak of the novel coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Wuhan, China [1], over 4.9 million cases have been diagnosed around the world [2].

Background Paravertebral block can be performed with the aid of surgical landmarks, ultrasound, or a thoracoscope. This study was designed to compare ultrasound-guided paravertebral block with the thoracoscopic technique. Methods This prospective randomized comparative study included 40 adults scheduled for elective thoracic surgery. Study participants were randomized to an ultrasound group or a thoracoscope group. A catheter for paravertebral block was inserted prior to thoracotomy with real-time ultrasound visualization in the ultrasound group, and under thoracoscopic guidance in the thoracoscope group. Total analgesic consumption, visual analogue pain score, technical difficulties, and complications were compared between the 2 groups. Results Total analgesic consumption in the first 24 hours was less in the ultrasound group than in the thoracoscope group (rescue intravenous fentanyl 121.25 ± 64.01 µg in the ultrasound group vs. 178.75 ± 91.36 µg in the thoracoscope group; p = 0.027). Total paravertebral bupivacaine consumption was 376.00 ± 33.779 mg in the ultrasound group and 471.50 ± 64.341 mg in the thoracoscope group ( p Conclusion Ultrasound-guided paravertebral catheter insertion is more effective, technically easier, and safer than the thoracoscope-assisted technique.

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Regional anaesthetic techniques are an indispensable element of acute and postoperative pain management. The benefits of regional blocks are particularly noticeable in trauma and orthopaedic, joint reconstruction or thoracic surgical procedures. Depending on the local anaesthetic (LA) used, the duration of analgesia is limited to a maximum of 12-16 hours. There are several methods affecting the prolongation of analgesia, e.g. continuous techniques with catheters, liposomal forms of LAs or adjuvants. Due to numerous limitations and problems associated with the use of continuous techniques, lack of approval or availability of liposomal LAs, the optimal measure to prolong the duration of postoperative analgesia is the use of adjuvants. The present study aims to collect and systematise the current knowledge about the most common adjuvants used for nerve / plexus blockades and intravenous regional anaesthesia.

Chylothorax is a condition in which chyle leaks into the thoracic cavity. The causes of chylothorax can be nontraumatic, traumatic or idiopathic. The most common cause of nontraumatic chylothorax is obstruction of the thoracic duct by tumor. Traumatic chylothorax is caused by disruption of the thoracic duct, most often due to cardiac surgery or a thoracic surgical procedure, although in rare cases by cough or vomiting. We report the case of a 3-month-old boy with respiratory syncytial (RS) virus infection who presented with right chylothorax. No obstructive tumor mass was identified in the thoracic duct. Clinical symptoms of Noonan syndrome and Down syndrome, which often accompany lymphatic anomaly, were not found. Therefore, we speculate that his severe cough caused a high thoracic pressure and a disruption of the thoracic duct. He was treated by thoracocentesis and MCT milk. One month later, pleural effusion disappeared and did not recur. RS virus infection might be a rare cause of chylothorax in infants.

Postoperative chylothorax is a rare occurrence after various thoracic surgical procedures, but it poses a substantial risk of morbidity and mortality. Thoracic duct embolization (TDE) is currently deemed the optimal treatment due to its safety and efficacy. This review offers an introduction to interventional options in this setting, detailing the steps of TDE for the edification of those engaged in postoperative care.

The extraordinary demands of managing the COVID-19 pandemic has disrupted the world's ability to care for patients with thoracic malignancies. As a hospital's COVID-19 population increases and hospital resources are depleted, the ability to provide surgical care is progressively restricted, forcing surgeons to prioritize among their cancer populations. Representatives from multiple cancer, surgical, and research organizations have come together to provide a guide for triaging patients with thoracic malignancies as the impact of COVID-19 evolves as each hospital.

