Influenza A virus exploits transferrin receptor recycling to enter host cells.

Influenza A virus (IAV) enters host cells mostly through clathrin-dependent receptor-mediated endocytosis. A single bona fide entry receptor protein supporting this entry mechanism remains elusive. Here we performed proximity ligation of biotin to host cell surface proteins in the vicinity of attached trimeric hemagglutinin-HRP and characterized biotinylated targets using mass spectrometry. This approach identified transferrin receptor 1 (TfR1) as a candidate entry protein. Genetic gain-of-function and loss-of-function experiments, as well as in vitro and in vivo chemical inhibition, confirmed the functional involvement of TfR1 in IAV entry. Recycling deficient mutants of TfR1 do not support entry, indicating that TfR1 recycling is essential for this function. The binding of virions to TfR1 via sialic acids confirmed its role as a directly acting entry factor, but unexpectedly even headless TfR1 promoted IAV particle uptake in trans. TIRF microscopy localized the entering virus-like particles in the vicinity of TfR1. Our data identify TfR1 recycling as a revolving door mechanism exploited by IAV to enter host cells.

Identification of a short sequence motif in the influenza A virus pathogenicity factor PB1-F2 required for inhibition of human NLRP3.

Influenza A virus infection activates the NLRP3 inflammasome, a multiprotein signaling complex responsible for the proteolytic activation and release of the proinflammatory cytokine IL-1ß from monocytes and macrophages. Some influenza A virus (IAV) strains encode a short 90-amino acid peptide (PB1-F2) on an alternative open reading frame of segment 2, with immunomodulatory activity. We recently demonstrated that contemporary IAV PB1-F2 inhibits the activation of NLRP3, potentially by NEK7-dependent activation. PB1-F2 binds to NLRP3 with its C-terminal 50 amino acids, but the exact binding motif was unknown. On the NLRP3 side, the interface is formed through the leucine-rich-repeat (LRR) domain, potentially in conjunction with the pyrin domain. Here, we took advantage of PB1-F2 sequences from IAV strains with either weak or strong NLRP3 interaction. Sequence comparison and structure prediction using Alphafold2 identified a short four amino acid sequence motif (TQGS) in PB1-F2 that defines NLRP3-LRR binding. Conversion of this motif to that of the non-binding PB1-F2 suffices to lose inhibition of NLRP3 dependent IL-1ß release. The TQGS motif further alters the subcellular localization of PB1-F2 and its colocalization with NLRP3 LRR and pyrin domain. Structural predictions suggest the establishment of additional hydrogen bonds between the C-terminus of PB1-F2 and the LRR domain of NLRP3, with two hydrogen bonds connecting to threonine and glutamine of the TQGS motif. Phylogenetic data show that the identified NLRP3 interaction motif in PB1-F2 is widely conserved among recent IAV-infecting humans. Our data explain at a molecular level the specificity of NLRP3 inhibition by influenza A virus. IMPORTANCE: Influenza A virus infection is accompanied by a strong inflammatory response and high fever. The human immune system facilitates the swift clearance of the virus with this response. An essential signal protein in the proinflammatory host response is IL-1b. It is released from inflammatory macrophages, and its production and secretion depend on the function of NLRP3. We had previously shown that influenza A virus blocks NLRP3 activation by the expression of a viral inhibitor, PB1-F2. Here, we demonstrate how this short peptide binds to NLRP3 and provide evidence that a four amino acid stretch in PB1-F2 is necessary and sufficient to mediate this binding. Our data identify a new virus-host interface required to block one signaling path of the innate host response against influenza A virus.

Diaphragmatic Endometriosis: Multidisciplinary Treatment.

STUDY OBJECTIVE: To demonstrate a safe laparoscopic procedure for diaphragmatic infiltrative endometriosis. DESIGN: Video case SETTING: Teaching hospital (Canadian Task Force classification III). PATIENTS: One patient presenting deep and severe diaphragmatic endometriosis. INTERVENTION: Laparoscopic cure of diaphragmatic endometriosis. MEASUREMENTS AND MAIN RESULTS: Throughout this video, which was approved by the institutional board review, we demonstrate safe and complete surgical treatment of a patient suffering severe pelvic and diaphragmatic endometriosis. The patient complained of menstrual dyspnea and shoulder pain persisting despite hormonal treatment, associated with persistent dyspareunia and pelvic pain despite a previous laparoscopic surgery. Patient positioning and anesthesia were adapted to the special requirements of the surgical technique and the expected risks. The operation consisted of the exposure of the right diaphragm by mobilization of the liver, CO2 laser vaporization of left and right diaphragmatic lesions, nerve-sparing excision of infiltrating nodules, and pleural exploration. Finally, we performed an excision of pelvic endometriosis. Participation of 3 surgical teams to this procedure allowed a safe and complete laparoscopic treatment with resolution of pain symptoms at a 1- and 3-month follow-up. CONCLUSION: Laparoscopic treatment allows a safe and complete treatment of diaphragmatic endometriosis.

