[Delphi Expert Consensus of the German Society for Thoracic Surgery on Segmentectomy for Non-small Cell Lung Cancer]. / Delphi-Experten-Konsens der Deutschen Gesellschaft für Thoraxchirurgie über die anatomische Segmentresektion bei nicht kleinzelligem Lungenkarzinom.

BACKGROUND: Findings from two recently published randomised controlled trials have shown favourable oncological results of segmentectomy for early-stage NSCLC < 2 cm. This has generated a growing interest in this procedure, which is however considered technically more challenging than lobectomy. The aim of the working group of the German Society for Thoracic Surgery (DGT) was to address, via an expert consensus project, topics concerning implementation of segmentectomy in lung cancer surgery. METHODS: The assigned group of the DGT designed and conducted two electronic rounds of questions in all major thoracic and lung cancer centres in Germany. The steering group predefined a priori the threshold of consensus of 75% or greater. The results were discussed in an expert meeting, leading to a final Delphi poll for selected topics and questions. RESULTS: Thirty-eight questions on segmentectomy for NSCLC were proposed in two rounds and voted on. After the final Delphi process, a consensus was reached for the following topics: non-inferiority of segmentectomy vs. lobectomy for tumours < 2 cm, segmentectomy as an alternative if lobectomy is functionally not feasible, use of intraoperative techniques for identification of intersegmental borders. No consensus could be reached for topics such as frozen section for intraoperative ascertainment of radicality, as also for the indication of a re-do lobectomy in case of an occult N1 lymph node status. CONCLUSION: Our manuscript depicts the results of a Delphi process in 2020/2021 involving experts of the German Society for Thoracic Surgery on the implementation of segmentectomy in lung cancer patients. In general, a very high rate of consensus was documented for the majority of the topics concerning the indication and execution of lung segmentectomy.

Results of the Diaphragmatic Plication Database: 10 Years' Experience.

BACKGROUND: Unilateral diaphragmatic paralysis or paresis (UDP) in adults is an often overlooked disease which relevantly impairs the patient's lung function and quality of life. Particularly in idiopathic UDP, there is no evidence for conservative therapy and only little evidence for surgical therapy. METHODS: The method involves retrospective single-center analysis of patients with UDP persistent for at least 1 year who were operated by diaphragmatic resection, plication, and augmentation with a polypropylene mesh. The patients were tested for lung and diaphragmatic function, six-minute walk test (6MWT), and blood gas analysis before, 3 and 12 months after surgery. RESULTS: In total, 85 patients received surgery for UDP. The most frequent reasons for UDP were idiopathic (67%), iatrogenic (mainly cardiac and cervical spine surgery; 24%), and trauma (9%). The mean operation time was 84 ± 24 minutes, the length of hospital stay 8.4 ± 3.9 days, chest tubes were removed after 11.7 ± 4.1 days. Overall morbidity was 42%, mortality 0%. Forced expiratory volume in one second (FEV1) in supine position improved by 12.4% absolute, vital capacity by 11.8% absolute, and sniff nasal inspiratory pressure by 1.4 kPa 12 months after surgery (p <0.001 each). Total lung capacity increased by 6.8% absolute at 12 months (p = 0.001) The 6MWT distance improved by 45.9 m at 3 months and 50.9 m at 12 months (p = 0.001, each). CONCLUSION: Surgical therapy for UDP is highly effective in the long term. The superiority over conservative treatments needs to be evaluated prospectively with standardized physiotherapeutic protocols. FEV1 in supine position and 6MWT are easy to perform tests and represent statistically and patient-relevant outcomes.

A New Approach in Airway Management for Tracheal Resection and Anastomosis: A Single-Center Prospective Study.