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Background Cardiothoracic surgeons are facing a big challenge in their surgical practice in the era of the COVID-19 pandemic. The attitude towards performing surgery is influenced by the pandemic. Setting special recommendations for safe cardiothoracic surgery is of extreme importance. Methods This was an observational cross-sectional survey that included 77 Egyptian cardiothoracic surgeons. The survey consisted of a self-administered constructed questionnaire with six sections, and was delivered as a Google Forms questionnaire ( https://www.google.com/forms/about ) that was sent to individuals via social networks and email. Results More than 80% of Egyptian cardiothoracic surgeons believe they and their patients are at risk. Out of all participants, none had actually been infected with COVID-19 but 26% had encountered a positive COVID-19 person in their surgical team. Although 51% were testing patients before surgery, they reported 9 confirmed cases postoperatively. Computed tomography was the most recommended investigation prior to surgery (by 69%). Most had postponed elective surgeries and only one-third of all surgeons recommended performing elective surgeries cautiously with pretesting for COVID-19 and maximizing protective measures, while more than 40% recommended not performing high-risk elective surgeries. Conclusion We are committed to the safety of our patients, ourselves, our staff, and our families. Planning for the new phase of reopening, whether total reopening or step-by-step reopening, should carefully consider how we should utilize our resources, respect social distancing, and prevent exposure to untested patients or health workers who might turn out to be an undetected positive case.

Background The risk stratification value of the 6-min walk test (6MWT) to decide the feasibility of surgical resection is not well elucidated in patients with non-small cell lung cancer (NSCLC) and moderately decreased lung function. Objective This study aimed to determine the role of the 6MWT in predicting postoperative cardiopulmonary complications in patients with NSCLC who underwent lobectomy and had moderately decreased lung function. Methods The data were obtained from a prospective cohort study called Coordinate Approach to Cancer Patient’s Health for Lung Cancer (CATCH-LUNG). Patients who underwent lobectomy for NSCLC were classified into two groups according to predicted postoperative pulmonary function (low-risk group or moderate-risk group); each group was then further classified into short-distance ( Results The adjusted ORs for any postoperative pulmonary complications, postoperative cardiac complications, and postoperative cardiopulmonary complications in patients with moderate-risk/short-distance relative to those with low-risk/long-distance were 10.26 (95% CI, 2.37-44.36), 5.65 (95% CI, 1.39-22.90), and 7.84 (95% CI, 2.24-27.46), respectively. However, these complications were not different between the patients with moderate-risk/long-term distance and those with low-risk/long-distance. Among patients in the moderate-risk group, those in the short-distance group had a significantly higher risk of postoperative cardiopulmonary complications compared with those in the long-distance group (adjusted OR, 4.95; 95% CI, 1.37-17.93). Conclusions Patients with NSCLC with moderate-risk/short-distance were at greater risk of developing postoperative cardiopulmonary complications; it may be feasible, however, for patients with NSCLC and moderate-risk/long-distance to undergo lobectomy compared with those with low-risk/long-distance. Our study suggests that the 6MWT could provide additional information in identifying optimal candidates for lung resection surgery of NSCLC. Trial Registry ClinicalTrials.gov; No.: NCT03705546 ; URL: www.clinicaltrials.gov .

As many as one third of patients undergoing minimally invasive thoracic surgery and one half undergoing thoracotomy will have chronic pain, defined as pain lasting 2 to 3 months. There is limited information regarding predictors of chronic pain and even less is known about its impact on health-related quality of life, known as pain interference. Currently, there is a focus on decreased opioid prescribing after surgery. Interestingly, thoracic surgical patients are the least likely to be receiving opioids before surgery and have the highest rate of new persistent opioid use after surgery compared with other surgical cohorts. These studies of opioid use have identified important predictors of new persistent opioid use, but their findings are limited by failing to correlate opioid use with pain. The objectives of this invited review are to present the findings of pertinent studies of chronic pain and opioid use after thoracic surgery, "where we are," and to discuss gaps in our knowledge of these topics and opportunities for research to fill those gaps, "where we need to go."

