Patients with Pulmonary Artery Reconstruction or Double Sleeve Resection Show Inferior Survival than Patients with Bronchial Sleeve Resection for Non-small Cell Lung Cancer.

Sleeve lobectomy or resection with pulmonary artery reconstruction is a technique that allows for resection of locally advanced central lung carcinoma, preserving lung function, and is associated with lower morbidity and mortality than pneumonectomy. This survey aimed to assess the long-term survival comparing different types of sleeve lobectomy and identify risk factors affecting survival.All consecutive patients who underwent anatomical resection for primary non-small cell lung cancer with bronchial sleeve or pulmonary artery reconstruction in our department between September 2003 and September 2021 were included in this study. Cases with carinal sleeve pneumonectomy were excluded. Data were evaluated retrospectively.Bronchial sleeve resection was performed in 227 patients, double sleeve resection in 67 patients, and 45 cases underwent isolated lobectomy with pulmonary artery reconstruction. The mean follow-up was 33.5 months. The 5-year survival was 58.5% for patients after bronchial sleeve, 43.2% after double sleeve, and 36.8% after resection with vascular reconstruction. The difference in overall survival of these three groups was statistically significant (p = 0.012). However, the UICC stage was higher in cases with double sleeve resection or resection with vascular reconstruction (p = 0.016). Patients with lymph node metastases showed shorter overall survival (p = 0.033). The 5-year survival rate was 60.1% for patients with N0 and 47% for patients with N1 and N2 status. Induction therapy, vascular sleeve resection, and double sleeve resection were independent adverse predictors for overall survival in multivariate analysis.Sleeve lobectomy and resection with vascular reconstruction are safe procedures with good long-term survival. However, double sleeve resection and vascular sleeve resection were adverse predictors of survival, possibly due to a higher UICC stage in these patients.

Pneumonectomy with Carinal Sleeve Resection in Patients with Non-Small-Cell Lung Cancer.

BACKGROUND: Carinal sleeve resection with pneumonectomy is one of the rarest procedures in thoracic surgery, but for locally advanced central lung cancer with infiltration of the carina, it is an option to achieve complete resection. Additionally, it might be the method of choice for patients with stump insufficiency after pneumonectomy or in the cases with anastomosis dehiscence after sleeve lobectomy. The aim of this study was to evaluate the morbidity and long-term survival of patients with non-small-cell lung cancer (NSCLC) who underwent sleeve pneumonectomy, either for curative intent or as an option to treat postoperative complications. METHODS: All consecutive patients with NSCLC who underwent carinal sleeve pneumonectomy for the aforementioned indications in our department between December 2021 and September 2003 were included in this study. An analysis of demographic characteristics, perioperative variables, and long-term survival was carried out. Data were evaluated retrospectively. RESULTS: Fifty patients underwent pneumonectomy with carina sleeve resection. Thirty-one cases for curative treatment of NSCLC (primary sleeve pneumonectomy [pSP]) and 19 patients were treated because of postpneumonectomy bronchial stump insufficiency or bronchial anastomosis dehiscence (secondary sleeve pneumonectomy [sSP]). Complications occurred in 30 patients (60%) and the 90-day mortality was 18% (n = 9). Patients with pSP had an estimated overall survival of 39.6 months, compared to estimated overall survival for patients after sSP of 24.5 months (p = 0.01). The N status did not appear to affect outcomes. CONCLUSION: Carinal sleeve resection with pneumonectomy is a feasible procedure with limited morbidity and mortality. This procedure is a reasonable therapeutic option for patients with locally advanced central NSCLC after mandatory patient selection.

[Prevention, Diagnosis, Therapy, and Follow-up of Lung Cancer - Interdisciplinary Guideline of the German Respiratory Society and the German Cancer Society - Abridged Version]. / Prävention, Diagnostik, Therapie und Nachsorge des Lungenkarzinoms.

