Analyzing disease recurrence with missing at risk information.

When analyzing time to disease recurrence, we sometimes need to work with data where all the recurrences are recorded, but no information is available on the possible deaths. This may occur when studying diseases of benign nature where patients are only seen at disease recurrences or in poorly-designed registries of benign diseases or medical device implantations without sufficient patient identifiers to obtain their dead/alive status at a later date. When the average time to disease recurrence is long enough in comparison with the expected survival of the patients, statistical analysis of such data can be significantly biased. Under the assumption that the expected survival of an individual is not influenced by the disease itself, general population mortality tables may be used to remove this bias. We show why the intuitive solution of simply imputing the patient's expected survival time does not give unbiased estimates of the usual quantities of interest in survival analysis and further explain that cumulative incidence function analysis does not require additional assumptions on general population mortality. We provide an alternative framework that allows unbiased estimation and introduce two new approaches: an iterative imputation method and a mortality adjusted at risk function. Their properties are carefully studied, with the results supported by simulations and illustrated on a real-world example.

Antiinflammatory effect of sevoflurane in open lung surgery with one-lung ventilation.

AIM: To prospectively assess the antiinflammatory effect of volatile anesthetic sevoflurane in patients undergoing open lung surgery with one lung ventilation (OLV). METHODS: This prospective, randomized study included 40 patients undergoing thoracic surgery with OLV (NCT02188407). The patients were randomly allocated into two equal groups that received either propofol or sevoflurane. Four patients were excluded from the study because after surgery they received blood transfusion or non-steroid antiinflammatory drugs. Inflammatory mediators (interleukins 6, 8, and 10, C-reactive protein [CRP], and procalcitonin) were measured perioperatively. The infiltration of the nonoperated lung was assessed on chest x-rays and the oxygenation index was calculated. The major postoperative complications were counted. RESULTS: Interleukin 6 levels were significantly higher in propofol than in sevoflurane group (P=0.014). Preoperative CRP levels did not differ between the groups (P=0.351) and in all patients they were lower than 20 mg/L, but postoperative CRP was significantly higher in propofol group (31±6 vs 15±7 ng/L; P=0.035); Pre- and postoperative procalcitonin was within the reference range (<0.04 µg/L) in both groups. The oxygenation index was significantly lower in propofol group (339±139 vs 465±140; P=0.021). There was no significant difference between the groups in lung infiltrates (P=0.5849). The number of postoperative adverse events was higher in propofol group, but the difference was not-significant (5 vs 1; P=0.115). CONCLUSION: The study suggests an antiinflammatory effect of sevoflurane in patients undergoing thoracotomy with OLV.

Resectable non-stage IV nonsmall cell lung cancer: the surgical perspective.

Surgery remains an essential element of the multimodality radical treatment of patients with early-stage nonsmall cell lung cancer. In addition, thoracic surgery is one of the key specialties involved in the lung cancer tumour board. The importance of the surgeon in the setting of a multidisciplinary panel is ever-increasing in light of the crucial concept of resectability, which is at the base of patient selection for neoadjuvant/adjuvant treatments within trials and in real-world practice. This review covers some of the topics which are relevant in the daily practice of a thoracic oncological surgeon and should also be known by the nonsurgical members of the tumour board. It covers the following topics: the pre-operative selection of the surgical candidate in terms of fitness in light of the ever-improving nonsurgical treatment alternatives unfit patients may benefit from; the definition of resectability, which is so important to include patients into trials and to select the most appropriate radical treatment; the impact of surgical access and surgical extension with the evolving role of minimally invasive surgery, sublobar resections and parenchymal-sparing sleeve resections to avoid pneumonectomy.

ERASURE: early autologous blood pleurodesis for postoperative air leaks-a randomized, controlled trial comparing prophylactic autologous blood pleurodesis versus standard watch and wait treatment for postoperative air leaks following thoracoscopic anatomic lung resections.