OBJECTIVES: The evaluation of the use of laryngeal mask airways (LMA) as an alternative form of airway management for surgical tracheal reconstruction. DESIGN: A prospective case series. SETTING: At a single German university hospital. PARTICIPANTS: Ten patients. INTERVENTIONS: The use of LMA for airway management in surgical reconstruction of the trachea. MEASUREMENTS AND MAIN RESULTS: Ten patients with tracheal stenosis of 50% to 90% were enrolled prospectively during the study period. The airway management consisted of the insertion of an LMA. During resection and reconstruction, high-frequency jet ventilation was used. Several arterial blood gas analyses (ABG) were performed before, during, and after the tracheal resection and reconstruction. All values were presented as median and interquartile ranges or as absolute and relative values, and no emergency change to cross-field intubation was necessary. The lowest PaO2 was 93 mmHg in 1 patient after 20 minutes of jet ventilation, whereas PaO2 increased after the induction phase and remained stable in 9 patients. There were no intraoperative complications related to anesthetic management apart from transient hypercarbia during and after jet ventilation. Preoperative and postoperative ABG were comparable. One patient required immediate postoperative ventilatory support. Two patients developed postoperative pneumonia, leading to their admission to the intensive care unit. One patient was operated with a palliative approach due to massive dyspnea and died in the next postoperative course. CONCLUSIONS: The use of LMA is an alternative option in airway management for tracheal reconstruction, even in patients with significant tracheal stenosis. Potential advantages compared to tracheal intubation are unimpaired access to the operative field and the lack of stress on the fresh anastomosis.

[Resection of Lung Cancer in Old Patients - Does Demographic Change Cause a Rethink?] / Thoraxchirurgische Resektion des Lungenkarzinoms beim alten Menschen ­ bedingt der demografische Wandel ein Umdenken?

Due to the demographic change prevailing in Germany, the age pyramid is shifting more and more upwards. According to the WHO, a patient over the age of 75 is considered to be old. Whether or not and to what extent an old patient can tolerate thoracic surgery purely based on his age and comorbidities remains unclear. Under most circumstances the surgeon's experience seems to be crucial in this decision. PATIENTS AND METHODS: The data analysis included data from 01. 2016-01. 2018 based on the German Thorax Register (Project ID: 2017-03), which was set up under the patronage of the German Society for Anesthesiology and Intensive Care Medicine (DGAI) and the German Society for Thoracic Surgery (DGT). A total of 1357 patients were included, 658 patients had histologically proven lung cancer stage I-II. These were divided into three groups according to their age; group I (< 65 years), group II (65- ≤ 75) years and group III (> 75 years). We were able to show that group III had essentially no increased postoperative complication rates (all = 48.00 %; group I = 40.90 %; group II = 53.00 %; group III = 52.90 %) and even performed better than group II (65 to ≤ 75) regarding pulmonary complications. (postoperative pneumonia group II = 19.20 %, group III = 12.90 %) The mortality was lowest in patients who were operated on in centers of the German Thorax Register (all = 1.70 %, group I = 1.90 %; group II = 1.70 %; group III = 1.30 %), compared to national german average. (all = 1.99 %; group I = 1.23 %; group II = 2.18 %; group III = 3.78 %) In particular, patients of group III showed the greatest difference. Furthermore, we saw that the majority of anatomical resections performed in centers of the German Thorax Register were resected by VATS (Video-assisted Thoracoscopic Surgery) as opposed to patients operated on in hospitals not affiliated with the German Thorax Register. DISCUSSION: Considering these results, the question arises whether in Germany all old patients were treated according to current guidelines. Although there is a certain selection bias in group III, operative candidates fit for surgery are operated in the centers of the German Thorax Register. Our results permit us to conclude that this group of patients should be given optimal surgical therapy when indicated. Age alone should not be the sole determining factor in decision-making regarding thoracic surgery.

Sleeve lobectomy versus lobectomy for primary treatment of non-small-cell lung cancer: A single-center retrospective analysis.