[Pulmonary metastasectomy]. / Métastases pulmonaires†: une maladie chirurgicale†?

The lung is the second site of metastasis after the liver, affecting 30 to 40 % of all patients with a malignant tumor. Chemotherapy seems to be ineffective for some types of tumor. Although there are no prospective randomized studies that confirm the benefit of surgical pulmonary metastasectomy, many studies have shown the existence of a group of patients with pulmonary metastases who benefit from a complete resection for curative purposes in case of complete resection of lung metastases. Different approaches are known to achieve a complete resection with maximum lung parenchyma sparing. Minimal invasive approaches appear to offer a better quality of life and have equivalent oncologic outcomes compared to the open approach.

Au cours d'un cancer, 40 % des patients vont développer des métastases pulmonaires et dans cette situation un traitement seul de chimiothérapie est généralement peu efficace. Même s'il n'existe pas d'études randomisées prospectives qui confirment le bénéfice de la métastasectomie pulmonaire chirurgicale, diverses études ont montré l'existence d'un groupe de patients atteints de métastases pulmonaires qui bénéficient d'une résection à visée curative en cas de résection complète des métastases pulmonaires. Différentes approches chirurgicales peuvent être utilisées ayant pour but principal une résection complète et une épargne maximale du parenchyme pulmonaire. Les approches minimales invasives semblent offrir une meilleure qualité de vie et un résultat oncologique équivalent à l'approche par voie ouverte.

Modification of the Surgical Strategy for the Dissection of the Recurrent Laryngeal Nerve Using Continuous Intraoperative Nerve Monitoring.

BACKGROUND: The aim of this study was to describe first experiences and changes in management using continuous intraoperative neuromonitoring (C-IONM) in thyroid and parathyroid surgery. METHOD: Retrospective analysis of patients who underwent surgery with C-IONM since 2012. Surgical maneuvers were modified when electrophysiologic events occurred. Patients with persistent loss of signal (LOS) underwent postoperative laryngoscopy. RESULTS: One hundred and one patients (of 1586 neck surgeries) were included and 19 had events: In 13 these were temporary (resolved before end of surgery) and led to intraoperative modifications in surgical approach; in all cases traction was released, and in 8, recurrent laryngeal nerve (RLN) approach was changed [superior approach (2), inferior approach (2), both (4)]. Six patients had persistent LOS (5.9%, present at end of procedure), with RLN palsy (RLNP) on postoperative day 1: In three, LOS occurred at electrode placement on the vagus nerve, leading to distal placement of the electrode allowing ipsilateral dissection under continuous monitoring; all three had complete recovery at 6 months. In the three other patients, LOS occurred on the RLN: one probable thermal, one traction lesion and one accidental section of the anterior RLN branch. The RLN recovered within 6 months in two patients, and in the third, RLNP persisted after 6 months (1/101 = 1%). CONCLUSION: C-IONM provides real-time evaluation of the RLN function, allowing for adaptation of surgical maneuvers to prevent RLNP. It seems particularly useful in difficult cases like redo neck surgery, invasive thyroid cancer and intrathoracic or large goiter. Care should be given at electrode placement on the vagus nerve.

Impact of iterative reconstructions on objective and subjective emphysema assessment with computed tomography: a prospective study.

