Study protocol for Near-infrared molecular imaging for lung cancer detection and treatment during mini-invasive surgery (phase II Trial) - (the RECOGNISE study).

INTRODUCTION: To date, radical surgery remains the best curative option in patients with early-stage lung cancer. In patients with small lung lesions, video-assisted thoracic surgery (VATS) should be increasingly chosen as a fundamental alternative to thoracotomy as it is associated with less postoperative pain and better quality of life. This scenario necessarily increases the need for thoracic surgeons to implement new localization techniques. The conventional near-infrared (NIR) indocyanine green (ICG) method demonstrated a significant limitation in deep cancer recognition, principally due to its intrinsic low-depth tissue penetration. Similarly, the lymph-node sentinel approach conducted by the ICG method was demonstrated to be inefficient, mainly due to the non-specificity of the tracker and the irregular pathway of pulmonary lymph node drainage. Our study aims to evaluate the effectiveness of Cetuximab- IRDye800CW in marking lung nodules and mediastinal lymph nodes. METHODS AND ANALYSIS: This study is defined as an open-label, single-arm, single-stage phase II trial evaluating the effectiveness of Cetuximab-IRDye800CW in detecting tumors and lymph-node metastases in patients with lung cancer who are undergoing video-assisted thoracic surgery (VATS). Cetuximab is a monoclonal antibody that binds, inhibits, and degrade the EGFR. The IRDye® 800CW, an indocyanine-type NIR fluorophore, demonstrated enhanced tissue penetration compared to other NIR dyes. The combination with the clinical approved monoclonal antibody anti-epidermal growth factor EGFR Cetuximab (Cetuximab-IRDye800) has shown promising results as a specific tracker in different cancer types (i.e., brain, pancreas, head, and neck). The study's primary outcome is focused on the proportion of patients with lung nodules detected during surgery using an NIR camera. The secondary outcomes include a broad spectrum of items, including the proportion of patients with detection of unexpected cancer localization during surgery by NIR camera and the proportion of patients with negative surgical margins, the evaluation of the time spawns between the insertion of the NIR camera and the visualization of the nodule and the possible morbidity of the drug assessed during and after the drug infusion. ETHICS AND DISSEMINATION: This trial has been approved by the Ethical Committee of Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino (Torino, Italy) and by the Italian Medicines Agency (AIFA). Findings will be written as methodology papers for conference presentations and published in peer-reviewed journals. The Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, the University of Torino, and the AIRC Public Engagement Divisions will help identify how best to publicize the findings.Trial registration EudraCT 202,100,645,430. CLINICALTRIALS: gov NCT06101394 (October 23, 2023).

Acute myocardial infarction as presenting symptom of thymoma with compression on a coronary stent.

We report the clinical case of a patient with acute myocardial infarction due to coronary stent compression as first manifestation of a large thymoma. The patient underwent a coronarography and thrombus aspiration + plain old balloon angioplasty restoring the stent patency. The mass resection was performed through left robotic-assisted thoracic surgery (RATS), resulting in a type A thymoma pT1a, IIb Masaoka-Koga. An uncommon presentation led to early diagnosis and treatment of a thymoma with both oncological and functional significance.

Acquired antithrombin deficiency in adult patients with postcardiotomy extracorporeal membrane oxygenation.

INTRODUCTION: This study aimed to investigate the relationship between acquired antithrombin deficiency in patients undergoing postcardiotomy extracorporeal membrane oxygenation (PC-ECMO) and thromboembolic or haemorrhagic events such as bleeding, peripheral arterial thromboembolism, and ischemic cerebrovascular events. METHODS: The study was designed as a single-center, prospective study and conducted at our hospital between November 2019 and June 2021. 50 patients who underwent ECMO due to postcardiotomy cardiogenic shock were included in the study. Antithrombin (AT) activity testing was performed immediately after ECMO placement and continued for 5 days. The total of haemorrhagic or thromboembolic events was defined as morbidity. The entire patient population was assessed daily for AT measurements according to morbidity status, and ROC analysis was applied to determine the cut-off point. The correlation between clinical outcomes and morbidities with antithrombin levels was analysed. RESULTS: In our study, we identified a cut-off for AT levels on the first postoperative day. The risk of both bleeding (p = .006) and thromboembolism (p = .012) was significantly higher in patients below the 48.9% cut-off value. AT levels were compared with data on separation from PC-ECMO. The rate of separation from ECMO was 7.969 times higher in cases with AT levels above 51.8 on the third postoperative day and 5.6 times higher in cases with AT levels above 47.5 on the fourth postoperative day. CONCLUSION: Acquired antithrombin deficiency may develop in adults undergoing PC-ECMO. In our study, we demonstrated that in patients with low antithrombin levels, the risk of bleeding and thromboembolism increased. Additionally, since AT levels were higher in survivors, this can be considered an indicator of severity. This study is the first prospective study related to determining target antithrombin levels in adult patients undergoing PC-ECMO.

