The role of thoracic surgery in the management of complicated acute and post-acute COVID-19 pneumonia (PASC).

INTRODUCTION: COVID-19 is considered a respiratory virosis in its classic form, although it may present with heterogeneous symptoms. Thoracic complications occur in a small percentage of patients. Our objective was to evaluate existing experience with this disease and its thoracic manifestations and to determine the real-world status of care of these patients. METHODS: This study is a retrospective, single-institution analysis of a group of patients hospitalized with acute and post-acute COVID-19 pneumonia at Thomayer Hospital in Prague in the period from December 2020 to March 2022 and indicated for a thoracic surgical procedure. RESULTS: During the peak of COVID-19 pandemic, a thoracic intervention was performed in 46 admitted patients. Thoracic drainage (due to pneumothorax in 18 cases, fluidothorax in 3 cases, CT-guided lung abscess drainage in 2 cases, and CT-guided pneumatocele drainage in 2 cases) were the most common thoracic surgical procedures. Pleurectomy/decortication surgery was done in 10 cases. Additionally, 12 lung parenchyma-sparing resections were performed, while lobectomy was required in 2 cases. Resection of postintubation tracheal stenosis due to a severe course of COVID-19 pneumonia was indicated in 2 patients. CONCLUSION: Even mild COVID-19 may cause a considerable morphological a functional alteration of the respiratory system. The most common complications of COVID-19 pneumonia that require a thoracic surgical intervention include pathologies associated with an air leak and accumulation of air (pneumothorax, pneumomediastinum and subcutaneous emphysema). The development of pulmonary necrosis, symptomatic bronchiectasis, pneumatocele, and bullous-fibrotic formations may result in pneumothorax, hemothorax or thoracic empyema in sporadic cases. An early thoracic surgical intervention to treat thoracic complications of COVID-19 pneumonia can improve the survival of COVID-19 patients.

VATS lobectomy, history, indication, contraindication and general techniques.

VATS lobectomy is a respected modality of anatomic lung resections nowadays. Video-assisted lobectomies without rib extractor fulfil all current requirements for minimally invasive lung resections. This type of an anatomic pulmonary resection with a targeted treatment of hilar structures doesn't traumatize the intercostal space by using rib retractor. Videothoracoscope serves to visualize the surgical field on the screen. Assisted VATS (aVATS) lobectomy is a procedure using 3-5 cm working incision. Fully endoscopic resection (VTS) or complete VATS lobectomy (cVATS) are operations performed only through ports, without working incision. The authors supplement the article with a videorecord of VATS lobectomy general technique (Fig. 4, Ref. 11).

Importance of histological verification of mediastinal lymphadenopathy in exact staging of non-small cell bronchogenic carcinoma.

BACKGROUND: Diagnostics and treatment of bronchogenic non-small cell lung carcinoma is a severe clinical problem. Radical surgery is the major treatment modality with the highest chance for a long-time survival. The aim of the study was to map metastasizing of bronchogenic non-small cell lung carcinoma into homolateral mediastinal lymph nodes and to assess the importance of histological verification of mediastinal lymphadenectomy for exact staging and treatment. METHODS: Study of 29 patients with non-small cell lung carcinoma in stage IIIa, IIIb and IV (TNM classification) diagnosed from September 2006 to March 2007, with mediastinal lymph nodes invasion according to CT, and with subsequent mediastinal lymph node dissection during autopsy. RESULTS: 50% of the right upper lobe tumors metastasized into group 1 nodes (N1-N4) and 50% into group 3 (N7). 66% of the right lower lobe tumors metastasized into group 3 nodes (N7) and 33.3% into group 1 (N1-4). 20.0% of the left upper lobe tumors metastasized into group 1 nodes (N1-4), 33.0% into group 2 (N5-6), 25.0% into group 3 (N7) and 16.7% into group 4 (N8-9). 23.5% of the left lower lobe tumors metastasized into group 1 nodes (N1-4), 23.5% into group 2 (N5-6), 23.5 % into group 4 (N8-9) and 29.5% into group 3 (N7). 27.6% of examined patients had false positivity of lymph node metastasis according to CT. CONCLUSION: Histological verification of suspect mediastinal lymph nodes via Endobronchial Ultrasound Biopsy (EBUS) or mediastinoscopy or thoracoscopy is crucial for determining the stage of the disease according to the TNM classification. False positivity of imaging methods in diagnostics of non-small cell brochogenic carcinoma can contraindicate up to quarter of potentially operable patients (Tab. 3, Ref. 11).

Importance of systemic mediastinal lymphadenectomy in exact staging of bronchogenic carcinoma.

BACKGROUND: Constituent part of radical lung resection for lung cancer is a dissection of mediastinal lymph nodes. Lymphadenectomy is a standard procedure in an assessment of clinical stage of the disease. The aim of the study was to map metastasizing of bronchogenic non-small cell lung carcinoma into homolateral mediastinal lymph nodes and to assess the importance of mediastinal lymphadenectomy for exact staging and survival. METHODS: Study of 31patients with lung resection and systematic mediastinal lymphadenectomy operated from August 2004 to January 2007, with pre-operative stage Ia to IIb (TNM classification) - according to CT without mediastinal lymph nodes invasion and with positive histological finding after systematic mediastinal lymphadenectomy. RESULTS: Tumors in right upper lobe metastasized in 45.5 % into group 1 nodes (stages N1-N4) and group 3 nodes (stages N7) and in 9 % into group 4 nodes (stages N8-N9). Tumors of the right middle lobe metastasized in 100 % into group 3 nodes (stage N7).Tumors of the right lower lobe metastasized in 87.5 % into group 3 nodes (N7) and in 12.5 % into group 4 nodes (stages N8-N9). Tumors of the left upper lobe metastasized in 9.0 % in group 1 nodes (stages N1-N4), in 82 % into group 2 nodes (stages N5-N6) and in 9.0 % were found skip metastases into group 4 nodes (stages N8-N9). Tumors of the left lower lobe metastasized in 26.7 % in group 4 nodes, 46.6 % into group 3 nodes, in 20,0 % into group 2 nodes and in 6,7 % into group 1 nodes. CONCLUSION: Systematic mediastinal lymphadenectomy is crucial for determining the stage of the disease according to the TNM classification. Systematic lymphadenectomy is essential for the diagnosis of stage IIIa disease and setting of additional therapy that prolongs survival (Ref. 17).