OBJECTIVES: To prospectively evaluate the impact of iterative reconstruction (IR) algorithms on pulmonary emphysema assessment as compared to filtered back projection (FBP). METHODS: One hundred ten unenhanced chest CT examinations were obtained on two different scanners. Image reconstructions from a single acquisition were done with different levels of IR and compared with FBP on the basis of the emphysema index (EI), lung volume and voxel densities. Objective emphysema assessment was performed with 3D software provided by each manufacturer. Subjective assessment of emphysema was performed as a blinded evaluation. Quantitative and subjective values were compared using repeated ANOVA analysis, Bland-Altman analysis and Kendall's coefficient of concordance (W). RESULTS: Lung volumes are stable on both units, throughout all IR levels (P ≥ 0.057). EI significantly decreases on both units with the use of any level of IR (P < 0.001). The highest levels of IR are responsible for a decrease of 33-36 % of EI. Significant differences in minimal lung density are found between the different algorithms (P < 0.003). Intra- and inter-reader concordance for emphysema characterisation is generally good (W ≥ 0.77 and W ≥ 0.86, respectively). CONCLUSIONS: Both commercially available IR algorithms used in this study significantly changed EI but did not alter visual assessment compared to standard FBP reconstruction at identical radiation exposure. KEY POINTS: • Objective quantification of pulmonary emphysema is sensitive to iterative reconstructions • Subjective evaluation of pulmonary emphysema is not influenced by iterative reconstructions • Consistency in reconstruction algorithms is of paramount importance for pulmonary emphysema monitoring.

Acute pancreatitis after thoracic duct ligation for iatrogenic chylothorax. A case report.

BACKGROUND: To report the association between thoracic duct ligation and acute pancreatitis. The association between sudden stop of lymphatic flow and pancreatitis has been established in experimental models. CASE PRESENTATION: A 57-year-old woman operated for thymoma presented a iatrogenic chylothorax. After thoracic duct ligation, she presented an acute pancreatitis which resolved after conservative treatment. The chylothorax disappeared within 4 days of thoracic duct ligation. CONCLUSIONS: This is the first report of acute pancreatitis following thoracic duct ligation. The pancreas and digestive tract should be assessed in symptomatic patients after thoracic duct ligation.

Intra-Operative Indocyanine Green Angiography of the Parathyroid Gland.

Major complications of thyroid and parathyroid surgery are recurrent laryngeal nerve injuries and definitive hypoparathyroidism. The use of intra-operative Indocyanine Green Angiography for confirmation of vascular status of the parathyroid gland is reported here.

[Pheochromocytoma and paraganglioma: basics for the general practitioner]. / Phéochromocytome et paragangliome: que doit retenir le praticien?

Pheochromocytomas (PHEO) and paragangliomas (PGL) are rare neuroendocrine tumors secreting catecholamines in most cases. The clinic can be very variable. Morbidity and mortality PHEO and PGL are primarily cardiovascular and haves catecholamine-mediated origin. The PHEO and PGL can sign in with a syndromic association with multiple tumors and genetic counseling is necessary in search of a germline mutation. The first step includes a diagnostic assay of metanephrine and normetanephrines. In case of positive biology a CT or MRI imaging will be needed to locate the tumor. Treatment with alpha-blocker before surgery reduces the perioperative risk. A long term follow up is recommended to detect recurrence.

An Optimized Method to Culture Human Primary Lung Tumor Cell Spheroids.

Lung cancer is the leading cause of cancer mortality worldwide, with a median survival rate at 5 years of less than 20%. While molecular mapping aids in selecting appropriate therapies, it cannot predict personalized treatment response and long-term efficacy. For addressing these challenges, there is a great need for functional tests. Within this context, we developed patient-derived spheroids (PDS) from tumor and adjacent normal tissue to biomimic the respective tissue for assessing the personalized drug treatment response in vitro. Surgically resected lung specimens were used to generate spheroids using a two-step culture procedure. Flow cytometry and immune staining enabled the characterization of different cell populations resulting from the lung samples. PDS phenotype, cell proliferation and apoptosis were evaluated. Differential gene expression between tumor and adjacent normal tissue was analyzed via RT-qPCR. PDS drug sensitivity was assessed using a cell metabolic assay in response to two chemotherapeutic drug combinations. Cellular and molecular analysis revealed the proportion of epithelial cells, fibroblasts, and immune cells in the patients' tissue samples. Subsequently, PDS models from tumor and normal lung were successfully established using the expanded epithelial cells. As a proof of concept, an analysis of the drug treatment using PDS of lung adenoid cystic carcinoma exhibited a dose-dependent effect in response to cisplatin/etoposide and cisplatin/paclitaxel. Our spheroid model of both tumor and non-tumor lung cells holds great promise for enhancing the treatment efficacy in the cancer patients.

