Evolutionary trajectories of small cell lung cancer under therapy.

The evolutionary processes that underlie the marked sensitivity of small cell lung cancer (SCLC) to chemotherapy and rapid relapse are unknown1-3. Here we determined tumour phylogenies at diagnosis and throughout chemotherapy and immunotherapy by multiregion sequencing of 160 tumours from 65 patients. Treatment-naive SCLC exhibited clonal homogeneity at distinct tumour sites, whereas first-line platinum-based chemotherapy led to a burst in genomic intratumour heterogeneity and spatial clonal diversity. We observed branched evolution and a shift to ancestral clones underlying tumour relapse. Effective radio- or immunotherapy induced a re-expansion of founder clones with acquired genomic damage from first-line chemotherapy. Whereas TP53 and RB1 alterations were exclusively part of the common ancestor, MYC family amplifications were frequently not constituents of the founder clone. At relapse, emerging subclonal mutations affected key genes associated with SCLC biology, and tumours harbouring clonal CREBBP/EP300 alterations underwent genome duplications. Gene-damaging TP53 alterations and co-alterations of TP53 missense mutations with TP73, CREBBP/EP300 or FMN2 were significantly associated with shorter disease relapse following chemotherapy. In summary, we uncover key processes of the genomic evolution of SCLC under therapy, identify the common ancestor as the source of clonal diversity at relapse and show central genomic patterns associated with sensitivity and resistance to chemotherapy.

[Carinal Resections]. / Resektionen der Trachealbifurkation.

Carinal resections are consistently described in the literature as one of the most challenging procedures in thoracic surgery. Depending on the underlying disease and its extent, different resection forms and reconstruction techniques are required. From a surgical point of view, the complex anatomy, and the technique of reconstruction of the central airway are particularly challenging. However, complex airway management and extensive postoperative follow-up demonstrate that these procedures require a multidisciplinary team effort beyond surgical expertise. This article reviews the most important pre-, intra-, and post-operative aspects of these challenging procedures.

[Idiopathic Subglottic Tracheal Stenosis]. / Idiopathische subglottische Tracheastenose.

Idiopathic subglottic stenosis is a circular scarred narrowing of the airway at the transition from the cricoid cartilage to the trachea. The stenosis is found radiologically and endoscopically at the level of the cricoid cartilage without involvement of the cricoid or tracheal cartilage itself. The disease practically only affects women between the ages of 20 and 60. The same clinical picture occurs in granulomatosis with polyangiitis and less frequently in other autoimmune diseases, where it requires systemic treatment. The clinical picture usually begins insidiously with coughing and sputum production and leads to dyspnoea and a restricted cough. As the course is insidious and the patients are otherwise healthy, the symptoms are often misinterpreted and the diagnosis is delayed. Treatment consists of local measures, ranging from dilatation and laser surgical resection, sometimes with local application of medication to inhibit the proliferation of new scar tissue, to laryngotracheal resection of varying degrees. The disease is located in the border area between the trachea and larynx and the patients are therefore treated by ENT medicine, pneumology and thoracic surgery.

[Anesthesia and Surgery of the Trachea]. / Anästhesie und Chirurgie der Trachea.

This article aims to review the current anaesthetic management of tracheal resections.Apart from the "traditional" approach of induction of general anaesthesia with conventional tracheal intubation and cross-field intubation or jet ventilation during the resection phase, there has lately been a trend towards less invasive techniques.Regional anaesthesia, laryngeal mask airways and preservation of spontaneous ventilation are among the new anaesthetic approaches. Current data suggest potential advantages compared with conventional tracheal intubation.Extracorporeal membrane oxygenation may provide adequate gas exchange and/or cardiovascular support for complex resections and reconstructions. In addition, it may serve as a reliable "backup" technique, in case of oxygenation difficulties with the use of other devices.Given the vast spectrum of different anaesthetic approaches to tracheal surgery, interdisciplinary planning is essential to identify the optimal technique on a case-by-case basis. During that process, the localisation and consistency of the airway lesion, comorbidities and the functional status of the respiratory system and specific surgical approach need to be taken into account.As there is a lack of high-quality data, evidence-based comparisons of different anaesthetic techniques are not possible.

[Functional, Radiological and Endoscopic Diagnostic of Tracheal Diseases]. / Funktionelle, radiologische und endoskopische Diagnostik trachealer Erkrankungen.

