Outcomes of patients discharged home with a chest tube after lung resection: a multicentre cohort study.

BACKGROUND: Prolonged air leaks are increasingly treated in the outpatient setting, with patients discharged with chest tubes in place. We evaluated the incidence and risk factors associated with readmission, empyema development and further interventions in this patient population. METHODS: We undertook a retrospective cohort analysis of all patients from 4 tertiary academic centres (January 2014 to December 2017) who were discharged home with a chest tube after lung resection for a postoperative air leak lasting more than 5 days. We analyzed demographics, patient factors, surgical details, hospital readmission, reintervention, antibiotics at discharge, empyema and death. RESULTS: Overall, 253 of 2794 patients were analyzed (9.0% of all resections), including 30 of 759 from centre 1 (4.0%), 67 of 857 from centre 2 (7.8%), 9 of 247 from centre 3 (3.6%) and 147 of 931 from centre 4 (15.8%) (p < 0.001). Our cohort consisted of 56.5% men, and had a median age of 69 (range 19-88) years. Despite similar initial lengths of stay (p = 0.588), 49 patients (19.4%) were readmitted (21%, 0%, 23% and 11% from centres 1 to 4, respectively, p = 0.029), with 18 (36.7%) developing empyema, 11 (22.4%) requiring surgery and 3 (6.1%) dying. Only chest tube duration was a significant predictor of readmission (p < 0.001) and empyema development (p = 0.003), with a nearly threefold increased odds of developing empyema when the chest tube remained in situ for more than 20 days. CONCLUSION: Discharge with chest tube after lung resection is associated with serious adverse events. Given the high risk of empyema development, removal of chest tubes should be considered, when appropriate, within 20 days of surgery. Our data suggest a potential need for proactive postdischarge outpatient management programs to diminish risk of morbidity and death.

Intubated Versus Nonintubated General Anesthesia for Video-Assisted Thoracoscopic Surgery-A Case-Control Study.

OBJECTIVE: General anesthesia with endobronchial intubation and one-lung positive-pressure ventilation always has been considered mandatory for thoracic surgery. Recently, there has been interest in nonintubated techniques for video-assisted thoracoscopic surgery (VATS) in awake and sedated patients. The authors' center developed a nonintubated technique with spontaneous ventilation with the patient under general anesthesia using a supraglottic airway device. The authors believe that this was the first study to compare a nonintubated general anesthetic technique with an intubated general anesthetic technique for VATS. DESIGN: Retrospective, observational study. SETTING: Specialist cardiothoracic hospital in the United Kingdom. PARTICIPANTS: All patients who underwent elective minor VATS over 8 months (n = 73). INTERVENTIONS: A nonintubated general anesthetic technique with spontaneous ventilation via a supraglottic airway device was used for minor VATS procedures. This was compared with a case-matched intubated group. MEASUREMENTS AND MAIN RESULTS: Both groups had comparable baseline characteristics and surgical procedures. The anesthetic time was shorter in the nonintubated group (13.6±8.3 v 24.1±10.9 minutes, p<0.001). Surgical operating time and feasibility were similar. Intraoperatively, there were increases in end-tidal carbon dioxide (59.1±12.9 v 41.8±4.6, p<0.001) and respiratory rate (17.8±5.6 v 13.5±2.0, p<0.001) in the nonintubated group. Fewer patients in the nonintubated group had moderate-severe pain during recovery (19.4% v 48.4%, p = 0.02) and pain on discharge to the ward (25.8% v 61.3%, p = 0.004). There was a trend toward shorter recovery times, reduced oxygen requirement, and shorter hospital stays in the nonintubated group. CONCLUSIONS: A nonintubated general anesthetic technique is a feasible alternative to intubated general anesthesia for minor VATS procedures.

Management of complications after chest wall resection and reconstruction: a narrative review.