Background Pectus excavatum is less common in females than in males, and it often aggravates a coexistent breast asymmetry. We conducted a study comparing female patients’ versus medical professionals’ evaluation of pectus excavatum repair to assess differences in aesthetic outcome ratings. Moreover, we evaluated the influence of surgical correction on patients’ self-perception. Methods Of 30 female patients who were initially screened, 18 patients (mean age, 20 years) who underwent bar removal after surgical correction of pectus excavatum deformity participated in the survey (60%). They completed a questionnaire rating their appearance before and after surgery and responded to a psychological questionnaire about the changes that they had experienced. The mean interval between pectus bar removal and evaluation was 28 months. Standardized preoperative and postoperative patient photographs were evaluated using the same questionnaire by a panel of medical professionals and students (n=24) and the results were compared. Results Patients rated their preoperative deformity as more severe than the other evaluators, revealing the significant impact of the deformity on patients’ self-perception. Postoperatively, patient and professional evaluations were much better than before and were very similar. The psychological evaluation showed a clear improvement in well-being. The ratings of the medical professionals were not influenced by their degree of medical education. Conclusions Surgical correction of pectus excavatum in female patients positively influences body perception and psychological well-being. It should therefore not be considered as a merely aesthetic correction, but as an important procedure to restore a patient’s self-perception.

Introduction: Microalbuminuria (MA) is considered a reflection of systemic capillary leak and an early marker of acute stress reaction to the surgical insult, proportional to the severity of the initiating condition and predictive of the individual response to surgical stress. Objectives: We conducted a prospective study to assess for the variation of MA within 4 days after thoracic surgery. We correlated observed MA levels with both their respective PaO2/FiO2 respiratory ratio and the onset of postoperative complications. Methods: This single-centre study enrolled 255 consecutive patients having an American Society of Anaesthesiologists (ASA)score≤3. The mean age was 62 years with 67% male. All patients were scheduled for elective pulmonary resection. MA was measured in urine samples as the albumin-to-creatinine ratio (A/C), prior to, at and after extubation up to 96 hours. PaO2/FiO2 was measured at extubation and on the first postoperative day. Results: Overall, preoperative A/C levels resulted normal, with a significant average increase at extubation which peaked 6 hours later (P 61mg/g (P=0.0003) was associated with postoperative cardio-pulmonary complications (OR 3.85; P=0.003). Conclusion: Within 6 hours after extubation, MA assessment may be a rapid and relatively inexpensive method for better predicting perioperative risk in an ASA score ≤3 population.

Introduction The reconstruction of defects in thoracic wall remains a challenge for plastic surgeons. Advances in surgical treatment of illnesses of thoracic wall have been fostering the treatment of lesions within more advanced levels. Consequently, larger and more complex defects are generated, demanding soft tissue covering and framework repair. Objective The aim of this study was to report the experience in chest wall reconstruction and demographics of a tertiary cancer center. Methods All patients submitted to thoracic wall reconstruction by the plastic surgery department from January 2012 to May 2018 in a tertiary cancer center were evaluated. Results Thirty-two patients have undergone thoracic wall reconstruction. The majority of patients in our series were submitted to surgical treatment of locally advanced breast cancer (84.3%). The most common defect location was the right anterolateral region (65.6%). The latissimus dorsi musculocutaneous flap was the most used in thoracic wall reconstructions. Three cases of thoracectomy with rib resection were reconstructed with methylmethacrylate and polypropylene surgical mesh associated with musculocutaneous flap. Four patients presented major complications, and 12 patients (37.5%) presented minor complications. There were no deaths related to procedures or instability of thoracic wall. Twenty-two patients presented progression of the disease, and 16 died due to the primary pathology. Conclusions Extended resection of the chest wall is associated in most cases with advanced disease, especially advanced breast cancer. Despite poor prognosis associated to locally advanced disease, it is imperative to perform chest wall reconstruction and allow the patient to continue adjuvant therapy (radiotherapy or chemotherapy) and improve quality of life.