Diseases of the trachea are rare, while other diseases associated with shortness of breath and pulmonary symptoms are common, which is why the necessary diagnosis and therapy are regularly delayed. At the same time, diseases range from simple scarring stenosis to extensive tumour disease. Patients may be otherwise healthy, suffer from autoimmune disease, or have severe general illnesses, as in tracheotomised patients. Therefore, history and clinical examination provide very important clues to a disease of the trachea. Subsequent diagnostics should be ordered in a reasonable manner and lead to the correct diagnosis and subsequent therapy in a timely manner. Functional, radiological and endoscopic examinations, each with a special focus in experienced hands, avoid duplicate examinations or misinterpretations. Patients are grateful because diseases of the trachea - a central airway that cannot be bypassed - are experienced as life-threatening or at least as severely limiting the quality of life.

Safety and efficacy of helical tomotherapy following lung-sparing surgery in locally advanced malignant pleural mesothelioma.

PURPOSE: To assess the value of radiation therapy (RT) with helical tomotherapy (HT) in the management of locally advanced malignant pleural mesothelioma (MPM) receiving no or lung-sparing surgery. METHODS: Consecutive MPM cases not undergoing extrapleural pneumonectomy and receiving intensity-modulated (IM) HT were retrospectively evaluated for local control, distant control, progression-free survival (PFS), and overall survival (OS). Impact of age, systemic treatment, RT dose, and recurrence patterns was analyzed by univariate and multivariate analysis. As a secondary endpoint, reported toxicity was assessed. RESULTS: A total of 34 localized MPM cases undergoing IMHT were identified, of which follow-up data were available for 31 patients. Grade 3 side effects were experienced by 26.7% of patients and there were no grade 4 or 5 events observed. Median PFS was 19 months. Median OS was 20 months and the rates for 1­ and 2­year OS were 86.2 and 41.4%, respectively. OS was significantly superior for patients receiving adjuvant chemotherapy (p = 0.008). CONCLUSION: IMHT of locally advanced MPM after lung-sparing surgery is safe and feasible, resulting in satisfactory local control and survival. Adjuvant chemotherapy significantly improves OS. Randomized clinical trials incorporating modern RT techniques as a component of trimodal treatment are warranted to establish an evidence-based standard of care pattern for locally advanced MPM.

[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.

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.

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.

Resistance to MET inhibition in MET-dependent NSCLC and therapeutic activity after switching from type I to type II MET inhibitors.

OBJECTIVES: Resistance to MET inhibition occurs inevitably in MET-dependent non-small cell lung cancer and the underlying mechanisms are insufficiently understood. We describe resistance mechanisms in patients with MET exon 14 skipping mutation (METΔex14), MET amplification, and MET fusion and report treatment outcomes after switching therapy from type I to type II MET inhibitors. MATERIALS AND METHODS: Pre- and post-treatment biopsies were analysed by NGS (next generation sequencing), digital droplet PCR (polymerase chain reaction), and FISH (fluorescense in situ hybridization). A patient-derived xenograft model was generated in one case. RESULTS: Of 26 patients with MET tyrosine kinase inhibitor treatment, eight had paired pre- and post-treatment biopsies (Three with MET amplification, three with METΔex14, two with MET fusions (KIF5B-MET and PRKAR2B-MET).) In six patients, mechanisms of resistance were detected, whereas in two cases, the cause of resistance remained unclear. We found off-target resistance mechanisms in four cases with KRAS mutations and HER2 amplifications appearing. Two patients exhibited second-site MET mutations (p.D1246N and p. Y1248H). Three patients received type I and type II MET tyrosine kinase inhibitors sequentially. In two cases, further progressive disease was seen hereafter. The patient with KIF5B-MET fusion received three different MET inhibitors and showed long-lasting stable disease and a repeated response after switching therapy, respectively. CONCLUSION: Resistance to MET inhibition is heterogeneous with on- and off-target mechanisms occurring regardless of the initial MET aberration. Switching therapy between different types of kinase inhibitors can lead to repeated responses in cases with second-site mutations. Controlled clinical trials in this setting with larger patient numbers are needed, as evidence to date is limited to preclinical data and case series.

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.

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.

[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.

Sarcoidosis involvement of the diaphragm leading to right diaphragmatic elevation: a case report.