BACKGROUND: The prolonged air leak is probably the most common complication following lung resections. Around 10-20% of the patients who undergo a lung resection will eventually develop a prolonged air leak. The definition of a prolonged air leak varies between an air leak, which is evident after the fifth, seventh or even tenth postoperative day to every air leak that prolongs the hospital stay. However, the postoperative hospital stay following a thoracoscopic lobectomy can be as short as 2 days, making the above definitions sound outdated. The treatment of these air leaks is also very versatile. One of the broadly accepted treatment options is the autologous blood pleurodesis or "blood patch". The purpose of this trial is to investigate the impact of a prophylactic autologous blood pleurodesis on reducing the duration of the postoperative air leak and therefore prevent the air leak from becoming prolonged. METHODS: Patients undergoing an elective thoracoscopic anatomic lung resection for primary lung cancer or metastatic disease will be eligible for recruitment. Patients with an air leak of > 100 ml/min within 6 h prior to the morning round on the second postoperative day will be eligible for inclusion in the study and randomization. Patients will be randomized to either blood pleurodesis or watchful waiting. The primary endpoint is the time to drain removal measured in full days. The trial ends on the seventh postoperative day. DISCUSSION: The early autologous blood pleurodesis could lead to a faster cessation of the air leak and therefore to a faster removal of the drain. A faster removal of the drain would relieve the patient from all the well-known drain-associated complications (longer hospital stay, stronger postoperative pain, risk of drain-associated infection, etc.). From the economical point of view, faster drain removal would reduce the hospital costs as well as the costs associated with the care of a patient with a chest drain in an outpatient setting. TRIAL REGISTRATION: German Clinical Trials Register (DRKS) DRKS00030810. 27 December 2022.

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.

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.

A prospective, randomized, double-blinded comparison between multimodal thoracic paravertebral bupivacaine and levobupivacaine analgesia in patients undergoing lung surgery.

OBJECTIVES: To compare the effects of paravertebral analgesia with levobupivacaine or bupivacaine on intra- and postoperative pain for thoracic surgery. DESIGN: A prospective, randomized, and double-blinded study. SETTING: A university hospital. PARTICIPANTS: Forty patients undergoing thoracic surgery. INTERVENTIONS: Patients received paravertebral catheterization and a bolus (14-20 mL) of 0.5% bupivacaine (n = 20) or 0.5% levobupivacaine (n = 20) with morphine, 60 µg/kg, before the induction of general anesthesia that consisted of a propofol infusion. A paravertebral continuous infusion (0.05 mL/kg/h) of 0.25% bupivacaine or 0.25% levobupivacaine, 100 mL, with added morphine, 10 mg, and clonidine, 0.15 mg, was started at the end of surgery for 72 hours postoperatively. Postoperative rescue diclofenac analgesia was available if required. MEASUREMENTS AND MAIN RESULTS: The primary outcome was intraoperative fentanyl consumption. Static and dynamic pain scores measured by a visual analog scale were assessed regularly. Intraoperative fentanyl consumption was significantly lower in the levobupivacaine group compared with the bupivacaine group (p = 0.001). On all 3 postoperative days, static pain scores were significantly lower in the levobupivacaine group compared with the bupivacaine group (p < 0.05). Dynamic pain scores were significantly lower in the levobupivacaine group compared with the bupivacaine group during the 2 postoperative days (p < 0.05). A smaller proportion of patients in the levobupivacaine group used rescue analgesia (p < 0.005). CONCLUSIONS: Paravertebral analgesia with levobupivacaine resulted in less intraoperative fentanyl consumption, lower static (3 days) and dynamic (2 days) pain scores, and less rescue analgesia than analgesia with bupivacaine.

Thoracic surgery in Slovenia.