Objective To assess bleeding following transection of the pulmonary artery with powered and manual endoscopic staplers. Methods Cases of video-assisted and open-chest thoracic surgical procedures for non-small cell lung cancer at Ishikawa Prefectural Central Hospital were reviewed between 2012 and 2018. Three stapler groups were assessed: Group 1 - Ethicon ECHELON FLEXTM Powered Vascular Stapler (PVS), Group 2 - Medtronic Endo-GIATM iDriveTM powered stapler, Group 3 - Ethicon and Medtronic manual staplers. Results Of 239 patients, 82 cases (34.3%) were Group 1, 94 cases (39.3%) were Group 2 and 63 cases (26.4%) were Group 3. Mean age was 68.3 years (range 36-88 years), and most patients received video-assisted right upper lobectomy (82.8%). Bleeding occurred in 24 cases: 17 (70.8%) in Group 2 and 7 (29.2%) cases in Group 3. No bleeding occurred in Group 1. The loaded ECHELON FLEXTM PVS and Endo-GIATM iDriveTM with gray cartridge combinations had the greatest and smallest closed anvil jaw gaps (>0.63 µm and

Background: In the current healthcare environment there is increasing pressure to deliver high quality care to more people at less cost. Robotic assisted thoracic surgical procedures (RATS) have been shown by some to be more expensive than conventional endoscopic or open surgery. We initiated this study to assess the financial impact of RATS compared to robotic non-thoracic surgery in an academic institution. Methods: A retrospective study was performed for all patients who underwent any robotically assisted surgical procedure at Temple University Hospital (TUH) in fiscal year 2015. Surgical volume, operative time, length of stay (LOS), case mix index (CMI), direct and indirect costs, hospital charges, surgical charges, contribution margin (CM) and net margin (NM) were collected for the thoracic surgery service in addition to other services which performed more than 20 robotic cases a year. We analyzed the data according to the following strategy: (I) financial performance for both inpatient and outpatient robotic procedures for the entire hospital; (II) compared financial data for robotic and non-robotic surgeries in the thoracic surgery division; (III) compared thoracic surgery data with the STS database for the same time period in order to calculate any potential cost saving (PCS). Results: In FY15, a total of 696 robotic procedures were performed by the various services at TUH with a mean of 58 cases each month. Although CM was highest for cardiovascular surgery, the highest NM was by thoracic surgery. Despite having the highest volume and a positive CM, the mostly outpatient urology service showed a negative NM in FY15. A CMI-adjusted comparison on 208 of the 589 robotic procedures where there was a comparable group of inpatients who had open procedures, the mean direct cost for non-robotic procedures was $6,239, 9% less than for robotic procedures. The mean total cost for non-robotic procedures was only 3.64% ($435) less than that for robotic procedures ($11,502 vs. $11,937). When compared with the UHC expected LOS, the robotic group had a lower LOS while the non-robotic group had a higher LOS. The mean total direct costs were $3,510 less for the robotic procedures ($16,502 vs. $20,012). When compared to similar cases reported to the STS in FY 2015, the length of stay, conversion rate, transfusion rate, post-operative complications and OR time compared favorably. Using calculations based on published data, the potential cost savings are in the 1 to 2 million dollar range compared to traditional endoscopic or open procedures reported to the STS. Conclusions: High acuity services such as Thoracic Surgery drive higher CM per case as long as variable costs especially LOS are kept low. Procedures with lower CMI may not provide a high enough CM to offset the fixed and variable costs. Robotic surgical cases performed in the outpatient setting may incur significant losses as the reimbursement does not cover the direct costs. Hospitals should preferentially allocate robotic resources to inpatient procedures with higher CMI and work to decrease overall LOS.