Safety of continuous intraoperative vagus nerve neuromonitoring during thyroid surgery.

BACKGROUND: Continuous intraoperative neuromonitoring has successfully demonstrated to predict impending damage to the recurrent laryngeal nerve, by detecting changes in electromyographic recordings. Despite the apparent benefits associated with continuous intraoperative neuromonitoring, its safety is still a debate. The aim of this study was to investigate the electrophysiological impact of continuous intraoperative neuromonitoring on the vagus nerve. METHODS: In this prospective study, the amplitude of the electromyographic wave of the vagus nerve-recurrent laryngeal nerve axis was measured both proximally and distally to the stimulation electrode placed upon the vagus nerve. Electromyographic signal amplitudes were collected at three distinct events during the operation: during the dissection of the vagus nerve, before application of the continuous stimulation electrode onto the vagus nerve and after its removal. RESULTS: In total, 169 vagus nerves were analysed, among 108 included patients undergoing continuous intraoperative neuromonitoring-enhanced endocrine neck surgeries. Electrode application resulted in a significant overall decrease in measured proximo-distal amplitudes of -10.94 µV (95 per cent c.i. -17.06 to -4.82 µV) (P < 0.005), corresponding to a mean(s.d.) decrease of -1.4(5.4) per cent. Before the removal of the electrode, the measured proximo-distal difference in amplitudes was -18.58 µV (95 per cent c.i. -28.31 to -8.86 µV) (P < 0.005), corresponding to a mean(s.d.) decrease of -2.50(9.59) per cent. Seven nerves suffered a loss of amplitude greater than 20 per cent of the baseline measurement. CONCLUSION: In addition to supporting claims that continuous intraoperative neuromonitoring exposes the vagus nerve to injury, this study shows a mild electrophysiological impact of continuous intraoperative neuromonitoring electrode placement on the vagus nerve-recurrent laryngeal nerve axis. However, the small observed differences are negligible and were not associated with a clinically relevant outcome, making continuous intraoperative neuromonitoring a safe adjunct in selected thyroid surgeries.

Local control and short-term outcomes after video-assisted thoracoscopic surgery segmentectomy versus lobectomy for pT1c pN0 non-small-cell lung cancer.

OBJECTIVES: The aim of this study was to compare short-term outcomes and local control in pT1c pN0 non-small-cell lung cancer that were intentionally treated by video-assisted thoracoscopic surgery (VATS) lobectomy or segmentectomy. METHODS: Multicentre retrospective study of consecutive patients undergoing VATS lobectomy (VL) or VATS segmentectomy (VS) for pT1c pN0 non-small-cell lung cancer from January 2014 to October 2021. Patients' characteristics, postoperative outcomes and survival were compared. RESULTS: In total, 162 patients underwent VL (n = 81) or VS (n = 81). Except for age [median (interquartile range) 68 (60-73) vs 71 (65-76) years; P = 0.034] and past medical history of cancer (32% vs 48%; P = 0.038), there was no difference between VL and VS in terms of demographics and comorbidities. Overall 30-day postoperative morbidity was similar in both groups (34% vs 30%; P = 0.5). The median time for chest tube removal [3 (1-5) vs 2 (1-3) days; P = 0.002] and median postoperative length of stay [6 (4-9) vs 5 (3-7) days; P = 0.039] were in favour of the VS group. Significantly larger tumour size (mean ± standard deviation 25.1 ± 3.1 vs 23.6 ± 3.1 mm; P = 0.001) and an increased number of lymph nodes removal [median (interquartile range) 14 (9-23) vs 10 (6-15); P < 0.001] were found in the VL group. During the follow-up [median (interquartile range) 31 (14-48) months], no statistical difference was found for local and distant recurrence in VL groups (12.3%) and VS group (6.1%) (P = 0.183). Overall survival (80% vs 80%) was comparable between both groups (P = 0.166). CONCLUSIONS: Despite a short follow-up, our preliminary data shows that local control is comparable for VL and VS.

Near-infrared fluorescent imaging techniques for the detection and preservation of parathyroid glands during endocrine surgery.