Immediate effects of upper limb exercises with and without deep breathing on lung function after cardiac surgery - a randomized crossover trial.

BACKGROUND: Open heart surgery, involving median sternotomy, may cause diminished chest wall motion and restrictive pulmonary function in the early postoperative period. Thoracic and upper extremity range of motion (ROM) exercises are often recommended after surgery but have not been evaluated regarding effect on lung volumes and oxygenation. The objective of this study was to evaluate the immediate effect of upper limb elevations, with or without simultaneous deep breathing, on lung function after cardiac surgery. METHODS: In a randomized 2 × 2 crossover trial, 22 adult patients (> 18 years old) were assessed during one of the first days after surgery in the spring of 2022 at Örebro University Hospital, Sweden. Exercises involving five bilateral upper limb elevations, performed either with simultaneous deep breathing (ROM-DB) or without (ROM), while sitting in an upright position at the edge of the bed, were evaluated. Peripheral oxygen saturation (Rad-5v; Masimo, Irvine, USA) was the primary outcome. Tidal volume and respiratory rate were recorded continuously during the exercises (Spiropalm; Cosmed, Rome, Italy). Heart rate, pain, exertion and dyspnoea were evaluated before and after the exercises. RESULTS: Both ROM-DB and ROM momentarily increased peripheral oxygen saturation (+ 1% ± 1, p = 0.004 and + 1% ± 1, p < 0.001, respectively), with no significant differences between these exercises (p = 0.525). ROM-DB significantly increased the VT compared with ROM (798 ± 316 vs. 602 mL ± 176, p = 0.004). However, ROM-DB induced more pronounced pain (p = 0.012), exertion (p = 0.035) and dyspnoea (p = 0.013) than ROM. CONCLUSIONS: Upper limb elevations improved oxygenation momentarily, both performed with and without simultaneous deep breathing, with no significant differences between these exercises. The additive deep breathing improved tidal volume compared with upper limb elevations alone, but induced more pain, exertion and dyspnoea during the performance of exercise. TRIAL REGISTRATION: ClinicalTrials.gov (NCT05278819).

Subxiphoid Single-Port Robotic Thymectomy Using the Single-Port Robotic System versus VATS: A Multi-Institutional, Retrospective, and Propensity Score-Matched Study.

Subxiphoid thymectomy is a novel alternative to the transthoracic approach and sternotomy, with potential benefits, such as reduced postoperative pain and faster recovery. We previously reported the initial experience with subxiphoid single-port robotic-assisted thoracic surgery (SRATS) thymectomy using the single-port robotic system (SPS). However, the efficacy of this technique remains unknown. Thus, this study examined the multi-institutional experience with SRATS thymectomy and compared the perioperative outcomes of this technique to those of subxiphoid single-port video-assisted thoracic surgery (SVATS) thymectomy. The data of patients who underwent subxiphoid SRATS and SVATS thymectomy, performed by three thoracic surgeons at three institutions between September 2018 and May 2024, were retrospectively collected. In total, 110 patients were included, with 85 and 25 undergoing SRATS and SVATS thymectomy, respectively. After propensity score matching, 25 patients were included in each group. The SRATS group was associated with a lower conversion rate to multi-port surgery (0% vs. 20%, p = 0.05), shorter chest tube drainage duration (1.32 ± 0.75 vs. 2.00 ± 1.29 days, p = 0.003), and a shorter postoperative hospital stay (2.52 ± 1.00 vs. 5.08 ± 5.20 days, p = 0.003). Subxiphoid SRATS thymectomy using the SPS is feasible and is a good alternative to conventional thymectomy. Further studies are necessary to confirm its benefits.