BACKGROUND AND OBJECTIVES: It is unclear how much additional perioperative risk a sleeve lobectomy could pose in comparison to lobectomy. The objective of this analysis was to compare the complication rate, 30-day mortality, and overall survival between lobectomy and sleeve lobectomy without prior neoadjuvant treatment in non-small-cell lung cancer (NSCLC). METHODS: This is a retrospective study using our prospective database for quality assurance in our hospital. Inclusion criteria for our study was a completed lobectomy or sleeve lobectomy for primary treatment of NSCLC. RESULTS: In 506 patients, the tumor was treated by means of standard lobectomy. In 252 patients with central tumor localization, sleeve lobectomy was performed. Postoperative complications occurred in n:148 (29.24%) patients of the lobectomy group and in n = 76 (30.15%) of the sleeve group. The mortality rate difference between the two groups was statistically significant and favored the lobectomy group (0.78% vs. 4.76%, p = .007). Five year survival was 69.97% for the lobectomy and 65.59% for the sleeve group (p = .829). CONCLUSION: Sleeve lobectomy for primary surgical treatment of NSCLC has comparable perioperative complications with lobectomy. Sleeve lobectomy does not seem to negatively influence survival. Postoperative mortality was higher in the sleeve group.

Hypercapnia in COPD Patients Undergoing Endobronchial Ultrasound under Local Anaesthesia and Analgosedation: A Prospective Controlled Study Using Continuous Transcutaneous Capnometry.

BACKGROUND: Flexible bronchoscopy (FB) in analgosedation causes alveolar hypoventilation and hypercapnia, the more so if patients suffer from COPD. Nonetheless, neither is capnometry part of standard monitoring nor is there evidence on how long patients should be monitored after sedation. OBJECTIVES: We investigated the impact of COPD on hypercapnia during FB with endobronchial ultrasound (EBUS) in sedation and how the periprocedural monitoring should be adapted. METHODS: Two cohorts of consecutive patients - with advanced and without COPD - with the indication for FB with EBUS-guided transbronchial needle aspiration in analgosedation received continuous transcutaneous capnometry (ptcCO2) before, during, and for 60 min after the sedation with midazolam and alfentanil. MAIN RESULTS: Forty-six patients with advanced COPD and 44 without COPD were included. The mean examination time was 26 ± 9 min. Patients with advanced COPD had a higher peak ptcCO2 (53.7 ± 7.1 vs. 46.8 ± 4.8 mm Hg, p < 0.001) and mean ptcCO2 (49.5 ± 6.8 vs. 44.0 ± 4.4 mm Hg, p < 0.001). Thirty-six percent of all patients reached the maximum hypercapnia after FB in the recovery room (8 ± 11 min). Patients with COPD needed more time to recover to normocapnia (22 ± 24 vs. 7 ± 11 min, p < 0.001). They needed a nasopharyngeal tube more often (28 vs. 11%, p < 0.001). All patients recovered from hypercapnia within 60 min after FB. No intermittent ventilation manoeuvres were needed. CONCLUSION: A relevant proportion of patients reached their peak-pCO2 after the end of intervention. We recommend using capnometry at least for patients with known COPD. Flexible EBUS in analgosedation can be safely performed in patients with advanced COPD. For patients with advanced COPD, a postprocedural observation time of 60 min was sufficient.

Use of Extracorporeal Membrane Oxygenation for Major Cardiopulmonary Resections.

BACKGROUND: In thoracic surgery, utilization of extracorporeal membrane oxygenation (ECMO) is mainly established for patients undergoing lung transplantation. The aim of our study was to summarize our single-center experience with intraoperative use of veno-venous- or veno-arterial-ECMO in patients undergoing complex lung surgery involving the main carina, or the left atrium or the descending aorta. METHODS: A total of 24 patients underwent combined complex lung, carinal, aortal, or left atrial resections. In cases of carinal resection, percutaneous veno-venous, jugular-femoral cannulation was considered suitable. For combined resection of lung and descending aorta, a percutaneous femoral veno-arterial cannulation was used. In cases of extended left atrial resection, a percutaneous jugular-femoral veno-venous-arterial cannulation was favored. RESULTS: Procedures were divided into three groups: carinal resections and reconstruction (n = 8), resections of the descending aorta and left lung (n = 7), resections of lung and left atrium (n = 9). No intraoperative complications occurred. Overall 30-day mortality was 25%. A complete resection was achieved in 18 patients. Median survival was 12 months. One- and 5-year survival were 48.1 and 22.7%, respectively. CONCLUSION: The present study shows that intraoperative use of ECMO for extended carinal, aortic, or atrial resections is feasible with minimal intraoperative complications allowing surgeons increased operating-field safety. Perioperative mortality is high, but this is rather an attribute of local extended disease and patient comorbidities.