The current S3 Lung Cancer Guidelines are edited with fundamental changes to the previous edition based on the dynamic influx of information to this field:The recommendations include de novo a mandatory case presentation for all patients with lung cancer in a multidisciplinary tumor board before initiation of treatment, furthermore CT-Screening for asymptomatic patients at risk (after federal approval), recommendations for incidental lung nodule management , molecular testing of all NSCLC independent of subtypes, EGFR-mutations in resectable early stage lung cancer in relapsed or recurrent disease, adjuvant TKI-therapy in the presence of common EGFR-mutations, adjuvant consolidation treatment with checkpoint inhibitors in resected lung cancer with PD-L1 ≥ 50%, obligatory evaluation of PD-L1-status, consolidation treatment with checkpoint inhibition after radiochemotherapy in patients with PD-L1-pos. tumor, adjuvant consolidation treatment with checkpoint inhibition in patients withPD-L1 ≥ 50% stage IIIA and treatment options in PD-L1 ≥ 50% tumors independent of PD-L1status and targeted therapy and treatment option immune chemotherapy in first line SCLC patients.Based on the current dynamic status of information in this field and the turnaround time required to implement new options, a transformation to a "living guideline" was proposed.

[Tracheobronchial Injuries]. / Tracheobronchiale Verletzungen.

Tracheobronchial injury is a rare, but potentially life-threatening condition. These injuries are associated with high morbidity and mortality, which is ascribed to underlying diseases and additional injuries. Lacerations of the airway are differentiated into iatrogenic and non-iatrogenic injuries, while the group of non-iatrogenic lesions are grouped into blunt and penetrating traumas.The exact incidence of tracheobronchial injury is unknown, because many iatrogenic injuries occur without symptoms and most patients after traumatic laceration die before inpatient treatment. All patients with suspicion of airway injury require fast and accurate management.Common signs and symptoms are dyspnoea, haemoptysis, stridor and subcutaneous emphysema.Bronchoscopy is the most important tool for diagnosis and in several cases also for initial treatment.Further management depends on the patient's clinical condition and findings of bronchoscopy and computed tomography. Surgery has been the cornerstone of therapy, but in selected patients bronchoscopic stent implantation or conservative management must be discussed.

Atrial resection for T4 non-small cell lung cancer with left atrium involvement: a systematic review and meta-analysis of survival.

PURPOSE: Extended resection for non-small cell lung cancer (NSCLC) with T4 left atrium involvement is controversial. We performed a systematic review and meta-analysis to evaluate the short- and long-term outcomes of this treatment strategy. METHODS: We searched the PubMed database for studies on atrial resection in NSCLC patients. The primary investigated outcome was the effectiveness of the surgery represented by survival data and the secondary outcomes were postoperative morbidity, mortality, and recurrence. RESULTS: Our search identified 18 eligible studies including a total of 483 patients. Eleven studies reported median overall survival and 17 studies reported overall survival rates. The estimated pooled 1, 3, 5-year overall survival rates were 69.1% (95% CI 61.7-76.0%), 21.5% (95% CI 12.3-32.3%), and 19.9% (95% CI 13.9-26.6%), respectively. The median overall survival was 24 months (95% CI 17.7-27 months). Most studies reported significant associations between better survival and N0/1 status, complete resection status, and neoadjuvant therapy. CONCLUSION: Extended lung resection, including the left atrium, for NSCLC is feasible with acceptable morbidity and mortality when complete resection is achieved. Lymph node N0/1 status coupled with the use of neoadjuvant therapies is associated with better outcomes.

Aspergillus niger pneumonia as superinfection in a patient with pulmonary tuberculosis.

We report a patient with severe cavitary pulmonary tuberculosis and Aspergillus niger superinfection, whose only comorbidity was untreated diabetes mellitus. A. niger pneumonia was proven by PCR, sequencing and culture of pleural and respiratory secretions. The patient was successfully treated with a four-drug antituberculous regimen, liposomal amphotericin B (up to 5 mg/kg/d) and pleuro-pneumonectomy. Histology of the resected lung revealed destroyed lung tissue with inflammatory cells and fungal conidia. There were large deposits of polarising material, which was found to be calcium oxalate. There was also nodular caseating necrosis bordered by epitheloid cells and connective tissue. Thus, all diagnostic criteria for invasive A. niger infection were met. Several local risk factors, such as extensive lung damage and tissue acidification, may have favoured superinfection by A. niger. This case highlights the diagnostic value of calcium oxalate crystals in lung tissue and the need for combined antimicrobial and surgical treatment in extensive invasive aspergillosis caused by A. niger.

Survival outcomes in a prospective randomized multicenter Phase III trial comparing patients undergoing anatomical segmentectomy versus standard lobectomy for non-small cell lung cancer up to 2 cm.