Background and Objective: Chest wall resection and reconstruction procedures carry high postoperative morbidity. Therefore, successful outcomes necessitate prevention, prompt identification, and appropriate management of ensuing complications. This narrative review aims to provide a comprehensive overview of evidence-based strategies for managing complications following chest wall resection and reconstruction. Methods: A literature search was conducted using the PubMed database for relevant English-language studies published since 1980. Key Content and Findings: Complications following chest wall resection and reconstruction can be broadly classified into surgical site-related, respiratory, or other systemic complications. Surgical site and respiratory complications are the most common, with reported incidence rates of approximately 40% across some series. Predisposing factors for respiratory morbidity include greater numbers of resected ribs and concurrent pulmonary lobectomy. Definitive correlations between specific prosthetic materials and complications remain elusive. Management should be tailored to the type and severity of the complication, surgical variables, and patient factors. Specific approaches for managing common complications are discussed in detail. Emerging preventive approaches, such as minimally invasive surgical techniques, are also briefly highlighted to help guide future research. Conclusions: An emphasis on anticipating and judiciously managing complications of chest wall resection and reconstruction, alongside a coordinated multidisciplinary approach, can optimize outcomes for patients undergoing this intrinsically complex surgery.

The future of artificial intelligence in thoracic surgery for non-small cell lung cancer treatment a narrative review.

Objectives: To present a comprehensive review of the current state of artificial intelligence (AI) applications in lung cancer management, spanning the preoperative, intraoperative, and postoperative phases. Methods: A review of the literature was conducted using PubMed, EMBASE and Cochrane, including relevant studies between 2002 and 2023 to identify the latest research on artificial intelligence and lung cancer. Conclusion: While AI holds promise in managing lung cancer, challenges exist. In the preoperative phase, AI can improve diagnostics and predict biomarkers, particularly in cases with limited biopsy materials. During surgery, AI provides real-time guidance. Postoperatively, AI assists in pathology assessment and predictive modeling. Challenges include interpretability issues, training limitations affecting model use and AI's ineffectiveness beyond classification. Overfitting and global generalization, along with high computational costs and ethical frameworks, pose hurdles. Addressing these challenges requires a careful approach, considering ethical, technical, and regulatory factors. Rigorous analysis, external validation, and a robust regulatory framework are crucial for responsible AI implementation in lung surgery, reflecting the evolving synergy between human expertise and technology.

Benign tumors of the chest wall.

Benign tumors of the chest wall are rare tumors that might arise from all the tissues of the chest: vessels, nerves, bones, cartilage, and soft tissues. Despite benign features, these tumors can have several histological characteristics and different behaviors. Even if they do not influence life expectancy, rarely they may have a potential risk of malignant transformation. They can cause several, oft, unspecific symptoms but more than 20% of affected patients are asymptomatic and are being diagnosed incidentally on chest radiograph or computed tomography scan. Pain is the most common described symptom. Together with a detailed medical history, a rigorous and meticulous clinical and radiological assessment is mandatory. If radiological features are unclear or in case surgery could not be performed, a biopsy should be indicated to establish a diagnosis. Radical surgical resection can often be offered to resect and cure these neoplasms, but this is might not be true for all types of tumors and, in some cases, their dimension or position might contra-indicate surgery. Given the rarity of these tumors, there is a lack of treatment's guidelines and prospective trials that include a significant number of patients. This review discusses, according to the latest evidence, the histological features and the best treatment of several chest wall benign tumors.

CARE-radiology statement explanation and elaboration: reporting guideline for radiological case reports.

Despite the increasing number of radiological case reports, the majority lack a standardised methodology of writing and reporting. We therefore develop a reporting guideline for radiological case reports based on the CAse REport (CARE) statement. We established a multidisciplinary group of experts, comprising 40 radiologists, methodologists, journal editors and researchers, to develop a reporting guideline for radiological case reports according to the methodology recommended by the Enhancing the QUAlity and Transparency Of health Research network. The Delphi panel was requested to evaluate the significance of a list of elements for potential inclusion in a guideline for reporting mediation analyses. By reviewing the reporting guidelines and through discussion, we initially drafted 46 potential items. Following a Delphi survey and discussion, the final CARE-radiology checklist is comprised of 38 items in 16 domains. CARE-radiology is a comprehensive reporting guideline for radiological case reports developed using a rigorous methodology. We hope that compliance with CARE-radiology will help in the future to improve the completeness and quality of case reports in radiology.

Surgery for Solitary Fibrous Tumors of the Pleura: A Review of the Available Evidence.