[Chest Wall Reconstruction Using Polypropylene Mesh: a Single-Center 8-Year Analysis]. / Brustwandrekonstruktion mittels Polypropylennetz: eine monozentrische 8-jährige Analyse.

BACKGROUND: Chest wall resection for malignant tumours is usually combined with reconstruction of the bony defect. We analysed our single centre, 8-year, experience using polypropylene mesh for chest wall reconstruction. The goal of our retrospective study was to identify material-related complications and to compare them with the existing literature. METHODS: The inclusion criterion in our retrospective cohort was a full-thickness chest wall excision and reconstruction using a polypropylene mesh with a mainly oncological indication spectrum (e.g. sarcomas, metastases, lung carcinomas with infiltration of the chest wall) in the period from January 2008 to January 2017. Primary endpoints were material-related complications: local infection, seroma, material migration, mesh explantation and chest wall instability. Secondary endpoints were the following postoperative complications: pneumonia, acute respiratory distress syndrome (ARDS), postoperative bleeding and prolonged postoperative ventilation (> 24 h postoperatively). RESULTS: A total of 202 chest wall resections were performed in our clinic over a period of 8 years. Of these, 138 defects were reconstructed using a polypropylene mesh. Pneumonia was the most common postoperative complication at a rate of 12.3%. In 5.7% of the cases, a wound seroma developed that made it necessary to insert a Redon suction drain. Local wound infection was confirmed microbiologically in three cases (2.1%). In one of these cases, the reconstruction material had to be removed. The 30-day mortality rate was 1.4% with two postoperative deaths. Material migration or chest wall instability with a paradoxical pattern of breathing movement were not documented. CONCLUSION: Chest wall reconstruction using polypropylene mesh is a technique with low material-related complication rate. The low rate of local infections, material explantation, and chest instability documented in our cohort can be a helpful decision factor for the operating thoracic surgeon looking for the appropriate reconstruction material.

Optimal timing of surgery for bronchial sleeve resection after neoadjuvant chemoradiotherapy.

INTRODUCTION: Sleeve resection is an established oncological operative treatment for centrally located tumors with reduced complications compared to pneumonectomy. In cases of neoadjuvant chemoradiotherapy, the optimal timing of surgery for bronchial anastomotic healing has not been adequately explored. MATERIALS AND METHODS: Between 2006 and 2017, 584 tracheobronchial sleeve resections were retrospectively analyzed. We selected all patients (n = 88) after sleeve lobectomy or sleeve bilobectomy for lung cancer with fully completed neoadjuvant chemoradiotherapy. Bronchial healing was assessed by bronchoscopy on the 7th postoperative day using our earlier published classification from grades 1 to 5. RESULTS: The median interval to surgery was 50 days (interquartile range 46-53, mean 50.03 ± 3.72). Mean anastomotic grade was 2.05 ± 1.03 and in 29.5% of the patients a critical anastomosis (grade ≥3) was documented. Anastomotic healing showed optimal results (bronchoscopic grade mean value: 1.5 ± 0.70) between the 6th and 8th postchemoradiotherapy week (P = .001). All patients operated before (bronchoscopic grade mean value: 2.3 ± 1.02) or after the above period (bronchoscopic grade mean value: 2.5 ± 1.15) had an increased ratio of anastomotic healing complications. CONCLUSION: It is safer to perform sleeve-resections for non-small cell lung cancer after neoadjuvant trimodal treatment between the 6th and 8th week of completion of chemoradiotherapy.

Anterior Chest Wall Reconstruction Using Polypropylene Mesh: A Retrospective Study.

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

[Delphi Expert Consensus of the German Thoracic Surgery Society on the Management of Chest Tube Drainage]. / Delphi-Konsens der Deutschen Gesellschaft für Thoraxchirurgie über das Management von Thoraxdrainagen.

