[ERAS Implementation in Thoracic Surgery]. / ERAS-Implementierung in der Thoraxchirurgie.

This manuscript provides an overview of the principles and requirements for implementing the ERAS program in thoracic surgery.The ERAS program optimises perioperative management of elective lung resection procedures and is based on the ERAS Guidelines for Thoracic Surgery of the ERAS Society. The clinical measures are described as in the current literature, with a focus on postoperative outcome. There are currently 45 enhanced recovery items covering four perioperative phases: from the prehospital admission phase (patient education, screening and treatment of potential risk factors such as anaemia, malnutrition, cessation of nicotine or alcohol abuse, prehabilitation, carbohydrate loading) to the immediate preoperative phase (shortened fasting period, non-sedating premedication, prophylaxis of PONV and thromboembolic complications), the intraoperative measures (antibiotic prophylaxis, standardised anaesthesia, normothermia, targeted fluid therapy, minimally invasive surgery, avoidance of catheters and probes) through to the postoperative measures (early mobilisation, early nutrition, removal of a urinary catheter, hyperglycaemia control). Most of these measures are based on scientific studies, with a high level of evidence and aim to reduce general postoperative complications.The ERAS program is an optimised perioperative treatment approach aiming to improve the postoperative recovery in patients after elective lung resection by reducing the overall complication rates and overall morbidity.

[Current State of ERAS Implementation in Thoracic Surgery in Germany]. / Aktuelle ERAS-Implementierung in der Thoraxchirurgie an deutschen Kliniken.

BACKGROUND, OBJECTIVES: In recent years, ERAS treatment pathways have found their way into many surgical fields, as they reduce complications and accelerate postoperative recovery. For thoracic surgery, the first ERAS guidelines were published by the ERAS Society and the European Society of Thoracic Surgeons (ESTS) in 2019. We have now evaluated how ERAS-items are implemented in clinical practice by using an online survey. MATERIAL AND METHODS: An online survey was conducted from 12/5/2021 until 1/6/2021. The survey consisted of 22 questions focusing on the key elements of an ERAS program according to the published ERAS guidelines. Results were summarised, descriptively analysed and put into context with the current literature. RESULTS: Of 155 thoracic surgeons, 32 responded to the survey. In 28.1% (n = 9) of the hospitals, an ERAS core unit was established, and a database to record the ERAS items existed in 15.6% (n = 5). Only 3.1% (n = 1) kept an ERAS-diary preoperatively. A so-called Carboloading was conducted at 15.6% (n = 5) of surgeons. Standard PONV prophylaxis was administered to 59.4% (n = 19) of the patients. In most cases (84.4%, n = 29), a single drain was inserted into the pleural cavity during anatomic resections. In 3% (n = 1) of the centres two drains, in 12.5% (n = 4) no drainage was placed. The most commonly applied initial suction was -10 cmH2O (75%, n = 24). Suction ≤ 2 cmH2O was used by only two of those interviewed. Drainage removal took place in 50% (n = 16) of cases between the 1st or 2nd POD, in 34.4% of cases (n = 11) between the 3rd and 4th POD and in 9.4% (n = 3) the drain remained longer than the 4th POD. The first postoperative mobilisation took place in 71.9% (n = 23) of the centres on the day of the operation. CONCLUSIONS: The implementation of ERAS guidelines varies in Germany between centres. Certain perioperative processes are covered sufficiently, but the implementation of key features of ERAS is yet to be fully established in clinical practice. The first steps in this direction have already been taken and lay the foundation for cooperation across centres.

Lipoprotein apheresis reduces biomarkers of plaque destabilization and cardiovascular risk.