OBJECTIVES: The oncological equivalence of anatomical segmentectomy for early stage non-small cell lung cancer (NSCLC) is still controversial. Primary aim of this study was survival outcomes in combination with improved quality of life after segmentectomy compared with lobectomy in patients with pathological stage Ia NSCLC (up to 2 cm, 7th edition) MATERIALS AND METHODS: We conducted a prospective, randomized, multicenter phase III trial to confirm the non-inferiority of segmentectomy to lobectomy in regard to prognosis (trial No. DRKS00004897). Patients were randomized to undergo either segmentectomy or lobectomy and followed up for 5-years survival and tumor recurrence. The 5-year hazard ratio comparing lobectomy with segmentectomy was required to remain above 0.5. RESULTS: Between October 2013 and June 2016, 108 patients with verified or suspected NSCLC up to 2 cm diameter were enrolled; 54 were assigned to lobectomy and 54 (1 drop-out) to segmentectomy. In-hospital and 90 days mortality was 0% in both groups. Overall survival at 5 years was 86.52% in the lobectomy compared to 78.21% in the segmentectomy group (HR = 0.61, (95% CI 0.23-1.66), p-value of non-inferiority test, p-ni = 0.687). Disease free survival was 77.29% for the lobectomy and 77.96% for the segmentectomy patients (HR = 1.50, (95% CI 0.60-3.76), p-ni = 0.019). At a median follow-up of 5 years, no differences were noted in either the locoregional or distant recurrent disease in both groups (9.4% vs 7.4%, p-ni = 0.506). CONCLUSION: Overall survival, locoregional and distant recurrences was not significantly difference for patients undergoing either segmentectomy or lobectomy for stage Ia NSCLC. The targeted non-inferiority of segmentectomy to lobectomy could not be proven for primary endpoint overall survival, but was significant for the secondary endpoint of disease free survival.

Postoperative outcome after palliative treatment of malignant pleural effusion.

BACKGROUND: The objective of this nationwide, registry-based study was to compare the two most frequently used procedures for the palliative treatment of a malignant pleural effusion (MPE) and to evaluate differentiated indications for these two procedures. METHODS: This was a retrospective observational study based on data of the "PLEURATUMOR" registry of the German Society for Thoracic Surgery. Patients who were documented in the period from January 2015 to November 2021 and had video-assisted thoracic surgery (VATS) talc pleurodesis or implantation of an indwelling pleural catheter (IPC) were included. RESULTS: A total of 543 patients were evaluated. The majority suffered from secondary pleural carcinomatosis (n = 402; 74%). VATS talc pleurodesis (n = 361; 66.5%) was performed about twice as often as IPC implantation (n = 182; 33.5%). The duration of surgery was significantly shorter in IPC-patients with 30 min compared to VATS talc pleurodesis (38 min; p = 0.000). Postoperative complication rate was 11.8% overall and slightly higher after VATS talc pleurodesis (n = 49; 13.6%) than after IPC implantation (n = 15; 8.2%). After VATS talc pleurodesis patients were hospitalized significantly longer compared to the IPC group (6 vs. 3.5 days; p = 0.000). There was no significant difference in postoperative wound infections between the groups (p = 0.10). The 30-day mortality was 7.9% (n = 41). CONCLUSION: The implantation of an IPC can significantly shorten the duration of surgery and the hospital stay. For this reason, the procedure should be matched with the patient's expectations preoperatively and the use of an IPC should be considered not only in the case of a trapped lung.

[Mediastinal Staging]. / Mediastinales Staging.

Thorough mediastinal staging is pivotal for prognostic assessment and treatment planning in patients with non-small-cell lung cancer (NSCLC) without distant metastasis. It aims to answer the question of whether a technically and functionally feasible operation also makes sense from an oncological point of view. In case of a nodal-free mediastinum, primary surgical therapy can be considered. If the ipsilateral mediastinal lymph nodes are affected, multimodal therapy should be sought. Operating is usually no longer the first step, especially with extensive lymph node infestation. Surgery is recommended, if neoadjuvant (radio-)chemotherapy has achieved downstaging or major response. If the contralateral mediastinal lymph nodes are involved, curative surgery is no longer part of the therapeutic concept. The therapy of choice in this situation is definitive chemo-radiotherapy.Guidelines for mediastinal staging consistently require to combine radiological, nuclear medicine and minimally invasive methods. Imaging with CT and PET allows an initial assessment of the mediastinal status. In most cases it has to be complemented with tissue confirmation. Echoendoscopic assessment of the mediastinum with needle biopsy is the minimally invasive method of first choice ("needle first"). Surgical staging methods are reserved for situations, that cannot be satisfactorily clarified by echoendoscopy.Technique and outcome of the different methods are described and algorithms are presented for different oncological situations.