Objectives: In over 30% of all thyroid surgeries, complications arise from transient and definitive hypoparathyroidism, underscoring the need for real-time identification and preservation of parathyroid glands (PGs). Here, we evaluate the promising intraoperative optical technologies available for the identification, preservation, and functional assessment of PGs to enhance endocrine surgery. Methods: We performed a review of the literature to identify published studies on fluorescence imaging in thyroid and parathyroid surgery. Results: Fluorescence imaging is a well-demonstrated approach for both in vivo and in vitro localization of specific cells or tissues, and is gaining popularity as a technique to detect PGs during endocrine surgery. Autofluorescence (AF) imaging and indocyanine green (ICG) angiography are two emerging optical techniques to improve outcomes in thyroid and parathyroid surgeries. Near-infrared-guided technology has significantly contributed to the localization of PGs, through the detection of glandular AF. Perfusion through the PGs can be visualized with ICG, which can also reveal the blood supply after dissection. Conclusions: Near infrared AF and ICG angiography, providing a valuable spatial and anatomical information, can decrease the incidence of complications in thyroid surgery.

Is the indocyanine green score an accurate predictor of postoperative parathyroid hormone level?

BACKGROUND: Hypoparathyroidism is common after total thyroidectomy, primarily due to inadvertent disruption of the parathyroid gland blood supply during thyroid dissection. Indocyanine green helps determine the degree of vascularization and correlates with parathyroid gland vitality. It is difficult to determine how the indocyanine green score affects postoperative parathyroid hormone levels because all 4 parathyroid glands must be evaluated during surgery. We determined whether there is a correlation between intraoperative indocyanine green score and postoperative serum parathyroid hormone levels. METHODS: We retrospectively studied patients who underwent total thyroidectomy where we could identify all 4 parathyroid glands and establish a global indocyanine green score. Each parathyroid gland was scored from 0 to 2 depending on indocyanine green uptake. The global indocyanine green score was the sum of the individual scores for each gland. The scores were then correlated to parathyroid hormone and calcium levels on days 1 and 10 after surgery. RESULTS: We included 83 patients, 11 of whom presented with postoperative transient hypoparathyroidism; all but one had an indocyanine green score lower than 4 of 8. There was a significant correlation between the global indocyanine green score and postoperative parathyroid hormone level. A global indocyanine green score >3.75 can exclude postoperative hypoparathyroidism with a true negative value of 98%. Indocyanine green angiography is a better diagnostic test to predict a postoperative transient hypoparathyroidism compared with visual perfusion scoring. CONCLUSION: These findings suggest that the indocyanine green score based on intraoperative indocyanine green angiography predicts parathyroid gland function. It is a valuable instrument to predict hypoparathyroidism after total thyroidectomy.

Contralateral Pneumonectomy 27 Years After Right Single-Lung Transplantation for Emphysema: A Case Report.

BACKGROUND Following single-lung transplantation, native lung inflation can progressively develop in patients with emphysema. CASE REPORT A 74-year-old female patient presented with worsening dyspnea during daily activities. She underwent a right single-lung transplantation for emphysema 27 years ago. Despite recurrent episodes of acute rejection of the grafted lung, the patient had satisfactory recovery of physical fitness during that period and did not report any serious complications or respiratory symptoms. Her recent dyspnea was due to hyperinflation of the native emphysematous lung with mediastinal shift, reduction of venous blood return, and compression of the grafted lung. Although surgical lung volume reduction had resulted in temporary functional improvement 2 years ago, a completion contralateral pneumonectomy was deemed necessary to allow re-expansion of the grafted lung. After anesthesia induction and placement of a double-lumen tube, selective ventilation of the left emphysematous native lung confirmed the absence of gas exchange based on near-zero end-expiratory carbon dioxide fraction. During selective ventilation of the grafted lung, satisfactory gas exchange was achieved and pneumonectomy proceeded uneventfully under minimally-invasive thoracotomy. Immediately after anesthesia emergence and tracheal extubation, the patient experienced respiratory improvement. Continuous thoracic epidural blockade allowed pain-free mobilization and respiratory therapy to facilitate re-expansion of the grafted lung. CONCLUSIONS After single-lung transplantation in COPD patients, native lung hyperinflation is a well-described rare complication. Lung volume reduction including pneumonectomy can be considered a valuable treatment option.

Operative Planning of Chest Wall Reconstructions Illustrated by a Large Defect in a Child.