Slovenia is a small country in the Southeastern part of Europe with a Gross Domestic Product slightly below the European average. There are eleven board-certified thoracic surgeons and four residents, dealing with roughly 2,500 thoracic cases per year. Thoracic Surgery in Slovenia is a challenging surgical specialty covering a wide range of problems such as lung cancer and other thoracic cancers, diseases of the esophagus, airway surgery, interventional endoscopy, pediatric thoracic surgery, lung transplantation, and even some nonthoracic problems such as surgery of the thyroid and parathyroid. Slovenian patients certainly enjoy the privilege of having free access to almost everything contemporary thoracic surgery can offer, including the most complex and least invasive procedures. In 2008 Slovenia was the first country in South-eastern Europe to adopt video-assisted thoracoscopic surgery (VATS) to treat lung cancer and other malignant diseases. It has also played an essential role in spreading the technique to neighboring countries. Slovenia also has a very successful lung transplantation program. On the other hand, most of the infrastructure is outdated, with both university hospitals built in the 1970s unable to provide a very comfortable hospital stay or increase their operating room capacities to meet the increased demand, thus waiting times for procedures of lesser priority, such as laparoscopic fundoplication and thyroidectomy became unacceptably long.

Case report: Congenital extrahepatic portocaval shunt presenting as pulmonary arterial hypertension in a pregnant patient.

Congenital extrahepatic portocaval shunt (CEPS) is a rare condition in which a rare congenital vascular anomaly of the portal system is present. CEPS may manifest as pulmonary arterial hypertension (PAH). When diagnosed and treated early, PAH can be reversible. We report a case of a previously asymptomatic woman, who manifested with severe pulmonary hypertension during pregnancy and was consequently diagnosed with CEPS. After unsuccessful medical treatment, urgent lung transplantation was done.

Gamma-glutamyltransferase is a strong predictor of secondary sclerosing cholangitis after lung transplantation for COVID-19 ARDS.

BACKGROUND: Lung transplantation (LTx) can be considered for selected patients suffering from COVID-19 acute respiratory distress syndrome (ARDS). Secondary sclerosing cholangitis in critically ill (SSC-CIP) patients has been described as a late complication in COVID-19 ARDS survivors, however, rates of SSC-CIP after LTx and factors predicting this detrimental sequela are unknown. METHODS: This retrospective analysis included all LTx performed for post-COVID ARDS at 8 European LTx centers between May 2020 and January 2022. Clinical risk factors for SSC-CIP were analyzed over time. Prediction of SSC-CIP was assessed by ROC-analysis. RESULTS: A total of 40 patients were included in the analysis. Fifteen patients (37.5%) developed SSC-CIP. GGT at the time of listing was significantly higher in patients who developed SSC-CIP (median 661 (IQR 324-871) vs 186 (109-346); p = 0.001). Moreover, higher peak values for GGT (585 vs 128.4; p < 0.001) and ALP (325 vs 160.2; p = 0.015) were found in the 'SSC' group during the waiting period. Both, GGT at the time of listing and peak GGT during the waiting time, could predict SSC-CIP with an AUC of 0.797 (95% CI: 0.647-0.947) and 0.851 (95% CI: 0.707-0.995). Survival of 'SSC' patients was severely impaired compared to 'no SSC' patients (1-year: 46.7% vs 90.2%, log-rank p = 0.004). CONCLUSIONS: SSC-CIP is a severe late complication after LTx for COVID-19 ARDS leading to significant morbidity and mortality. GGT appears to be a sensitive parameter able to predict SSC-CIP even at the time of listing.

Postoperative transverse sternal nonunion with a chest wall defect managed by a tibial locking plate and a Gore-Tex dual mesh membrane: a case report.

BACKGROUND: Transverse sternal nonunion is a rare but disabling complication of chest trauma or a transverse sternotomy. Fixation methods, mainly used to manage the more common longitudinal sternal nonunion, often fail, leaving the surgical treatment of transverse nonunion to be a challenge. CASE PRESENTATION: We present a case of a highly-disabling, postoperative chest wall defect resulting from transverse sternal nonunion after a transverse thoracosternotomy (clamshell incision) and a concomitant rib resection. Following unsuccessful surgical attempts, the sternal nonunion was fixed with a tibial locking plate and bone grafted, while the post-rib resection chest defect was reconstructed with a Gore-Tex dual mesh membrane. Adequate chest stability was achieved, enabling complete healing of the sternal nonunion and the patient's complete recovery. CONCLUSION: We believe it is important to address both in the rare case of combined postoperative transverse sternal nonunion and the chest wall defect after rib resection. A good outcome was achieved in our patient by fixing the nonunion with an appropriately sized and shaped locking plate with bone grafting and covering the chest defect with a dual mesh membrane.