BACKGROUND: Chest tubes are a valuable instrument and are used on a daily basis - not only by thoracic surgeons but also by a variety of medical specialists who treat pneumothorax or pleural effusions. The goal of the working group of the German Thoracic Society (DGT) was to achieve a consensus on the management of chest tube/drainage using the Delphi process. METHODS: The assigned group of the DGT designed and conducted two electronic rounds of questions in all major thoracic and lung cancer centres. Consensus was considered as 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: Thirteen questions on the management of chest tubes were proposed and voted on. A consensus was reached for the following topics: conditions for chest tube insertion, size of drainage/tube, technique of insertion, diagnostic measures after insertion and prior to removal, post-interventional management, documentation, number of chest tubes after anatomical lung resection, use of fibrinolytic agents, type of negative pressure. No consensus was reached for the following topics: autologous blood pleurodesis, reduction of suction in cases of persistent air leakage. CONCLUSION: Our manuscript depicts the results of a Delphi process in 2017 - 1018 involving experts of the German Thoracic Society from high volume departments certified for thoracic surgery. A very high rate of consensus was documented for topics such as chest tube insertion, peri-interventional management and removal algorithm. The most important topic for which there was no consensus was the case of persistent air leakage. The resulting expert recommendations of the Delphi process could be used as a starting point for internal clinical procedures.

[Video-assisted Thoracoscopic Surgery in Local Anaesthesia and Analgosedation - a Survey of the Members of the German Society of Thoracic Surgeons]. / Videoassistierte thorakoskopische Chirurgie in Lokalanästhesie und Analgosedierung ­ eine Umfrage unter den Mitgliedern der Deutschen Gesellschaft für Thoraxchirurgie.

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

[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.

New Approaches to Airway Management in Tracheal Resections-A Systematic Review and Meta-analysis.

OBJECTIVES: Although endotracheal intubation, surgical crossfield intubation, and jet ventilation are standard techniques for airway management in tracheal resections, there are also reports of new approaches, ranging from regional anesthesia to extracorporeal support. The objective was to outline the entire spectrum of new airway techniques. DESIGN: The literature databases PubMed/Medline and the Cochrane Library were searched systematically for prospective and retrospective trials as well as case reports on tracheal resections. SETTING: No restrictions applied to hospital types or settings. PARTICIPANTS: Adult patients undergoing surgical resections of noncongenital tracheal stenoses with end-to-end anastomoses. INTERVENTIONS: Airway management techniques were divided into conventional and new approaches and analyzed regarding their potential risks and benefits. MEASUREMENTS AND MAIN RESULTS: A total of 59 publications (n = 797 patients) were included. The majority of publications (71.2%) describe conventional airway techniques. Endotracheal tube placement after induction of general anesthesia and surgical crossfield intubation after incision of the trachea were used most frequently without major complications. A total of 7 new approaches were identified, including 4 different regional anesthetic techniques (25 cases), supraglottic airways (4 cases), and new forms of extracorporeal support (25 cases). Overall failure rates of new techniques were low (1.8%). Details on patient selection and procedural specifics are provided. CONCLUSIONS: New approaches have several theoretical benefits, yet further research is required to establish criteria for patient selection and evaluate procedural safety. Given the low level of evidence, it currently is impossible to compare methods of airway management regarding outcome-related risks and benefits.

[Trimodal Therapy for Stage IIIA-B NSCLC Involving High Dose Neoadjuvant Chemoradiotherapy. Is Surgery a Rational Option?] / Trimodale Therapie des NSCLC im Stadium IIIA-B mittels neoadjuvanter Hochdosisradiochemotherapie. Stellt die Operation eine sinnvolle Option dar?