Primary Clear Cell Sarcoma of the Lung: a Case Report.

BACKGROUND: Clear Cell Sarcoma of Soft Tissue (CCSST), or melanoma of the soft part, is a rare, aggressive tumor that originates in the aponeurosis and fasciae of the distal parts of the extremities. Reports from other sites of the body are rare. OBJECTIVE: We are reporting an extremely rare tumor that presented as a central left-sided lung mass and found to be clear cell sarcoma of soft tissue. METHODS: We report a 24-year-old male patient presented with recurrent attacks of left-sided chest pain associated with cough and dyspnea. RESULTS: Imaging showed a central left-sided 8*5.5*5 cm lung mass. The age of the patient and the radiological characteristics of the lesion were suggestive of a benign pathology. After histopathological assessment of the lesion, suspicion of the malignant process was raised, mainly melanoma of soft part and PEComa. The patient underwent left-sided pneumonectomy. The postoperative histological examination, immunohistochemical findings including positive staining for S-100, HMB-45, and Melan-A, and positive FISH study for EWSR1 gene rearrangements supported the diagnosis of CCSST originating primarily in the major fissure of left the lung. CONCLUSION: The rarity of CCSST in general and tumors originating in the lung primarily raise the challenges in hypothesizing a differential diagnosis, choosing proper investigations and treatment methods. The histological examination, immunohistochemical, and cytogenetics of the tumor are mandatory to reach the final diagnosis.

Mediastinales Staging.

Thorough mediastinal staging is pivotal for prognostic assessment and treatment planning in patients with non-small-cell lung cancer (NSCLC) without distant metastasis. It aims to answer the question of whether a technically and functionally feasible operation also makes sense from an oncological point of view. In case of a nodal-free mediastinum, primary surgical therapy can be considered. If the ipsilateral mediastinal lymph nodes are affected, multimodal therapy should be sought. Operating is usually no longer the first step, especially with extensive lymph node infestation. Surgery is recommended, if neoadjuvant (radio-)chemotherapy has achieved downstaging or major response. If the contralateral mediastinal lymph nodes are involved, curative surgery is no longer part of the therapeutic concept. The therapy of choice in this situation is definitive chemo-radiotherapy.Guidelines for mediastinal staging consistently require to combine radiological, nuclear medicine and minimally invasive methods. Imaging with CT and PET allows an initial assessment of the mediastinal status. In most cases it has to be complemented with tissue confirmation. Echoendoscopic assessment of the mediastinum with needle biopsy is the minimally invasive method of first choice ("needle first"). Surgical staging methods are reserved for situations, that cannot be satisfactorily clarified by echoendoscopy.Technique and outcome of the different methods are described and algorithms are presented for different oncological situations.

Carinal sleeve resection: last exit for bronchial insufficiency-a 17-year, single-centre experience.

OBJECTIVES: Bronchopleural fistula after pneumonectomy and dehiscence of an anastomosis after sleeve lobectomy are severe complications. Several established therapeutic options are available. Conservative treatment is recommended for a small fistula without pleural infection. In patients with a bronchopleural fistula and subsequent pleural empyema, surgical management is the mainstay. Overall, the associated morbidity and mortality are high. Carinal sleeve resection is the last resort for patients with a short stump after pneumonectomy or anastomotic dehiscence after sleeve resection near the carina. METHODS: All patients with bronchopleural fistula after pneumonectomy or sleeve resection who underwent secondary carinal sleeve resection between 2003 and 2019 in our institution were evaluated retrospectively. Patients with anastomotic dehiscence after sleeve lobectomy underwent a completion pneumonectomy. The surgical approach was an anterolateral thoracotomy; the anastomosis was covered with muscle flap, pericardial fat or omentum majus. In case of empyema, povidone-iodine-soaked towels were introduced into the cavity and changed at least twice. RESULTS: A total of 17 patients with an initial sleeve lobectomy in 12 patients and pneumonectomy in 5 patients were treated with carinal sleeve resection in our department. Morbidity was 64.7% and 30-day survival was 82.4% (n = 14). A total of 70.6% of the patients survived 90 days (n = 12). Median hospitalization was 17 days and the median stay in the intensive care unit was 12 days. CONCLUSIONS: Carinal sleeve resection is a feasible option in patients with a post-pneumonectomy fistula or anastomotic insufficiency following sleeve lobectomy in the absence of alternative therapeutic strategies. Nevertheless, postoperative morbidity is high, including prolonged intensive care unit stay.