Urgent lung transplantation for thymic neoplasm-associated severe constrictive bronchiolitis with bronchiectasis and radiotherapy-induced organizing pneumonia: A case report.

Here, we present the case of a 28-year-old woman who developed severe and progressive thymoma-associated constrictive bronchiolitis with bronchiectasis, despite undergoing thymectomy. The disease was further complicated by radiation-induced organizing pneumonia (RIOP), which developed after adjuvant radiotherapy (RT) for Masaoka stage II thymoma. The patient was successfully treated with an urgent lung transplantation (LTx) for irreversible respiratory failure.

Outcome of lung transplantation in cystic fibrosis patients with severe asymmetric chest cavities.

Objective: A small but relevant proportion of patients with cystic fibrosis develop severely asymmetric chest cavities during the course of their disease. For these patients, the best surgical approach for lung transplantation (LTx) and optimal size matching strategies are controversial. Methods: All cystic fibrosis patients with asymmetric chest cavities who underwent LTx at the Medical University of Vienna between 2003 and 2017 were identified (n = 13). Patients were grouped according to different surgical strategies: unilateral full-size and contralateral lobar transplantation (n = 4), standard double LTx after mobilization/repositioning of the mediastinum (n = 3), oversized single LTx followed by pneumonectomy on the smaller contralateral side (n = 4), and single LTx after a remote contralateral pneumonectomy (n = 2). Results: Compared with cystic fibrosis patients with symmetric chests (n = 276, control group), the perioperative management of patients with asymmetric chests was often more complicated. Consequently, 90-day mortality was heightened (23.1% vs 6.5%). Despite this, long-term survival was good with a 5-year survival rate of 69% compared with 78%. Of note, outcome seemed superior for patients who surgery was undertaken with a bilateral compared with a unilateral approach. Conclusions: Severely asymmetric chest cavities present challenges in regard to the surgical strategy, size matching, and postoperative management. However, in carefully selected patients, LTx provides an adequate long-term outcome.

Lung Transplantation for End-Stage Respiratory Failure After Severe COVID-19: A Report of 2 Cases.

We report 2 cases of bilateral lung transplantation for nonresolving coronavirus disease 2019 associated respiratory failure. In the first patient, the severe acute respiratory syndrome coronavirus 2 infection caused acute respiratory distress syndrome requiring prolonged extracorporeal membrane oxygenation support; in the second patient, coronavirus disease 2019 resulted in irreversible pulmonary fibrosis requiring only ventilatory support. The 2 cases represent the 2 ends of the spectrum showing significant differences in preoperative and postoperative courses.

Single-port video-assisted thoracoscopic surgery (VATS) right pneumonectomy: a case report.

When it comes to surgical treatment of non-small cell lung cancer (NSCLC), modern principles dictate that every possible effort should be made to avoid pneumonectomy, its debilitating consequences and a higher rate of complications. In marginal cases where video-assisted thoracoscopic surgery (VATS) sleeve or double sleeve lobectomy cannot be performed a conversion to open sleeve lobectomy is always preferred over a VATS pneumonectomy. We present a case of a 64-year-old male patient with two synchronous tumors of the right lung, both centrally located in the right upper and the right lower lobe. A single-port VATS right pneumonectomy was performed. The patient was discharged on the post-operative day 5 in good general condition.

Endovascular embolization prior to surgical resection of symptomatic intralobar pulmonary sequestration in an adult.

Intralobar pulmonary sequestration is a rare congenital malformation, conventionally managed by surgical resection. Recently, the endovascular embolization has been proposed for the definite treatment of this disease. Additionally, preoperative embolization of aberrant arteries to minimize the risk of serious intraoperative haemorrhage has also been described. We report the case of 43-year old female patient who presented with cough and haemoptysis, and was successfully treated with endovascular embolization followed by a Video-assisted thoracoscopic wedge resection.