The therapy of severely injured patients is demanding and promising only in an interdisciplinary context. From a thoracic surgical perspective, the blunt chest trauma is in the foreground; as it is the 2nd leading cause of death after traumatic brain injury. The first step is to identify the potentially life-threatening injury and its treatment (airway obstruction, prevention of gas exchange, tension pneumothorax, serious bleeding complications in lung-/vascular injuries). Pneumothorax or tension pneumothorax is present in 20% of all polytrauma patients and 50% of all patients with severe chest trauma. In most cases, the use of a chest tube is sufficient in the acute phase (90%). For complex injuries with persistent thoracic haemorrhage and haemodynamic instability of the patient or pleural fistulization with increasing skin emphysema, surgical treatment should be performed at an early interval. Nevertheless, emergency thoracotomy is rarely required at this early stage.

Introduction and objectives: Blockade of the Erector Spinal Muscle (ESP Block) is a relatively new block, initially described for chronic thoracic pain analgesia, but it has already been described for anesthesia and analgesia in thoracic surgical procedures and, more recently, for high abdominal surgeries. The aim of the study was to compare two techniques, ESP Block and Epidural Block, with morphine and local anesthetic for postoperative analgesia of open cholecystectomy surgeries. Methods: Controlled single-blind randomized clinical trial with 31 patients (ESP Block, n = 15; Epidural, n = 16), of both genders, ages between 27 and 77 years. The ESP block was performed at the T8 level with injection of 20 mL of 0.5% ropivacaine bilaterally. The epidural block was performed at the T8-T9 space with 20 mL of 0.5% ropivacaine and 1 mg of morphine. Results: The ESP Block group presented higher mean Numeric Pain Scale (NPS) values for pain in the up to 2 hour (p = 0.001) and in the 24 hour (p = 0.001) assessments. The ESP Block group had a three-fold increased risk (43.7% vs. 13.3%) of rescue opioid use in the 24 postoperative hours when compared to the epidural group (RR = 3.72, 95% CI: 0.91 to 15.31, p = 0.046). Conclusion: ESP Block did not prove to be an effective technique for postoperative analgesia of open cholecystectomy, at the doses performed in this study, having required more use of rescue opioid, and without differences in NPS. More comprehensive studies are required to assess the efficacy of ESP block for the visceral and abdominal somatic component, considering the specific blockade level. Resumo Justificativa e objetivo: O Bloqueio do Plano do Músculo Eretor da Espinha (ESP block) é um bloqueio relativamente novo, inicialmente descrito para analgesia de dor torácica crônica, porém já descrito para anestesia e analgesia em procedimentos cirúrgicos torácicos e, mais recentemente, para cirurgias abdominais altas. O estudo objetivou comparar as técnicas de bloqueio ESP e bloqueio Epidural com morfina e anestésico local para analgesia pós-operatória de cirurgias de colecistectomia aberta. Método: Estudo clínico randomizado controlado, unicego com 31 pacientes (ESP block, n = 15; Epidural, n = 16), de ambos os sexos, idades entre 27 e 77 anos. O ESP block foi realizado no nível de T8 com injeção de 20 mL de ropivacaína 0,5% bilateral. O bloqueio Epidural foi realizado no espaço T8-T9 com 20 mL de ropivacaína 0,5% e 1 mg de morfina. Resultados: O grupo ESP block apresentou valores médios de dor pela Escala Visual Numérica (EVN) maiores nas avaliações até 2 horas (p= 0,001) e em 24 horas (p= 0,001). O grupo ESP block apresentou um risco três vezes maior - 43,7%vs.13,3% - de uso de opioide de resgate em 24 horas pós-operatórias do que o grupo epidural (RR = 3,72; 95% IC 0,91 a 15,31; p= 0,046). Conclusão: Nas doses realizadas nesse estudo, o ESP block não se mostrou uma técnica efetiva para analgesia pós-operatória de colecistectomia aberta, com mais uso de opioide de resgate e sem diferenças na escala visual numérica de dor. Necessita-se de estudos mais abrangentes avaliando a eficácia do ESP block para o componente visceral e somático abdominal, considerando o nível do bloqueio específico.