The Lung Cancer Surgical Study Group of the Japan Clinical Oncology Group: outstanding contribution and entering a new phase.

The Lung Cancer Surgical Study Group (LCSSG) of the Japan Clinical Oncology Group (JCOG) was organized in 1986 and initially included 26 collaborative institutions, which has increased to 52 institutions currently. JCOG-LCSSG includes thoracic surgeons, medical oncologists, pathologists, and radiotherapists. In the early period, the JCOG-LCSSG mainly focused on combined modality therapies for lung cancer. Since the 2000s, the JCOG-LCSSG has investigated adequate modes of surgical resection for small-sized and peripheral non-small cell lung cancer and based on the radiological findings of whole tumor size and ground-glass opacity. Trials, such as JCOG0802, JCOG0804, and JCOG1211, have shown the appropriateness of sublobar resection, which has significantly influenced routine clinical practice. With the introduction of targeted therapy and immunotherapy, treatment strategies for lung cancer have changed significantly. Additionally, with the increasing aging population and medical costs, tailored medicine is strongly recommended to address medical issues. To ensure comprehensive treatment, strategies, including surgical and nonsurgical approaches, should be developed. Currently, the JCOG-LCSSG has conducted numerous clinical trials to adjust the diversity of lung cancer treatment strategies. This review highlights recent advancements in the surgical field, current status, and future direction of the JCOG-LCSSG.

Early adoption of robotic lung resection in an established video assisted thoracic surgery practice.

Background: Reported advantages to robotic thoracic surgery include shorter length of stay (LOS), improved lymphadenectomy, and decreased complications. It is uncertain if these benefits occur when introducing robotics into a well-established video-assisted thoracoscopy (VATS) practice. We compared the two approaches to investigate these advantages. Materials and methods: IRB approval was obtained for this project. Patients who underwent segmentectomy or lobectomy from May 2016-December 2018 were propensity-matched 2: 1 (VATS: robotic) and compared using weighted logistic regression with age, gender, Charlson Comorbidity Index, surgery type, stage, Exparel, and epidural as covariates. Complication rates, operation times, number of sampled lymph nodes, pain level, disposition, and LOS were compared using Wilcoxon rank-sum and with Rao-Scott Chi-squared tests. Results: 213 patients (142 VATS and 71 robot) were matched. Duration of robotic cases was longer than VATS (median 186 min (IQR 78) vs. 164 min (IQR 78.75); p < 0.001). Significantly more lymph nodes (median 11 (IQR 7.50) vs. 8 (IQR 7.00); p = 0.004) and stations were sampled (median 4 (IQR 2.00) vs. 3 (IQR 1.00); p < 0.001) with the robot. Interestingly, robotic resections had higher 72-hour pain scores (median 3 (IQR 3.25) vs. 2 (IQR 3.50); p = 0.04) and 48-hour opioid usage (median 37.50 morphine milligram equivalents (MME) (IQR 45.50) vs. 22.50 MME (IQR 37.50); p = 0.01). Morbidity, LOS, and disposition were similar (all p > 0.05). Conclusions: The robotic approach facilitates better lymph node sampling, even in an established VATS practice.

Anesthetic management of a case of a lip mass with paraseptal emphysema and multiple bilateral giant bullae for surgical resection under mental nerve block.

Anesthesia in patients with emphysematous giant bulla undergoing non-thoracic surgery is challenging and can cause serious complications. We report a successful case of lip mass resection in a 65-year-old male with paraseptal emphysema and giant bullae under regional anesthesia using a mental nerve block. The patient presented with a slow-growing ulcerative mass on his lower lip and had a history of non-compliant COPD management. An excisional biopsy was planned. Preoperative workup revealed extensive lung pathology with giant bullae. General anesthesia with positive pressure ventilation in patients with emphysematous giant bullae can cause compression of lung parenchyma, vena cava kinking, circulatory collapse, and even death. To circumvent such risks, regional anesthesia was preferred and surgery was successfully done under ultrasound-guided bilateral mental nerve block. The procedure was uneventful, with stable hemodynamics throughout.

Maryland's Global Budget Revenue Program and Equitable Access to Esophagectomy for Esophageal Cancer.