Reconstruction of large chest wall defects is challenging. Here we discuss the process of decision-making in planning chest wall reconstruction, considering the requirements of tumor removal, stabilization of the chest wall, and soft tissue coverage, illustrated by a case of a hemi-chest wall defect in a child. Ewing sarcoma measuring 10 × 9 × 13 cm was resected in a 9-year-old boy, followed by stabilization using a Gore-Tex patch. Due to extension of the oncologic resection far into the superomedial quadrant of the chest, tension-free coverage with a classical latissimus-dorsi flap could not be achieved. Integrating the serratus-anterior muscle into the flap creating a chimeric latissimus-dorsi/serratus-anterior flap allowed for excellent soft tissue coverage of the foreign body. As the skin could be preserved, careful incision planning was necessary to allow for best possible exposure during oncologic resection and flap harvest, while ensuring skin vascularization impaired by underlying tumor resection. Two vertical skin incisions were chosen, one presternal and a second in the mid-axillary fold delineating a large bipedicled skin flap. Postoperative recovery was excellent. Solid skin vascularization and adequate soft tissue coverage of the alloplastic material allowed for the patient to receive two cycles of postoperative radiotherapy without developing wound dehiscence. Careful interdisciplinary planning of skin incisions allowed for good exposure for tumor resection and flap harvest while preserving skin vascularization. Choosing a chimeric latissimus-dorsi/serratus-anterior flap provided larger coverage than a classical latissimus-dorsi flap with minimal additional donor site morbidity. Taken together, we here present a pragmatic solution to a complex problem.

Performance of prolonged air leak scoring systems in patients undergoing video-assisted thoracoscopic surgery segmentectomy.

OBJECTIVES: We assessed the accuracy of 3 validated lobectomy scoring systems to predict prolonged air leak (PAL) in patients undergoing video-assisted thoracoscopic surgery (VATS) segmentectomy. METHODS: We reviewed all consecutive patients who had a VATS segmentectomy between January 2016 and October 2020. We determined PALs on postoperative day 5. These findings were correlated with the calculated Brunelli (gender, age, body mass index [BMI], forced expiratory volume in 1 s < 80 and pleural adhesion), Epithor (gender, location, dyspnoea score, BMI, type of resection and pleural adhesion) and European Society of Thoracic Surgeons (ESTS) (gender, BMI and forced expiratory volume in 1 s) scores of each patient. RESULTS: A total of 453 patients (mean age: 66.5 years, female/male sex ratio: 226/227) underwent a VATS segmentectomy for malignant (n = 400) and non-malignant (n = 53) disease. Postoperative cardiopulmonary complications and in-hospital mortality rates were 19.6% and 0.4%, respectively. Median chest tube drainage duration and hospital stay were 2 (interquartile range: 1-4) and 4 (interquartile range: 3-7) days, respectively. On day 5, the prevalence of PAL was 14.1%. The ESTS, Brunelli and Epithor scores for the treated population were, respectively, class A (6.8%), class B (3.2%), class C (10.8%) and class D (28.2%); very low and low (0%), moderate (5%), high (6.3%) and very high (21%); and class A (7%), class B (13.2%), class C (24%) and class D (27.8%). All scores correlated with PAL (p ≤ 0.001). The areas under the receiver operating characteristic (ROC) curve were 0.686, 0.680 and 0.644, respectively. CONCLUSIONS: All 3 scoring systems were correlated with PAL > 5 days following the VATS segmentectomies. ESTS scores seem easier to introduce in clinical practice, but validation by a multicentre cohort is mandatory.

Ventilatory efficiency slope is associated with cardiopulmonary complications after thoracoscopic anatomical lung resection.