Lipoprotein apheresis (LA) is believed to exert anti-atherosclerotic effects beyond LDL-cholesterol reduction. We investigated 22 patients undergoing regular LA on a weekly basis (group A) before (AP) and after LA procedure (EP), 15 healthy individuals (group B), and 22 hyperlipoproteinemic patients with concomitant cardiovascular end organ damage treated without LA therapy (group C). Biomarkers of endothelial inflammation (hsCRP), plaque destabilization, and rupture (sVCAM, MMP-9, PAPP-A, ADMA) were quantified. Intergroup comparison revealed a statistically significant lower MMP-9 level in group A (AP and EP) compared with group C (P < 0.01), whereas PAPP-A levels were lower in group B compared with group A and C (P = 0.04). EP ADMA-levels and EP sVCAM levels in group A were statistically lower compared with group B and C. AP and EP values comparison revealed a significant reduction for hsCRP (mean 41.0 ± 16.7%, P < 0.01), sVCAM (mean 69.6 ± 14.0%, P < 0.01), PAPP-A (mean 88.7 ± 20.4%, P < 0.01), ADMA (mean 69.7 ± 18.4% P < 0.01). In conclusion, we observed a transient decrease in the plasma concentrations of several biomarkers expressed during plaque destabilization and elevated cardiovascular risk after a single LA treatment.

Chest wall resections for non-small cell lung cancer: a literature review.

Background and Objective: The development of early screening for lung cancer has led to improved overall survival in patients with non-small cell lung cancer (NSCLC). However, the management of NSCLC patients with resectable and potentially resectable chest wall invasion (CWI) requires attention. The purpose of this review is to summarize the role of surgery (chest wall resections) in NSCLC patients with CWI. Methods: A literature search and review from three databases (PubMed, Embase, and ScienceDirect) comprised the last 39 years. This review was focused on the treatment of NSCLC patients with CWI, mainly including the preoperative evaluation, principles of treatment and strategic decision-making, surgical complications, and prognostic factors. Key Content and Findings: Through the collection of relevant literature on NSCLC that invades the chest wall, this narrative review describes the actual role in clinical practice and future developments of chest wall resections. Preoperative treatment requires the multidisciplinary team (MDT) team to conduct accurate clinical staging of the patient and pay attention to the patient's lymph node status and rib invasion status. The successful implementation of chest wall resection and possible chest wall reconstruction requires refined individualized treatment based on the patient's clinical characteristics, supplemented by possible postoperative systemic treatment. Conclusions: Surgery plays an important role in treating NSCLC patients with CWI, and a collaborative, experienced MDT is an essential component of the successful treatment of CWI with lung cancer. In the future, more high-quality clinical research is needed to focus on CWI patients so that patients can receive more effective treatment options and better clinical prognosis.

Robotic-assisted extended thymectomy for large resectable thymoma: 21 years' experience.

OBJECTIVE: This study aims to evaluate the perioperative and midterm oncological outcomes of robotic-assisted thoracic surgery extended thymectomy for patients with large resectable thymomas compared with small thymomas. METHODS: This retrospective single-center study included 204 patients with thymomas who underwent robotic-assisted thoracic surgery extended thymectomy between January 2003 and February 2024. Patients were divided into 2 groups based on the thymoma size (5-cm threshold). RESULTS: The study comprised 114 patients (55.9%) in the small thymoma group and 90 patients (44.1%) in the large thymoma group. No significant differences were found between the groups regarding gender, age, proportion of elderly patients, or pathologic high-risk classifications. Apart from a longer operative time (P = .009) in the large thymoma group, no differences were observed between the 2 groups regarding surgical parameters and postoperative outcomes. No deaths occurred within 30 days in either group. During a median follow-up of 61.0 months (95% CI, 48.96-73.04), 4 patients experienced recurrence (1.96%). No significant differences in the 5-year overall survival (P = .25) or recurrence-free survival (P = .43) were observed between groups. CONCLUSIONS: Robotic-assisted thoracic surgery extended thymectomy is technically feasible, safe, and effective for treating large resectable thymomas. Moreover, midterm outcomes for patients with completely resected large thymomas were comparable to those with small thymomas during a median follow-up period of up to 5 years.