INTRODUCTION: We evaluated equity in access to esophagectomy after Maryland's 2014 "Global Budget Revenue" (GBR) implementation, which equalizes reimbursement rates irrespective of patient insurance and employs an annual hospital revenue ceiling to incentivize reductions in unnecessary resource utilization. We hypothesized that more traditionally underserved patients would undergo surgical treatment for esophageal cancers after GBR. METHODS: Using Maryland's Health Services Cost Review Commission database, we retrospectively analyzed patient demographics, insurance statuses, inflation-adjusted hospital charges, postoperative outcomes, and discharge dispositions for esophagectomies for neoplasms between 2012 and 2018. RESULTS: Four hundred eighty six patients were included: 22.0% (107) pre-GBR and 78.0% (379) post-GBR. The proportion of African-American patients increased post-GBR (5.6% versus 12.9%, P = 0.035) and subsequently exhibited year-over-year increases. While not statistically significant, the proportion of Medicaid patients increased from 4.7% to 10.0% (P = 0.085). The post-GBR era also saw patients from 10 new counties, six of which were in Maryland's bottom half of counties ranked by median household income, receive operative esophageal cancer treatment without losing representation from pre-GBR counties. Patient age and sex were comparable between the two groups, and there were no significant differences in mortality or 30-day readmissions. Inflation-adjusted hospital charges and length of hospital stay did not appreciably change post-GBR, including after adjusting for age, comorbidities, and surgical approach. CONCLUSIONS: GBR increased access to esophagectomy for African-Americans, those insured by Medicaid, and those from lower socioeconomic status counties. Contrary to prior studies of outpatient and emergency room settings, we found the GBR program's goal of reduction of resource utilization and cost were not apparent in this complex surgical population.

Effect of age on postoperative 24-hour moderate-to-severe pain after radical resection of lung cancer-specific pain in the post-anaesthesia care unit: a single-centre retrospective cohort study.

OBJECTIVES: To explore the relationship between age and postoperative 24-hour moderate-to-severe pain after radical resection of lung cancer and the specific effect of moderate-to-severe pain in the post-anaesthesia care unit (PACU) on this relationship. DESIGN: Retrospective cohort study. SETTING: Single medical centre. PARTICIPANTS: Patients ≥18 years having radical resection of lung cancer between 2018 and 2020. MEASUREMENTS: Postoperative 24-hour moderate-to-severe pain. RESULTS: A total of 3764 patients were included in the analysis. The incidence of postoperative 24-hour moderate-to-severe pain was 28.3%. Age had a significant effect on the prediction model of postoperative 24-hour moderate-to-severe pain. Among the whole population and those without moderate-to-severe pain in the PACU, those who were younger than 58.5 years were prone to experience moderate-to-severe pain 24 hours after surgery, and in patients with moderate-to-severe pain in the PACU, the age threshold was 62.5 years. CONCLUSION: For patients who underwent elective radical resection for lung cancer, age was related to postoperative 24-hour moderate-to-severe pain, and moderate-to-severe pain in the PACU had a specific effect on this relationship. Patients among the whole population and those patients without moderate-to-severe pain in the PACU were more likely to experience postoperative 24-hour moderate-to-severe pain when they were younger than 58.5 years old, and in patients with moderate-to-severe pain in the PACU, the age threshold was 62.5 years old.

Extralobar Pulmonary Sequestration: A Rare Entity.

Lung sequestration is a rare congenital anomaly characterized by non-functional lung tissue that lacks normal bronchial communication and receives blood supply from an aberrant systemic artery. Extralobar sequestration (ELS) is less common and usually found in the lower thoracic or upper abdominal regions. It is often diagnosed in infancy or early childhood due to associated congenital anomalies or respiratory symptoms. The complexity of highly variable anatomy and the involvement of multiple systemic arteries pose significant diagnostic and therapeutic challenges. Patients may present with a variety of nonspecific symptoms, such as recurrent respiratory infections, chronic coughs, or unexplained abdominal pain, which often leads to delayed diagnosis. This case report details the unique presentation of extrapulmonary lung sequestration in a 32-year-old male who presented with persistent respiratory symptoms and intermittent abdominal discomfort. Through comprehensive imaging studies and surgical intervention, the diagnosis was confirmed, and the sequestered tissues were successfully resected. This report aims to highlight the importance of considering bilateral extrapulmonary sequestration in differential diagnoses of recurrent respiratory and abdominal symptoms and to discuss the diagnostic approach and management strategies for this rare condition with highly variable anatomy.