Introduction Stage III non-small cell lung cancer (NSCLC) and its possible multimodal therapy present a challenge to the responsible oncologist, chest surgeon and radiologist. The aim of the present retrospective study was to analyse and evaluate the treatment algorithm in our hospital for patients with stage III NSCLC (intention to treat). We compared an aggressive treatment regime with primary trimodal therapy (high dose radiochemotherapy and resection), independently of "multilevel" N2 or "single level" N3 status. These results were then compared with a historical group of our patients who solely received simultaneous radiochemotherapy (bimodal therapy). Materials and Methods Within the period of the study, 156 patients were diagnosed with stage III NSCLC and treated with trimodal therapy. The median age was 71 years. 103 patients (60%) were male, 53 (34%) female. In the group with bimodal therapy, 102 patients were evaluated. Results After radiological restaging and checking functional resectability, 90 patients (57.7%) in the trimodal therapy group received secondary resection, including 37 (41.1%) lobectomies/bilobectomies, 37 (41.1%) sleeve lobectomies, 13 (14.4%) pneumonectomies and 3 (3.3%) segmentectomies (for severely restricted pulmonary function). The median survival time in the trimodal therapy group was 535 days and in the bimodal group 388 days; this difference was not statistically significant (p = 0.1377). Finally the 5-year survival after actual therapy was performed ("as-treated trimodally" vs. "as-treated bimodally"). The median survival time was then 807 days for trimodal therapy and 427 days for bimodal therapy. Conclusion High dose neoadjuvant radiochemotherapy followed by secondary resection is still a valuable option for selected patients with stage III NSCLC. However, this retrospective analysis failed to find a statistically significant survival advantage for the "intention-to-treat" trimodal patients.

Unilateral Lobe Resection by Video-Assisted Thoracoscopy Leads to the Most Optimal Functional Improvement in Severe Emphysema.

Background Lung volume reduction surgery (LVRS) is a well-established treatment option for pulmonary emphysema, but the most advantageous technical approach remains debatable. Methods Short- and long-term outcomes were comparably assessed in pulmonary emphysema patients who underwent unilateral LVRS with either lobe or sublobe (segment or wedge) resection. Patients were consecutively enrolled in the study after careful conventional and computer-based definition of the target region. Results A total of 36 patients with a mean age of 62.1 ± 8.9 years (range, 41-79 years) were recruited. Video-assisted thoracoscopy (VATS) was performed in 33 patients, while 3 patients with additional early-stage lung cancer received anterolateral thoracotomy. Surgery duration was longer for lobectomy (median 93 minutes, range 44-168 minutes) as compared with sublobe resection (median 52 minutes, range 25-131 minutes; p = 0.0007), but complication rates were similar. After 90 days postsurgery, mortality was zero and lung function improved to a similar degree in both the groups. After 1 year, total lung capacity (TLC) was still reduced by 17.2 ± 20.6% predicted as compared with the baseline values for lobe resection, while TLC was increased by 12.1 ± 14.5% predicted for sublobe resection. In addition, the 6-minute walking distance improved following LVRS, with slightly better results in lobe resection patients. Conclusions By careful definition of the target region, unilateral VATS-LVRS with lobe resection in severely affected pulmonary emphysema patients is a safe procedure that is superior to unilateral sublobe VATS resection in terms of improving long-term 1-year lung hyperinflation. Therefore, unilateral VATS lobe resection is a promising treatment approach that should be further evaluated by randomized controlled trials.

Patients' satisfaction with local and general anaesthesia for video-assisted thoracoscopic surgery-results of the first randomized controlled trial PASSAT.

OBJECTIVES: The objective of this single-centre, open, randomized control trial was to compare the patients' satisfaction with local anaesthesia (LA) or general anaesthesia (GA) for video-assisted thoracoscopy. METHODS: Patients with indication for video-assisted thoracoscopy pleural management, mediastinal biopsies or lung wedge resections were randomized for LA or GA. LA was administered along with no or mild sedation and no airway devices maintaining spontaneous breathing, and GA was administered along with double-lumen tube and one-lung ventilation. The primary end point was anaesthesia-related satisfaction according to psychometrically validated questionnaires. Patients not willing to be randomized could attend based on their desired anaesthesia, forming the preference arm. RESULTS: Fifty patients were allocated to LA and 57 patients to GA. Age, smoking habits and lung function were similarly distributed in both groups. There was no significant difference between the 2 groups with regard to patient satisfaction with anaesthesiology care (median 2.75 vs 2.75, P = 0.74), general perioperative care (2.50 vs 2.50, P = 0.57), recovery after surgery (2.00 vs 2.00, P = 0.16, 3-point Likert scales). Surgeons and anaesthesiologists alike were less satisfied with feasibility (P < 0.01 each) with patients in the LA group. Operation time, postoperative pain scales, delirium and complication rate were similar in both groups. LA patients had a significantly shorter stay in hospital (mean 3.9 vs 6.0 days, P < 0.01). Of 18 patients in the preference arm, 17 chose LA, resulting in similar satisfaction. CONCLUSIONS: Patients were equally satisfied with both types of anaesthesia, regardless of whether the type of anaesthesia was randomized or deliberately chosen. LA is as safe as GA but correlated with shorter length of stay. Almost all patients of the preference arm chose LA. Considering the benefits of LA, it should be offered to patients as an equivalent alternative to GA whenever medically appropriate and feasible.