Solitary fibrous tumors of the pleura (pSFT) are a relatively rare neoplasms that can arise from either visceral or parietal pleura and may have different aggressive biological behaviors. Surgery is well known to be the cornerstone of the treatment for pSFT. We reviewed the existing literature, focusing on the role of surgery in the management and treatment of pSFT. All English-written literature has been reviewed, focusing on those reporting on the perioperative management and postoperative outcomes. Surgery for pSFT is feasible and safe in all experiences reported in the literature, but surgical approaches and techniques may vary according to the tumor dimensions, localization, and surgeons' skills. Long-term outcomes are good, with a 10-year overall survival rate of more than 70% in most of the reported experiences; on the other hand, recurrence may happen in up to 17% of cases, which occurs mainly in the first two years after surgery, but case reports suggest the need for a longer follow-up to assess the risk of late recurrence. Malignant histology and dimensions are the most recognized risk factors for recurrence. Recurrence might be operated on in select patients. Surgery is the treatment of choice in pSFT, but a radical resection and a careful postoperative follow-up should be carried out.

Multi-level analysis and evaluation of organizational improvements in thoracic surgery according to a Value-Based HealthCare approach.

Background: Value-Based HealthCare (VBHC), designed by Harvard University, is an evolving model of healthcare delivery that achieves better patient outcomes and greater financial sustainability for the healthcare professionals. According to this innovative approach, the value is determined by a panel of indicators and the ratio between results and costs. Our goal was to develop a panel of thoracic-fashioned key-performance indicators (KPIs) creating a model that could be applied in thoracic surgery for the first time, reporting our early experience. Methods: Fifty-five indicators were developed based on literature review: 37 for outcomes and 18 for costs. Outcomes were measured by a 7 level Likert scale, while overall costs were defined through the sum of the individual economic performance on each resource indicator. An observational retrospective cross-sectional study was designed to make a cost-effective evaluation of the indicators. Therefore, the Patient Value in Thoracic Surgery (PVTS) score calculated value gained for every lung cancer patient undergoing lung resection at our surgical department. Results: A total of 552 patients were enrolled. From 2017 to 2019 mean outcome indicators per patient were 109, 113 and 110 while mean costs per patient were 7.370, 7.536 and 7.313 euros respectively. Hospital stay and waiting time from consultation to surgery for lung cancer patients decreased from 7.3 to 5 and from 25.2 to 21.9 days, respectively. On the contrary, number of patients increased but overall costs decreased, despite cost of consumables has gone from 2.314 to 3.438 euros, since cost of hospitalization and occupancy of the operating room (OR) improved (from 4.288 to 3.158 euros). Variables analyzed showed that overall value delivered grew from 14.8 to 15. Conclusions: Introducing a new concept of value, the VBHC theory applied to thoracic surgery may revolutionize traditional organizational management in lung cancer patients, showing how value delivered can increase in accordance with outcomes, despite the growth of part of the costs. Our panel of indicators has been created to provide an innovative score to successfully identify improvements needed and quantify their effectiveness in Thoracic Surgery and our early experience reports encouraging results.

Salvage Surgery for Small-Cell Lung Cancer-A Literature Review.

(1) Background: Salvation surgery for small-cell lung cancer (SCLC) is exceptionally performed, and only a few cases are published. (2) Methods: There are 6 publications that present 17 cases of salvation surgery for SCLC-the salvation surgery was performed in the context of modern clearly established protocols for SCLC and after including SCLC in the TNM (tumor, node, metastasis) staging in 2010. (3) Results: After a median follow-up of 29 months, the estimated overall survival (OS) was 86 months. The median estimated 2-year survival was 92%, and the median estimated 5-year survival was 66%. (4) Conclusion: Salvage surgery for SCLC is a relatively new and extremely uncommon concept and represents an alternative to second-line chemotherapy. It is valuable because it may offer a reasonable treatment for selected patients, good local control, and a favorable survival outcome.

The SUPER reporting guideline suggested for reporting of surgical technique: explanation and elaboration.