Rib Osteoblastoma as a Cause of Neurogenic Thoracic Outlet Syndrome: A Case Report.

BACKGROUND Osteoblastoma is a very rare bone tumor accounting for 1% of all bone tumors. Most of the time it involves the spine and long bones and it involves the ribs very rarely. While osteoblastoma occurrence in the first rib has been reported, causing neurogenic thoracic outlet syndrome (TOS) has never been reported. CASE REPORT A 23-year-old woman presented with a left cervical mass associated with pain and paresthesia in the medial aspect of the left upper extremity and 4th and 5th fingers for the previous 3 months. The patient denied any previous illness or trauma in her history. Physical examination revealed a hard mass in the posterior triangle of the left neck with altered sensation in the left 4th and 5th fingers. The patient was investigated by a chest roentgenogram, nerve conduction study, computer tomography (CT) of the chest, and magnetic resonance image (MRI), as well as incisional biopsy. Although all radiological investigations were suggesting osteochondroma with a differential diagnosis of chondrosarcoma, the incisional biopsy showed osteoblastoma. Radical surgical excision of the lesion followed through a left supraclavicular approach. The patient's preoperative symptoms were relieved completely and there was no recurrence of the tumor at 2 years. CONCLUSIONS Osteoblastoma of the first rib is very rare tumor and to present with TOS is extremely rare. The nonspecific radiological characteristics of the tumor, especially on CT, makes the preoperative certainty of the diagnosis unlikely.

Rupture of pulmonary hydatid cyst in pediatrics: A cross-sectional study.

INTRODUCTION: Pulmonary hydatid cyst is a parasitic disease causing an endemic and a health burden in many regions. Lung cysts are more common than liver cysts in children and patients may remain asymptomatic. Cyst rupturing is not uncommon, and it is considered the most feared complication. In this cohort study, we aimed to identify the risk factors related to cyst rupture in a Jordanian pediatric population. METHODS: We retrospectively evaluated all pediatric patients who underwent cystostomy and capitonnage for pulmonary hydatid cyst between 2003 and 2020 at King Abdullah University Hospital. RESULTS: We found 43 patients with a mean age of 13 ± 4 years who suffered from 61 pulmonary cysts. 55.6% of them were males. The most prevalent symptom was shortness of breath. The rupture rate for patients was 39.5%, and 29.5% for cysts. None of the patients with cyst rupture had an anaphylactic reaction. The left lower lobe was the most common location for both intact and ruptured cysts. 25.6% of the patients had giant cysts (>10 cm) with a mean of 7.4 cm for all cysts. Patients with intact cysts had higher-rates of cough (42.3% vs. 29.4%) and lower-rates of shortness of breath (34.6% vs. 52.9%) than patients with ruptured cysts, which were not statistically significant. Although statistically insignificant, patients with ruptured cysts tended to have multiple cysts in one lung (29.4% vs. 7.7%, p = 0.180), and more complication rates (29.4% vs 7.7%, p = 0.09). Both groups had almost identical IgG-ELISA positive results. We found no significant association between cyst rupture and age, gender, presenting symptoms, cyst size, cyst location, and rate of postoperative complications. CONCLUSION: The rupture of pulmonary hydatid cyst has clinical consequences in pediatric patients, further studies on larger populations are needed to identify factors that make patients more prone to rupture and prioritize them for clinical monitoring and management.

Thoracoscopic sleeve segmentectomy for bipulmonal non-small-cell lung cancer with curative approach.

