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hospital stay following a thoracoscopic lobectomy can be as short as 2 days, making the above definitions sound outdated.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.

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.

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.

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.

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.

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.

Uniportal video-assisted thoracoscopic bronchoplastic and carinal sleeve procedures.

Despite of the recent advanced with the video-assisted thoracoscopic surgery (VATS), the most common approach for bronchial and carinal resection is still the open surgery. The technical difficulties, the steep learning curve and the concerns about performing an oncologic and safe reconstruction in advanced cases, are the main reasons for the low adoption of VATS for sleeve resections. Most of the authors use 3-4 incisions for thoracoscopic sleeve procedures. However these surgical techniques can be performed by a single incision approach by skilled uniportal VATS surgeons. The improvements of the surgical instruments, high definition cameras and recent 3D systems have greatly contributed to facilitate the adoption of uniportal VATS techniques for sleeve procedures. In this article we describe the technique of thoracoscopic bronchial sleeve, bronchovascular and carinal resections through a single incision approach.

Uniportal video-assisted thoracoscopic bronchovascular, tracheal and carinal sleeve resections†.

Locally advanced lung tumours often require complex surgical techniques to achieve an oncological and safe procedure. Sleeve resections when operating on endobronchial lesions or hilar tumours should be attempted whenever possible rather than performing a pneumonectomy. These procedures result in improved survival, better quality of life, a reduced loss of lung function and an improved operative mortality compared with pneumonectomy. Although the most common approach is an open thoracotomy, these complex surgical techniques can be performed in a thoracoscopic way with the skills and the experience gained from major video-assisted thoracoscopic procedures (VATS). However, despite the multiple advantages of VATS compared with thoracotomy, such as decreased postoperative pain and better recovery, this minimally invasive approach is still not widely adopted for advanced stages of lung cancer and complex resections. Concerns about performing an adequate oncological resection and safe reconstruction VATS are the main reasons for the low adoption of these minimally invasive approaches. Like other thoracoscopic techniques, VATS sleeve procedures also have a steep learning curve, and should therefore be performed either by or with skilled and experienced VATS surgeons to ensure safety and avoid complications. In this article, we describe the technique of thoracoscopic sleeve procedures through a single-incision (uniportal) approach for bronchial, bronchovascular, tracheal and carinal reconstruction, and review the literature reporting sleeve resections by VATS.

Intraoperative bleeding control by uniportal video-assisted thoracoscopic surgery†.

Owing to advances in video-assisted thoracic surgery (VATS), the majority of pulmonary resections can currently be performed by VATS in a safe manner with a low level of morbidity and mortality. The majority of the complications that occur during VATS can be minimized with correct preoperative planning of the case as well as careful pulmonary dissection. Coordination of the whole surgical team is essential when confronting an emergency such as major bleeding. This is particularly important during the VATS learning curve, where the occurrence of intraoperative complications, particularly significant bleeding, usually ends in a conversion to open surgery. However, conversion should not be considered as a failure of the VATS approach, but as a resource to maintain the patient's safety. The correct assessment of any bleeding is of paramount importance during major thoracoscopic procedures. Inadequate management of the source of bleeding may result in major vessel injury and massive bleeding. If bleeding occurs, a sponge stick should be readily available to apply pressure immediately to control the haemorrhage. It is always important to remain calm and not to panic. With the bleeding temporarily controlled, a decision must be made promptly as to whether a thoracotomy is needed or if the bleeding can be solved through the VATS approach. This will depend primarily on the surgeon's experience. The operative vision provided with high-definition cameras, specially designed or adapted instruments and the new sealants are factors that facilitate the surgeon's control. After experience has been acquired with conventional or uniportal VATS, the rate of complications diminishes and the majority of bleeding events are controlled without the need for conversion to thoracotomy.

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.

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.

Comparison of continuous thoracic epidural with paravertebral block on perioperative analgesia and hemodynamic stability in patients having open lung surgery.

BACKGROUND: Epidural analgesia can result in perioperative hypotension in patients having thoracotomy. This randomized prospective study assessed the effects of epidural and paravertebral analgesia on hemodynamics during thoracotomy. METHODS: Thirty-two patients were randomized to receive either epidural analgesia (n = 16, 0.25% levobupivacaine and 30 µg/kg morphine) or paravertebral block (n = 16; 0.5% levobupivacaine and 30 µg/kg morphine). Oxygen delivery, stroke volume and systemic vascular resistance indices, heart rate, and mean arterial pressure measurements were performed before administration of local anesthetic, after induction of general anesthesia, institution of 1-lung ventilation, first skin incision, retractor placement, lung-inflation maneuver, and at last skin suture. The primary end point was the volume of the colloid infusion necessary to maintain oxygen delivery index of 500 mL/min per squared meter or higher. Postoperative analgesia was provided immediately after surgery by an infusion of 0.125% levobupivacaine and 20 µg/mL morphine in epidural/paravertebral infusion. Pain, rescue-analgesia consumption, arterial pressure, and heart rate were recorded at 6, 24, and 48 hrs after surgery. Administration of anesthesia and data collection were done by research staff blinded to the regional analgesia technique. RESULTS: The groups did not differ significantly in heart rate, mean arterial blood pressure, or systemic vascular resistance indices. However, to maintain the targeted oxygen delivery index, a greater volume of colloid infusion and phenylephrine were required, respectively, in the epidural than in the paravertebral group (554 ± 50 vs 196 ± 75 mL, P = 0.04; and 40 ± 10 vs 17 ± 4 µg, P = 0.04). Pain intensity before and after respiratory physiotherapy as well as 24 hr rescue piritramide consumption was similar in the epidural (4.1 ± 3.1 mg) and the paravertebral (2.5 ± 1.5 mg) groups (P = 0.14). Systolic blood pressure after 24 and 48 hrs was lower in the epidural group. CONCLUSIONS: Under the conditions of our study, continuous paravertebral block resulted in similar analgesia but greater hemodynamic stability than epidural analgesia in patients having thoracotomy. Paravertebral block also required smaller volume of colloids and vasopressors to maintain the target oxygen delivery index (DO2I).