Background: Surgical technique plays an essential role in achieving good health outcomes. However, the quality of surgical technique reporting remains heterogeneous. Reporting checklists could help authors to describe the surgical technique more transparently and effectively, as well as to assist reviewers and editors evaluate it more informatively, and promote readers to better understand the technique. We previously developed SUPER (surgical technique reporting checklist and standards) to assist authors in reporting their research that contains surgical technique more transparently. However, further explanation and elaboration of each item are needed for better understanding and reporting practice. Methods: We searched surgical literature in PubMed, Google Scholar and journal websites published up to January 2023 to find multidiscipline examples in various article types for each SUPER item. Results: We explain the 22 items of the SUPER and provide rationales item by item alongside. We provide 69 examples from 53 literature that present optimal reporting of the 22 items. Article types of examples include pure surgical technique, and case reports, observational studies and clinical trials that contain surgical technique. Examples are multidisciplinary, including general surgery, orthopaedical surgery, cardiac surgery, thoracic surgery, gastrointestinal surgery, neurological surgery, oncogenic surgery, and emergency surgery etc. Conclusions: Along with SUPER article, this explanation and elaboration file can promote deeper understanding on the SUPER items. We hope that the article could further guide surgeons and researchers in reporting, and assist editors and peer reviewers in reviewing manuscripts related to surgical technique.

Reporting guidelines for surgical technique could be improved: a scoping review and a call for action.

OBJECTIVES: To identify reporting guidelines related to surgical technique and propose recommendations for areas that require improvement. STUDY DESIGN AND SETTING: A protocol-guided scoping review was conducted. A literature search of MEDLINE, the EQUATOR Network Library, Google Scholar, and Networked Digital Library of Theses and Dissertations was conducted to identify surgical technique reporting guidelines published up to December 31, 2021. RESULTS: We finally included 55 surgical technique reporting guidelines, vascular surgery (n = 18, 32.7%) was the most common among the clinical specialties covered. The included guidelines generally showed a low degree of international and multidisciplinary cooperation. Few guidelines provided a detailed development process (n = 14, 25.5%), conducted a systematic literature review (n = 13, 23.6%), used the Delphi method (n = 4, 7.3%), or described post-publication strategy (n = 6, 10.9%). The vast majority guidelines focused on the reporting of intraoperative period (n = 50, 90.9%). However, of the guidelines requiring detailed descriptions of surgical technique methodology (n = 43, 78.2%), most failed to provide guidance on what constitutes an adequate description. CONCLUSION: Our study demonstrates significant deficiencies in the development methodology and practicality of reporting guidelines for surgical technique. A standardized reporting guideline that is developed rigorously and focuses on details of surgical technique may serve as a necessary impetus for change.

The SUPER reporting guideline suggested for reporting of surgical technique.

Background: Existing reporting guidelines pay insufficient attention to the detail and comprehensiveness reporting of surgical technique. The Surgical techniqUe rePorting chEcklist and standaRds (SUPER) aims to address this gap by defining reporting standards for surgical technique. The SUPER guideline intends to apply to articles that encompass surgical technique in any study design, surgical discipline, and stage of surgical innovation. Methods: Following the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network approach, 16 surgeons, journal editors, and methodologists reviewed existing reporting guidelines relating to surgical technique, reviewed papers from 15 top journals, and brainstormed to draft initial items for the SUPER. The initial items were revised through a three-round Delphi survey from 21 multidisciplinary Delphi panel experts from 13 countries and regions. The final SUPER items were formed after an online consensus meeting to resolve disagreements and a three-round wording refinement by all 16 SUPER working group members and five SUPER consultants. Results: The SUPER reporting guideline includes 22 items that are considered essential for good and informative surgical technique reporting. The items are divided into six sections: background, rationale, and objectives (items 1 to 5); preoperative preparations and requirements (items 6 to 9); surgical technique details (items 10 to 15); postoperative considerations and tasks (items 16 to 19); summary and prospect (items 20 and 21); and other information (item 22). Conclusions: The SUPER reporting guideline has the potential to guide detailed, comprehensive, and transparent surgical technique reporting for surgeons. It may also assist journal editors, peer reviewers, systematic reviewers, and guideline developers in the evaluation of surgical technique papers and help practitioners to better understand and reproduce surgical technique. Trial Registration: https://www.equator-network.org/library/reporting-guidelines-under-development/reporting-guidelines-under-development-for-other-study-designs/#SUPER.

Blood patch for persistent air leak: a review of the current literature.