OBJECTIVES: The aim of this study was to identify whether steeper V.E/V. CO2 slope was associated with cardiopulmonary complications (CPC) after anatomical resection by video-assisted thoracic surgery. Long-term survival was analysed as secondary outcome. METHODS: We reviewed the files of all consecutive patients who underwent pulmonary anatomical resections by video-assisted thoracic surgery between January 2010 and October 2020 at the Centre for Thoracic Surgery of Western Switzerland. Logistic regression was used to investigate the risk of CPC associated with the V.E/V.CO2 slope and other possible confounders. Survival was analysed with Kaplan-Meier curves. Risk factors associated with survival were analysed with a Cox proportional hazards model. RESULTS: The V.E/V.CO2 slope data were available for 145 patients [F/M: 66/79; mean age (standard deviation): 65.8 (8.9)], which were included in the analysis. Patients underwent anatomical resection [lobectomy (71%) or segmentectomy (29%)] mainly for lung cancer (96%). CPC and all-cause 90-day mortality were 29% and 1%, respectively. The mean (standard deviation) percentage of the predicted V.O2peak was 70% (17). Maximum effort during cardiopulmonary exercise test was reached in only 31% of patients. The V.E/V.CO2 slope (standard deviation) was not different if the maximum effort was reached or not [39 (6) vs 37 (7), P = 0.21]. V.E/V.CO2 slope >35 was associated with an increased risk of CPC (odds ratio 2.9, 95% confidence interval 1.2, 7.2, P = 0.020). V.E/V.CO2 slope >35 was not associated with shorter survival censored for lung cancer-related death. CONCLUSIONS: V . E/V.CO2 slope >35 is significantly associated with postoperative CPC after anatomical resections by video-assisted thoracic surgery. CLINICAL REGISTRATION NUMBER CER-VD (SWITZERLAND): Project ID: 2021-00620.

Effectiveness of rib fixation compared to pain medication alone on pain control in patients with uncomplicated rib fractures: study protocol of a pragmatic multicenter randomized controlled trial-the PAROS study (Pain After Rib OSteosynthesis).

BACKGROUND: Persistent pain and disability following rib fractures result in a large psycho-socio-economic impact for health-care system. Benefits of rib osteosynthesis are well documented in patients with flail chest that necessitates invasive ventilation. In patients with uncomplicated and simple rib fractures, indication for rib osteosynthesis is not clear. The aim of this trial is to compare pain at 2 months after rib osteosynthesis versus medical therapy. METHODS: This trial is a pragmatic multicenter, randomized, superiority, controlled, two-arm, not-blinded, trial that compares pain evolution between rib fixation and standard pain medication versus standard pain medication alone in patients with uncomplicated rib fractures. The study takes place in three hospitals of Thoracic Surgery of Western Switzerland. Primary outcome is pain measured by the brief pain inventory (BPI) questionnaire at 2 months post-surgery. The study includes follow-up assessments at 1, 2, 3, 6, and 12 months after discharge. To be able to detect at least 2 point-difference on the BPI between both groups (standard deviation 2) with 90% power and two-sided 5% type I error, 46 patients per group are required. Adjusting for 10% drop-outs leads to 51 patients per group. DISCUSSION: Uncomplicated rib fractures have a significant medico-economic impact. Surgical treatment with rib fixation could result in better clinical recovery of patients with uncomplicated rib fractures. These improved outcomes could include less acute and chronic pain, improved pulmonary function and quality of life, and shorter return to work. Finally, surgical treatment could then result in less financial costs. TRIAL REGISTRATION: ClinicalTrials.gov NCT04745520 . Registered on 8 February 2021.

Expert consensus on indocyanine green fluorescence imaging for thoracoscopic lung resection (The Version 2022).

The use of the white-light thoracoscopy is hampered by the low contrast between oncologic margins and surrounding normal parenchyma. As a result, many patients with in situ or micro-infiltrating adenocarcinoma have to undergo lobectomy due to a lack of tactile and visual feedback in the resection of solitary pulmonary nodules. Near-infrared (NIR) guided indocyanine green (ICG) fluorescence imaging technique has been widely investigated due to its unique capability in addressing the current challenges; however, there is no special consensus on the evidence and recommendations for its preoperative and intraoperative applications. This manuscript will describe the development process of a consensus on ICG fluorescence-guided thoracoscopic resection of pulmonary lesions and make recommendations that can be applied in a greater number of centers. Specifically, an expert panel of thoracic surgeons and radiographers was formed. Based on the quality of evidence and strength of recommendations, the consensus was developed in conjunction with the Chinese Guidelines on Video-assisted Thoracoscopy, and the National Comprehensive Cancer Network (NCCN) guidelines on the management of pulmonary lesions. Each of the statements was discussed and agreed upon with a unanimous consensus amongst the panel. A total of 6 consensus statements were developed. Fluorescence-guided thoracoscopy has unique advantages in the visualization of pulmonary nodules, and recognition and resection of the anterior plane of the pulmonary segment. The expert panel agrees that fluorescence-guided thoracoscopic surgery has the potential to become a routine operation for the treatment of pulmonary lesions.