A 69-year-old male Caucasian presenting with dyspnea on exertion related to unilateral diaphragmatic dysfunction as caused by sarcoidosis is described. First, right diaphragmatic elevation was unexplained, while the patient presented with a restrictive pattern in lung function testing using bodyplethysmography and with reduced global and diaphragmatic respiratory muscle strength as evidenced by respiratory pressures. Subsequently, surgical diaphragm plication was performed, unfortunately, without any clinical improvement. Microscopic examination of diaphragm sections revealed a lymphocytic myositis with granulomatous pleuritis showing multiple non-caseating epithelioid granulomas. Accordingly, a lymphocytic alveolitis (26% lymphocytes) with an elevated CD4/CD8 T cell ratio of 8.0% and elevated serum parameters (neopterin and sIL-2 receptor) were established. Consequently, the diagnosis of pulmonary sarcoidosis with diaphragm involvement but without extrapulmonary involvement has been established. Therefore, sarcoidosis needs to be considered in any patient presenting with unilateral diaphragmatic dysfunction. The optimal treatment strategy, however, needs to be established in the future.

Guidelines on analgosedation, monitoring, and recovery time for flexible bronchoscopy: a systematic review.

BACKGROUND: Patients undergoing bronchoscopy in spontaneous breathing are prone to hypoxaemia and hypercapnia. Sedation, airway obstruction, and lung diseases impair respiration and gas exchange. The restitution of normal respiration takes place in the recovery room. Nonetheless, there is no evidence on the necessary observation time. We systematically reviewed current guidelines on bronchoscopy regarding sedation, monitoring and recovery. METHODS: This review was registered at the PROSPERO database (CRD42020197476). MEDLINE and awmf.org were double-searched for official guidelines, recommendation or consensus statements on bronchoscopy from 2010 to 2020. The PICO-process focussed on adults (Patients), bronchoscopy with maintained spontaneous breathing (Interventions), and recommendations regarding the intra- and postprocedural monitoring and sedation (O). The guideline quality was graded. A catalogue of 54 questions was answered. Strength of recommendation and evidence levels were recorded for each recommendation. RESULTS: Six guidelines on general bronchoscopy and three expert statements on special bronchoscopic procedures were identified. Four guidelines were evidence-based. Most guidelines recommend sedation to improve the patient's tolerance. Midazolam combined with an opioid is preferred. The standard monitoring consists of non-invasive blood pressure, and pulse oximetry, furthermore electrocardiogram in cardiac patients. Only one guideline discusses hypercapnia and capnometry, but without consensus. Two guidelines discuss a recovery time of two hours, but a recommendation was not given because of lack of evidence. CONCLUSION: Evidence for most issues is low to moderate. Lung-diseased patients are not represented by current guidelines. Capnometry and recovery time lack evidence. More primary research in these fields is needed so that future guidelines may address these issues, too.

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.

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.

Development of the Diaphragmatic Paralysis Questionnaire: a simple tool for patient relevant outcome.

OBJECTIVES: Measurement tools of health-related quality of life (HRQL) that are specific for the underlying disorder are inevitably needed to assess HRQL changes following specific treatment strategies. The aim of the current study was to develop a questionnaire assessing HRQL in patients with unilateral diaphragmatic paresis. METHODS: Firstly, topics of health impairments covering physical, psychological, social and functional aspects were predefined by a physician expert panel to ensure face validity. Secondly, all predefined topics were rated by a patient group with unilateral diaphragmatic paresis (untreated: n = 11; postoperative: n = 9) using a 5-point Likert scale ranging from 'not relevant at all' (-2) to 'absolutely relevant' (+2) to guarantee content validity. Thirdly, only relevant topics (0 to +2) were used for item development, while non-relevant items (<0) were not subject for item development. RESULTS: In total, 20 patients rated a total of 43 topics covering a broad spectrum of health impairment. 21 were considered as relevant for item development. Items are answered on a 5-point Likert scale ranging from 'completely untrue' (-2) to 'always true' (+2). The Diaphragmatic Paralysis Questionnaire (DPQ) Summary Score ranges from 0 (worst HRQL) to 100 (best HRQL). Finally, the German DPQ was professionally translated and transculturally adapted into English, Italian, Dutch, French, Greek and Spanish, using translation/back-translation procedures. CONCLUSIONS: The DPQ is the first diseases-specific HRQL measure developed for patients with diaphragmatic paresis. In addition, the DPQ is available in 7 languages free of charge for non-profit purposes. CLINICAL TRIAL REGISTRATION: German clinical trials register: DRKS00017056.

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.