Advanced statistical methods for hazard modeling in cardiothoracic surgery: a comprehensive review of techniques and approaches.

Hazard modeling in cardiothoracic surgery, crucial for understanding patient outcomes, utilizes survival analysis like the Cox proportional hazards model. Kaplan-Meier curves are employed in survival analysis to represent the probability of survival over time. While Cox assumes proportional hazards, the Fine-Gray model deals with competing risks. Parametric models (e.g., Weibull) specify survival distributions, unlike Cox. Bayesian analysis integrates prior knowledge with data. Machine learning, including decision trees and support vector machines, enhances risk prediction by analyzing extensive datasets. However, it is important to note that whatever new approaches one may adopt will enhance the quality of risk assessment and not the risk assessment as such. Preprocessing is vital for data quality in complex cardiovascular datasets, alongside robust validation methods like cross-validation for model reliability across patient cohorts.

Where are they now? An analysis of integrated cardiothoracic surgery residency applicants.

Changes in cardiothoracic surgery (CTS) workforce trends have affected training paradigms to include the establishment of integrated six-year CTS residency (I6) programs. This study aimed to determine commitment of selected I6 program applicants to the specialty. Internal archives at a single institution were accessed to identify applicants interviewed for an I6 position from 2014 to 2016. A systematic internet search of publicly available information was performed to identify the trainee's current specialty. Descriptive analysis was performed. Forty-seven applicants were identified. Successful search results were achieved for 97.9 % of the applicants. One applicant was excluded, resulting in a cohort of 45. 48.9 % of the applicants successfully matched into I6 programs. Of the 23 who did not match into an I6 program, 91.3 % began a General Surgery (GS) residency. When looking solely at the GS trainees, 71.4 % sought and matched into a traditional or 4/3 CTS residency. In total, 77.8 % of the cohort are currently pursuing careers in cardiothoracic surgery. The study identified a strong continued interest in the field of CT Surgery among those interviewed for integrated residency. The methodology used in this study provided an effective way to follow career choice of applicants interviewed and could be applied by additional programs to further elucidate career choice and levels of commitment.

Preoperative quality of life predicts complications in thoracic surgery: a retrospective cohort study.

OBJECTIVES: Patients undergoing thoracic surgery experience high complication rates. It is uncertain whether preoperative health-related quality of life (HRQOL) measurements can predict patients at higher risk for postoperative complications. The objective of this study was to determine the association between preoperative HRQOL and postoperative complications among patients undergoing thoracic surgery. METHODS: This was a retrospective cohort study of prospectively collected data. Consecutive patients undergoing elective thoracic surgery at a Canadian tertiary care centre between January 2018 and January 2019 were included. Patient HRQOL was measured using the Euroqol-5 Dimension (EQ-5D) survey. Complications were recorded using the Ottawa Thoracic Morbidity and Mortality system. Uni- and multivariable analysis were performed. RESULTS: Of 515 surgeries performed, 133 (25.8%) patients experienced at least 1 postoperative complication; 345 (67.0%) patients underwent surgery for malignancy. A range of 271 (52.7%) to 310 (60.2%) patients experienced pain/discomfort at each timepoint. On multivariable analysis, lower preoperative EQ-5D visual analogue scale scores were significantly associated with postoperative complications (adjusted odds ratio 0.97, 95% confidence interval 0.95-0.99; P = 0.01). Presence of malignancy was not independently associated with complications (P = 0.68). CONCLUSIONS: Self-reported preoperative HRQOL can predict incidence of postoperative complications among patients undergoing thoracic surgery. Assessments of preoperative HRQOL may help identify patients at higher risk for developing complications. These findings could be used to direct preoperative risk-mitigation strategies in areas of HRQOL where patients suffer most, such as pain. The full perioperative trajectory of patient HRQOL should be discerned to identify subsets of patients who share common risk factors.

Priorities and strategy for the implementation of enhanced recovery after surgery (ERAS) in thoracic surgery.