PURPOSE OF REVIEW: Persistent air leak (PAL) poses a significant challenge to the thoracic surgeon. Of the numerous methods employed to manage this problem, autologous blood 'patch' pleurodesis (ABPP) remains one of the most controversial, seemingly due to a lack of robust data and consensus of opinion regarding its efficacy, technique of application and its role in clinical practice. Despite a lack of randomized control trials, the evidence to-date has shown ABPP to be an efficacious, cheap, simple, well tolerated and readily available treatment, with minimal side effects and broad range of applications, allowing for earlier chest drain removal, decreased complications and decreased hospital stay. A review is therefore required to assess the role for ABPP in contemporary clinical practice. RECENT FINDINGS: Recent studies have demonstrated that ABPP is an effective management for PAL in specific patient groups and there is an argument that it has the potential to be the gold-standard or first-line treatment in certain clinical scenarios such as for patients with interstitial lung disease or acute respiratory distress syndrome. SUMMARY: This review aims to discuss the relevance of recent findings and to suggest a firm role for ABPP in current practice. In addition, the evidence for the efficacy of ABPP will be assessed and compared with other established methods of pleurodesis. Finally, the review will include a summary of relevant research to-date in order to suggest an evidence-based standardized protocol for the application of ABPP.

Perioperative systemic therapies for non-small-cell lung cancer: Recent advances and future perspectives.

The mainstay of treatment for early-stage non-small-cell lung cancer (NSCLC) is surgical resection. Traditionally, chemotherapy has been used perioperatively in locally extensive disease to improve the oncologic outcomes of surgery, with a 5-year absolute survival benefit of approximately 5%. In recent years, immunotherapy and molecular targeted therapy have shown excellent results in the treatment of locoregionally advanced and metastatic NSCLC, replacing chemotherapy as first-line treatment in certain cases. Consequently, researchers have been increasingly investigating the use of immunotherapy or targeted therapy in combination with surgery for the treatment of early-stage disease. This growing research interest has resulted in several published and ongoing studies of various size and design. In this mini review, we provide a succinct and up-to-date overview of recently published, phase 3 randomized clinical trials on adjuvant and neoadjuvant immunotherapy or targeted therapy for NSCLC. We subsequently discuss some important unresolved clinical issues, including the optimal duration of treatment, scheduling with respect to surgery, and potential combinations of different systemic therapies. Finally, we reference large, randomized, phase 3 studies that are currently in progress and may give answers to those and other clinical questions.

COVID-19 After Lung Resection in Northern Italy.

We reviewed surgical cases from 4 Thoracic Surgery departments in the Lombardia region of Italy, the area mostly affected by Coronavirus pandemic in Europe, with the aim to describe the impact of COVID-19 on the treatment of thoracic surgical patients. Clinical, radiological and laboratory data from patients who underwent lung resection from December 2019 to March 2020 were retrospectively collected until June 2020. Univariable Cox regression models were estimated to evaluate potential prognostic factors for developing COVID-19 and to investigate postoperative mortality among patients who developed symptomatic COVID-19 infection. We examined data from 107 patients. (74 lobectomies, 32 wedge/segmentectomies and 1 pneumonectomy). Twelve patients developed COVID-19 (Group 1), whereas 95 patients were not infected (Group 2). In Group 1, 6 patients (50%) died from complications related to infection; in Group 2, one patient (1%) died because of non-COVID-19-related causes. Median days from surgery to first symptoms, CT confirmation, clinical confirmation and PCR positivity was 48.1, 54.3, 55.1, and 55.2 respectively. At univariable analysis, DLCO/VA% (P = 0.008), duration of the surgery (P = 0.009), smoking history (pack/year) (P < 0.001), BMI (P< 0.001) and number of segments resected (P = 0.010) were associated with COVID-19 onset. Moreover, CCI (P < 0.001), DLCO/VA% (P = 0.002), cigarette pack/year (P < 0.001), BMI (P < 0.001) and COVID-19 (P < 0.001) were associated with death. Patients who undergo lung resection and then develop symptomatic COVID-19 infection are at higher risk of developing severe respiratory complications and postoperative death. Insidious symptoms' onset may lead to a delay in diagnosis. We suggest two mitigating strategies: (1) Improve symptoms surveillance and isolation during recovery period, (2) Be aware of a potential greater risk of developing symptomatic COVID-19 and death correlated with elevated CCI, BMI, smoking history, DLCO/VA%, number of resected segments and duration of surgery.