A patient with simultaneous bilateral non-small-cell lung cancer underwent a thoracoscopic sleeve segmentectomy on the right side to avoid lobectomy in curative approach. The patient also had a second, left-sided tumour requiring at least a left-sided sleeve upper lobectomy for complete resection. In anticipation of the second pulmonary resection in a patient whose lung function was already impaired by the first operation, we opted for a thoracoscopic approach with fast recovery. The left-sided operation was performed 60 days after the right-sided sleeve segmentectomy without any complications.

[Delphi Expert Consensus of the German Thoracic Surgery Society on Perioperative Management of Oncological Anatomical Lung Resections]. / Delphi-Konsens der Deutschen Gesellschaft für Thoraxchirurgie über das perioperative Management bei onkologischen anatomischen Lungenresektionen.

BACKGROUND: Anatomical lung resection for curative treatment of a tumour disease is the most common selective procedure in oncological thoracic surgery. The goal of the working group of the German Thoracic Surgery Society (DGT) was to achieve a consensus on the perioperative management of selective oncological lung resection procedures. METHODS: The assigned group of the DGT designed and conducted two electronic rounds of questions in all major thoracic and lung centres. Consensus was considered as a rate of ≥ 75%. After statistical analysis of the results, an expert meeting took place and a final Delphi process poll was used in order to reach consensus for controversial topics. RESULTS: Fourteen questions on the perioperative management of anatomical oncological lung resections were proposed and voted on. A consensus was reached for the following topics: preoperative infectiological screening, extended respiratory diagnostics for impaired lung function, use of a cardiac risk assessment score, postoperative monitoring, prophylaxis for venous thromboembolism, control bronchoscopy after sleeve resections or pneumonectomy, blood gas test before discharge from the hospital. No consensus was reached for the following topics: preoperative endobronchial microbiological diagnostics, pleural rinsing, standardised clinical chemistry blood test postoperatively. CONCLUSION: Our manuscript depicts the results of a Delphi process in 2018/2019 involving experts of the German Thoracic Surgery Society from high volume departments certified for thoracic surgery and/or lung cancer surgery. In general, a very high rate of consensus was documented for the majority of the topics concerning the perioperative management of oncological anatomical selective lung resection procedures. The most important topic for which no consensus could be reached was preoperative endobronchial microbiological diagnostic testing.

Perioperative course and quality of life in a prospective randomized multicenter phase III trial, comparing standard lobectomy versus anatomical segmentectomy in patients with non-small cell lung cancer up to 2 cm, stage IA (7th edition of TNM staging system).

OBJECTIVES: For early stage non-small cell lung cancer (NSCLC) retrospective data of functionally compromised patients undergoing segmentectomy showed equal outcomes for perioperative complications and quality of life (QoL) compared with lobectomy patients. However no prospectively randomized data comparing patients eligible for both procedures are available. MATERIALS AND METHODS: We conducted a prospective, randomized, multicenter phase III trial and investigated perioperative complications and QoL in patients with NSCLC stage IA (7th edition) undergoing segmentectomy versus lobectomy. The EORTC Questionnaire Core-30 (QLQ C-30) supplemented by thirteen-item lung cancer-specific module (LC13) was assessed before surgery, at discharge, 6 weeks, 3, 6 and 12 months post-surgery. RESULTS: 108 patients with verified or suspected NSCLC up to 2 cm diameter were enrolled, whereby 54 were assigned to lobectomy and 54 to segmentectomy. Due to nodal disease, tumor size and surgical reasons estimated during the operation, eight patients of the segmentectomy group received a lobectomy. In hospital and 90 days mortality was 0% in both groups. Perioperative complications were observed in 6 (11.3%) patients after segmentectomy and in 8 patients (14.8%) after lobectomy (p = 0.563), while the 90-day morbidity were 17% and 25.9% (9 and 14 patients), respectively (p = 0.452). Twelve months after surgery, there was a significant deterioration to the baselines of physical (p < 0.001) and cognitive functioning (p = 0.025), dyspnea (p < 0.001) and fatigue (p = 0.003) in the lobectomy group. Dyspnea showed a faster recovery in the segmentectomy compared to lobectomy group with statistical significance (p = 0.016 after 12 months). CONCLUSION: In patients with early-stage NSCLC, segmentectomy is associated with a statistically not significant lower perioperative morbidity and appears to provide a superior recovery in QoL compared with lobectomy patients.

[Tracheal Surgery]. / Chirurgie der Trachea.