Background The Covid-19 pandemic has caused changes in the surgical treatment of non-Covid patients, especially in thoracic surgery because most procedures are aerosol generating. Hospital Kuala Lumpur, where thoracic procedures are performed, was badly affected. We describe our experience in performing aerosol generating procedures safely in thoracic surgery during the Covid-19 era. Methods Medical records of patients who underwent thoracic surgery from March 18, 2020 to May 17, 2020 were reviewed retrospectively. All patients undergoing thoracic surgery were tested for Covid-19 using the reverse transcriptase polymerase chain reaction method. Patients with malignancy were observed for 10 to 14 days in the ward after testing negative. The healthcare workers donned personal protective equipment for all the cases, and the number of healthcare workers in the operating room was limited to the minimum required. Results A total of 44 procedures were performed in 26 thoracic surgeries. All of these procedures were classified as aerosol generating, and the mean duration of the surgery was 130 ± 43 minutes. None of the healthcare workers involved in the surgery were exposed or infected by Covid-19. Conclusion Covid-19 will be a threat for a long time and thoracic surgeons must continue to provide their services, despite having to deal with aerosol generating procedures, in the new normal. Covid-19 testing of all surgical candidates, using the reverse transcriptase polymerase chain reaction, donning full personal protective equipment for healthcare workers, and carefully planned procedures are among the measures suggested to prevent unnecessary Covid-19 exposure in thoracic surgery.

During anesthesia for a thoracic surgical procedure, many alterations in physiology occur, including changes in oxygenation and ventilation. Monitoring of oxygenation and ventilation are of vital importance, particularly in thoracic anesthesia because one-lung ventilation is often necessary to perform the surgery safely. Pulse oximetry, oxygen reserve index, spirometry, and capnography are the major monitoring methods the anesthesiologist should be proficient with when administering anesthesia for thoracic surgeries.

Double lumen tubes (DLTs) are most commonly used to achieve one lung ventilation (OLV) in most thoracic surgical procedures unless contraindicated. Left-sided DLT (LDLT) is most commonly used nowadays for most thoracic surgical procedures. Though, the use of LDLT dates long back in history, two clinical and technical issues are yet to be resolved. The first issue is the ideal size of DLT which is defined as that which provides near-complete seal of the bronchial lumen without cuff inflation. There are no guidelines in literature which help in selecting the size of DLT. However, general consensus among thoracic anesthesiologists recommends the use of smaller sizes to avoid airway trauma. In our practice and for the last few years, we are using smaller size LDLT 35 F for females and 37 F for males with minimal airway trauma and had encouraging results. The second issue is the insertion depth of the LDLT. We have introduced a height-based formula to predict the insertion depth of LDLT with encouraging results. However, even with the use of the formula, we still recommend the use of fiberoptic bronchoscopic confirmation method for final positioning of the LDLT.