How effective is indocyanine green (ICG) in localization of malignant pulmonary nodules? A systematic review and meta-analysis.

Background: Video-Assisted and Robotic-Assisted techniques become constantly more prominent practice in thoracic surgery for lung cancer. Furthermore, the increased frequency in detection of small lung cancers makes the intra-operative identification of these cancers even more challenging. Indocyanine Green (ICG) is one of the most commonly used dyes that assists surgeons identify small lung cancers intra-operatively. Our study aimed to evaluate the effectiveness and safety of ICG in lung cancer detection. Methods: We performed a systematic review of the literature by screening the databases of MEDLINE, EMBASE, CENTRAL and Scopus until 30th April 2022 and the first 300 articles of Google Scholar for any suitable grey literature. We included any study that investigated the effectiveness of ICG in lung cancer detection. We excluded studies that explored the use of ICG only in identification of intersegmental planes, lymph node mapping, case reports and non-English articles. We aimed to perform a meta-analysis on test accuracy studies using hierarchical summary receiver operating characteristic (HSROC) and the bivariate random-effects models. In cases where the data for a localization technique was not sufficient for that analysis, it was presented with tables with narrative purposes. Each study was assessed for Risk of Bias (RoB) and Applicability using the QUADAS-2 tool. Results: We found 30 eligible studies that included a total of 1,776 patients who underwent ICG localization of pulmonary nodules. We identified three ICG localization techniques: CT-guided, endobronchial and intravenous. From the 30 studies, 13 investigated CT-guided localization, 12 explored an endobronchial method while 8 studies administered ICG intravenously the median reported success rate was 94.3% (IQR: 91.4%-100%) and 98.3% (IQR: 94%-100%) for the first two techniques respectively. Intravenous ICG lung cancer localization showed Sensitivity of 88% (95% CI: 59%-0.97%) and Specificity of 25% (95% CI: 0.04%-0.74%). There were 15.2% (150/989) patients who experienced complications from CT guided ICG localization. No ICG-related complications were reported in endobronchial or intravenous techniques. Conclusion: Our study provides a comprehensive review of the literature on ICG localization techniques for lung cancer. Current evidence suggests that ICG is boh effective and safe. Further prospective research with standardized protocols across multiple thoracic units is required in order to accurately validate these findings.

Thoracic Outlet Syndrome: Single Center Experience on Robotic Assisted First Rib Resection and Literature Review.

Background: Thoracic outlet syndrome (TOS) is a pathological condition caused by a narrowing between the clavicle and first rib leading to a compression of the neurovascular bundle to the upper extremity. The incidence of TOS is probably nowadays underestimated because the diagnosis could be very challenging without a thorough clinical examination along with appropriate clinical testing. Beside traditional supra-, infraclavicular or transaxillary approaches, the robotic assisted first rib resection has been gaining importance in the last few years. Methods: We conducted a retrospective cohort analysis of all patients who underwent robotic assisted first rib resection due to TOS at Lucerne Cantonal Hospital and then we performed a narrative review of the English literature using PubMed, Cochrane Database of Systematic Reviews and Scopus. Results: Between June 2020 and November 2021, eleven robotic assisted first rib resections were performed due to TOS at Lucerne Cantonal Hospital. Median length of stay was 2 days (Standard Deviation: +/- 0.67 days). Median surgery time was 180 min (Standard Deviation: +/- 36.5). No intra-operative complications were reported. Conclusions: Robotic assisted first rib resection could represent a safe and feasible option in expert hands for the treatment of thoracic outlet syndrome.

The Role of Surgery in Patients with COVID-19-Related Thoracic Complications.