Surgery of the trachea is a specialised field in which many disciplines work jointly due to the variety of indications and the extended topography. Not only because of its particular functional importance, but also because of its complex morphology, anatomy and physiology, this organ represents a special therapeutic challenge. A variety of diseases require surgical procedures of the trachea; the therapeutic strategy is influenced both by the disease itself as well as patient-dependent parameters. Regardless of the nature of the underlying disorder, good results require a high level of expertise in airway management, a careful diagnosis and interventional planning as well as an experienced surgical team that masters extended operative techniques. An optimal treatment decision always requires a multidisciplinary assessment of the patient's individual situation by interventional pulmonologists, thoracic surgeons, visceral surgeons, ENT (ear, nose and throat) surgeons and anaesthesiologists.

[Failure of Endo-VAC or Stenting Therapy after Oesophageal Anastomotic Insufficiency - How to Avoid Oesophagectomy]. / Interdisziplinäres Management bei Anastomoseninsuffizienz nach Ösophagusresektion zur Vermeidung der Ösophagektomie.

INTRODUCTION: Oesophageal anastomotic leak after oesophagectomy is a severe complication and associated with a high mortality rate. Initial treatment is conservative and includes stent implantation or endo-VAC therapy. This study describes a combined treatment strategy of endoscopic and surgical management after failure of conservative management. MATERIALS AND METHODS: All patients were included who had been treated after oesophagectomy with gastric conduit reconstruction in our department of thoracic surgery between May 2008 and December 2016. Clinical data was evaluated from a prospectively acquired database. We surgically managed these patients with a combination of oesophageal stent implantation, transmural stent fixation with absorbable suture, stent coverage with muscle flap, radical debridement of mediastinal and pleural empyema and discontinuous pleural space irrigation, when conservative management failed. We evaluated the factors influencing mortality rate after surgical treatment of anastomotic insufficiency repair. RESULTS: 18 patients were introduced to our department after external failure of conservative therapy. 15 patients were introduced < 20 days after conservative therapy and three cases after > 20 days of conservative therapy. All patients presented with right sided pleural empyema, pneumonia, mediastinitis and sepsis. Three cases were accompanied by bilateral pleural empyema. Definitive successful surgical reconstruction occurred in 100%. The 90-day mortality rate was 20% (three patients), who died because of multi-organ failure. CONCLUSION: Oesophageal anastomotic leak after oesophagectomy can be managed successfully by the combined treatment strategy of endoscopic and surgical procedures following failure of conservative treatment. The only factor influencing mortality seems to be a prolonged conservative therapy of more than 20 days.

Does less surgical trauma result in better outcome in management of iatrogenic tracheobronchial laceration?

BACKGROUND: Iatrogenic tracheobronchial injury is a rare, but severe complication of endotracheal intubation. Risk factors are emergency intubation, percutaneous dilatational tracheostomy and intubation with double lumen tube. Regarding these procedures, underlying patients often suffer from severe comorbidities. The aim of this study was to evaluate the results of a standardized treatment algorithm in a referral center with focus on the surgical approach. METHODS: Sixty-four patients with iatrogenic tracheal lesion were treated in our department by standardized management adopted to clinical findings between 2003 and 2019. Patients with superficial laceration were treated conservatively. In the case of transmural injury of the tracheal wall and necessity of mechanical ventilation, patients underwent surgery. We decided on a cervical surgical approach for lesions limited to the trachea. In case of involvement of a main bronchus we performed thoracotomy. Data were evaluated retrospectively. RESULTS: In 19 patients the tracheal lesion occurred in elective intubation and in 17 patients during emergency intubation. In 23 cases a tracheal tear occurred during percutaneous dilatational tracheostomy and in three patients at replacement of a tracheostomy tube. Two patients received laceration during bronchoscopy. Twenty-nine patients underwent surgery with cervical approach and 14 underwent thoracotomy. There was no difference in the mortality of these groups. Treatment of tracheal tear was successful in 62 individuals. Nine patients died of multi organ dysfunction syndrome (MODS), two of them during surgery. CONCLUSIONS: Iatrogenic tracheal laceration is a life-threatening complication and the mortality after tracheal injury is high, even in a specialized thoracic unit. Conservative management in patients with superficial tracheal lesion is a feasible procedure. In case of complete laceration of tracheal wall, surgical therapy is recommendable, whereby several approaches of surgical management seem to be equivalent.