Clinical and bronchoscopic aspects of bronchial healing after sleeve resection for lung cancer: a multivariate analysis on 541 cases.

Background: Anastomotic insufficiency is a feared complication after sleeve lobectomy. Bronchoscopy can help to identify anastomoses at risk. We evaluated negative predictors of anastomotic healing using a bronchoscopic grading system in a large collective of lung cancer patients. Methods: From 2006 to 2019, 541 sleeve lobectomies for lung cancer were performed. Anastomotic healing was documented by bronchoscopy on the seventh postoperative day using a standardized classification system for anastomotic grading (grade 1, perfect healing to 5, insufficiency). Grade 1 and 2 were considered satisfactory and the patients were discharged. Grade 3 or higher was considered critical. These patients received systemic antibiotic treatment and re-bronchoscopy was performed 4 days later. Results: In 18.5% of the patients, the anastomosis was assessed as critical. 19% of patients with critical anastomosis on the 7th postoperative day developed anastomotic insufficiency during the postoperative course, compared to 0.2% in patients with satisfactory anastomotic healing. Bilobectomies, low preoperative forced expiratory volume in 1 second (FEV1) values, high preoperative levels of C-reactive protein and neoadjuvant radiation were identified as independent risk factors for critical anastomotic healing. Conclusions: Bronchoscopic assessment of anastomotic healing is an effective tool to identify critical anastomoses. Neoadjuvant radiation, bilobectomies and acute or chronic inflammation were independent risk factors for bronchial healing disorders and should be considered at the planning stage of surgery.

Most patient conditions do not a priori debilitate the sensitivity of thoracic ultrasound in thoracic surgery-a prospective comparative study.

BACKGROUND: The few existing studies on the accuracy of lung ultrasound in the detection of a postoperative pneumothorax after thoracic surgery differ in the sonographic technique and the inclusion criteria. Several conditions are considered unfavourable in the sonographic examination of the lung. We aim to test these conditions for their impact on the diagnostic accuracy of lung ultrasound. METHODS: We compared lung ultrasound and chest roentgenograms for the detection of a pneumothorax after lung-resecting surgery in two prospective trials (register ID DRKS00014557 and DRKS00020216). The ultrasound examiners and radiologists were blinded towards the corresponding findings. We performed posthoc subgroup analyses to determine the influence of various patient or surgery related conditions on the sensitivity and specificity of ultrasound in the detection of pneumothorax. RESULTS: We performed 340 examinations in 208 patients. The covariates were age, gender, body mass index, smoking status, severity of chronic obstructive pulmonary disease, previous ipsilateral operation or irradiation, thoracotomy, postoperative skin emphysema, indwelling chest tube and X-ray in supine position. In univariate analysis, an indwelling chest-tube was associated with a higher sensitivity (58%, p = 0.04), and a postoperative subcutaneous emphysema with a lower specificity (73% vs. 88%, p = 0.02). None of the other subgroups differed in sensitivity or specificity from the total population . CONCLUSIONS: Most of the patient- or surgery related conditions usually considered unfavourable for lung ultrasound did not impair the sensitivity or specificity of lung ultrasound. Further studies should not excluce patients with these conditions, but test the accuracy under routine conditions. TRIAL REGISTRATION: DRKS, DRKS00014557, registered 06/09/2018, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00014557 and DRKS00020216, registered 03/12/2019, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00020216.