Objective: Patients with several thoracic complications induced by SARS-CoV-2 infection may benefit from surgery, but its role in this condition is largely unknown, and many surgeons' advice against any surgical referrals. Our aim is to investigate the efficacy and safety of surgery in COVID-19 patients with thoracic complications requiring surgery. Methods: We designed a multicenter observational study, involving nine thoracic surgery departments, evaluating patients who developed thoracic complications in hospital, surgically managed from March 1, 2020, to May 31, 2021. An overall 30-day mortality was obtained by using the Kaplan-Meier method. Multivariable Cox regression model and logistic models were applied to identify the variables associated with mortality and postoperative complications. Results: Among 83 patients, 33 (40%) underwent surgery for complicated pneumothorax, 17 (20.5%) for pleural empyema, 13 (15.5%) for hemothorax, 8 (9.5%) for hemoptysis, 5 patients (6%) for lung abscess, 4 (5%) for infected pneumatoceles, and 3 (3.5%) for other causes. Within 30 days of surgery, 60 patients (72%) survived. At multivariable analysis, age (HR 1.05 [95% CI, 1.01, 1.09], p = 0.022), pulmonary hypertension (HR 3.98 [95% CI, 1.09, 14.5], p = 0.036), renal failure (HR 2.91 [95% CI, 1.19, 7.10], p-value 0.019), thoracotomy (HR 4.90 [95% CI, 1.84, 13.1], p-value 0.001) and infective affections (HR 0.17 [95% CI, 0.05, 0.58], p-value 0.004) were found to be independent prognostic risk factors for 30-day mortality. Age (OR 1.05 [95% CI, 1.01, 1.10], p = 0.023) and thoracotomy (OR 3.85 [95% CI, 1.35, 12.0] p = 0.014) became significant predictors for 30-day morbidity. Conclusion: Surgical management of COVID-19-related thoracic complications is affected by high mortality and morbidity rates, but a 72% survival rate still seems to be satisfactory with a rescue intent. Younger patients without pulmonary hypertension, without renal insufficiency and undergoing surgery for infectious complications appear to have a better prognosis.

Post-intubation tracheal lacerations: Risk-stratification and treatment protocol according to morphological classification.

Background: Post-intubation tracheal laceration (PITL) is a rare condition (0.005% of intubations). The treatment of choice has traditionally been surgical repair. Following our first report in 2010 of treatment protocol tailored to a risk-stratified morphological classification there is now clear evidence that conservative therapy represents the gold standard in the majority of patients. In this paper we aim to validate our risk-stratified treatment protocol through the largest ever reported series of patients. Methods: This retrospective analysis is based on a prospectively collected series (2003-2020) of 62 patients with PITL, staged and treated according to our revised morphological classification. Results: Fifty-five patients with Level I (#8), II (#36) and IIIA (#11) PITL were successfully treated conservatively. Six patients with Level IIIB injury and 1 patient with Level IV underwent a surgical repair of the trachea. No mortality was reported. Bronchoscopy confirmed complete healing in all patients by day 30. Statistical analysis showed age only to be a risk factor for PITL severity. Conclusions: Our previously proposed risk-stratified morphological classification has been validated as the major tool for defining the type of treatment in PITL.

Does Myasthenia Gravis Affect Long-Term Survival in Thymic Carcinomas? An ESTS Database Analysis.

Background: Thymic carcinoma is a rare and highly malignant tumor with a dismal prognosis, which occasionally coexists with myasthenia gravis (MG). This study aims to investigate the MG incidence on a surgical cohort of patients with thymic carcinoma and to explore its influence on long-term survival. Methods: the prospectively collected data from the ESTS database on thymic epithelial tumors were reviewed. Clinical, pathological, and survival information on thymic carcinoma were analyzed. Results: the analysis was conducted on 203 patients, with an equal gender distribution (96 males and 107 females). MG was detected in 22 (10.8%) patients, more frequently elderly (>60 years, p = 0.048) and male (p = 0.003). Induction therapy was performed in 22 (10.8%) cases. After surgery, 120 (59.1%) patients had a Masaoka stage II−III while complete resection (R0) was achieved in 158 (77.8%). Adjuvant therapy was performed in 68 cases. Mean follow-up was 60 (SD = 14) months. The 3-year, 5-year and 10-year survival rates were 79%, 75% and 63%, respectively. MG did not seem to influence long-term survival (5-year survival in non-MG−TCs 78% vs. 50% in MG−TCs, p = ns) as age < 60 years, female gender, early Masaoka stage, and postoperative radiotherapy did, conversely. Conclusions: myasthenia occurred in about 10% of thymic carcinomas and it did not seem to affect significantly the long-term prognosis in surgically treated thymic carcinoma-patients.