BACKGROUND Severe thoracic trauma (TT) has a significant impact on the selection of treatment strategy in patients with polytrauma. Our aim was to assess the impact of severe TT on choosing the optimal surgical procedure to decrease mortality. MATERIAL AND METHODS Overall, 66 patients with polytrauma and significant TT were analyzed. Demographic data, trauma history, admittance imaging, injury details, injury severity scores, conservative treatment, surgical treatment, days of hospital stay, and mortality data were gathered. Frequencies of thoracic surgical procedures and other treatments were collected and compared with those in the literature. RESULTS All patients had Abbreviated Injury Scale (AIS) scores of thorax >3. Injuries to extremities and/or the osseous pelvis accounted for 50% of injuries ; 47.0% included the head and/or neck ; 45.5% were external injuries ; and 27.3% were abdominal injuries or included pelvic organs and/or lumbar spine. Mean prehospital time was 40.3 min. Mean time from trauma occurrence to tertiary treatment was 125 min. Blunt TT (BTT) was recorded in 59 patients (89.4%), and penetrant TT (PTT) was recorded in 7 patients (10.6%). Thoracic drainage, urgent thoracotomy and laparotomy were recorded procedures. The mean Injury Severity Score (ISS) of all patients was 31.17. Nine patients died (13.6%) and had BTT with a mean ISS of 48.44. The Trauma Injury Severity Score for BTT injuries was 77.08% and for PTT, 85.6%. CONCLUSIONS Factors that decreased hospital stay and mortality and increased survival included arriving in time after injury, aggressive reanimation/intensive care, and mandatory thoracic surgical procedure combined with laparotomy.

Executive Summary Cardiothoracic surgical patients are at risk of increased coronavirus disease severity. Several important factors influence the administration of the coronavirus disease vaccine in the perioperative period. This guidance statement outlines current information regarding vaccine types, summarizes recommendations regarding appropriate timing of administration, and provides information regarding side effects in the perioperative period for cardiac and thoracic surgical patients.

Background:Phrenic nerve injury is a common complication of cardiac and thoracic surgical procedures, with potentially severe effects on the health of a child. This review aims to summarise the available literature on the diagnosis and management of PNI post-cardiac surgery in paediatric patients with CHD.Main body:The presence of injury post-surgery can be difficult to detect and may present with non-specific symptoms, emphasising the importance of an effective diagnostic strategy. Chest X-ray is usually the first investigation for a suspected diagnosis of PNI, which is usually confirmed using fluoroscopy, ultrasound scan, or phrenic nerve stimulation (gold standard). Management options include supportive ventilation and/or invasive diaphragmatic plication surgery. While the optimal timing of plication surgery remains controversial, it is now the most widely accepted treatment for PNI in children post-CHD surgery, especially for very young patients who cannot be weaned off supportive ventilation. Further research is needed to determine the optimal timing of surgical intervention for positive outcomes and to explore the benefits of using minimally invasive surgical techniques in children.Conclusion:PNI is a common and serious complication of CHD surgery, therefore, its diagnosis and management in the paediatric population are of major importance. Further research is needed to determine the optimal timing of surgical intervention for positive outcomes and to explore the benefits of using minimally invasive surgical techniques in children.

Since the beginning of use of video-assisted techniques for performance of thoracic surgical procedures more than two decades ago, the advances have been undeniable. Along that time, conversion of the initially planned video-assisted procedure to an open-chest technique because of intraoperative difficulties and/or accidents, was reasonable practiced and patients advised of that possibility beforehand. Along the same period, although numerous published studies can be find, still remain under discussion, two important areas worth to consider: 1. If in practice, similar or even better results are generally obtained. 2. If new, proved and recommended developments are in fact, followed. In this chapter, reasons for that conversion attitude of the past are reviewed in light of the advances achieved and considerations are made about quality of video-assisted procedures. Particularly on how well advances, recommendations and guidelines are followed, specially regarding lung cancer treatment.

In more than a century, Approaches to performing thoracic surgical procedures have been changed significantly. A milestone of those changes has been the advent of video-assisted techniques which quickly progressed from minor diagnostic procedures to the performance of almost any major thoracic surgery. by video-assisted thoracic surgery (VATS). Despite this, there are still indications for open chest surgeries, as well as the fact that thoracotomy techniques have grown to be significantly less invasive than the full thoracotomy of the past. This chapter examines the evolution of open chest techniques and describes in detail the current method of performing low invasiveness open chest surgery, which leads in excellent results with a mild postoperative course. Unresolved concerns in the comparison of video-assisted and open surgical procedures, notably in lung cancer surgery, are also discussed.