Background: Enhanced recovery after surgery (ERAS) is a perioperative care protocol, which was introduced several years ago and has gained increasing importance in thoracic surgery. The aim of this study was to provide guidance through clinical implementation and to identify factors for better compliance. Methods: This prospective cohort study collected data between July 2021 and June 2022 at the Department of Thoracic Surgery (University Hospital Regensburg, Germany). A modified enhanced recovery after thoracic surgery (ERATS) protocol with recommendations covering the pre-, intra- and postoperative phases was established and followed. The primary objective was to evaluate the implementation of the ERATS protocol. Secondary, specific and clinically relevant recommendations were analyzed regarding their compliance. Results: The study included 139 patients undergoing elective lung resections. Many ERATS recommendations were already part of standard perioperative care, including perioperative antibiotics, venous thromboembolism prophylaxis and intraoperative warming. Other measures such as anemia management, carbohydrate loading or chest drain management were updated or newly established and standardized according to our ERATS protocol. The recommendations emphasizing early postoperative mobilization were found to be crucial. We identified three groups with significantly different compliance rates: (I) patient-dependent measures which require active participation (49.3%); (II) treatment measures requiring interdisciplinary consensus (85.8%); and (III) surgical measures (88%). Conclusions: The implementation and continuous evaluation of our perioperative ERATS protocol led to a new categorization of targeted measures into three groups with actors of different competencies. The new grouping enables gradual implementation and a step-by-step targeted approach in order to achieve a higher compliance of ERATS in the future as well as long-term sustainability.

The early and long-term occurrence of symptomatic venous thromboembolism after lung cancer surgery without extended thromboprophylaxis-a single center experience with 435 patients.

Background: The incidence of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), after lung cancer resections varies in the literature, and there is limited evidence regarding the optimal duration of thromboprophylaxis. This study aimed at determining the early and long-term occurrence of thromboembolic complications in patients who received in-hospital thromboprophylaxis and underwent resective surgery for lung cancer. Methods: The study included all patients who underwent lung cancer surgery at Tampere University Hospital between 2004 and 2016. Postoperative thromboprophylaxis was administered for the duration of the hospitalization. Data on subsequent episodes of VTE and survival were obtained from national registries. The results were compared to a demographically matched reference population. Results: The study comprised 435 patients and 4,338 individuals in the reference population. The overall occurrence of VTE in patients and the reference group was 0.3% vs. 0.2% at 90 days (P=0.56), 3.5% vs. 0.7% at 1 year (P<0.001), 9.2% vs. 2.2% at 3 years (P<0.001), and 18.7% and 3.9% at 5 years (P<0.001), respectively. The majority of cases represented PE. The overall mortality at 5 years was 44.4% vs. 11.6% (P<0.001). No associations between patient characteristics and the occurrence of VTE during follow-up were detected. Conclusions: Patients undergoing lung cancer surgery and who receive in-hospital medical thromboprophylaxis do not seem to be in high risk for symptomatic VTE during the early postoperative period. However, during long-term follow-up the occurrence of symptomatic VTE was significant.

Emergent robotic surgery conversions: improving operating room team performance through high fidelity simulations.

Background: Although robotic surgery has gained popularity, safety concerns remain due to potential delay in addressing intraoperative hemorrhages since the surgeon is not at the bedside. This study aimed to test whether a training program for emergency robotic undocking protocols improved the performance of thoracic operating room (OR) teams. Methods: An emergency undocking protocol and checklists were created for massive hemorrhage during robotic thoracic surgery. In phase I, two OR teams participated in in-situ simulations of the scenarios in the OR without knowledge of the protocols. In phase II, the protocol and checklists were introduced to four different OR teams by either high-fidelity lab simulation or video-based didactic sessions. The teams' performances were tested with in-situ OR simulations. Performance assessments included the number of missed critical steps, participant-reported feedback, and timeliness of crucial steps. Results: All teams successfully converted from robot-assisted to open, with the attending at bedside within five minutes from the decision to convert, regardless of phase or education type. Phase I (control) teams had an average of 2.55 critical misses per team while the average was 0.25 for phase II teams (P=0.08). There was no significant difference between phases in time required for the surgeon to be at the bedside (average 132.2 seconds, P=0.64). Conclusions: Targeted education can lead to improved team performance. This study shows that high-fidelity simulation and didactic sessions can both be used to effectively teach emergency undocking protocols.

Efficacy of ultrasound-guided second serratus anterior plane block on postoperative quality of recovery and analgesia after video-assisted thoracic surgery: a randomized, triple-blind, placebo-controlled study.

Background: Despite widespread application of minimally invasive video-assisted thoracic surgery (VATS), postoperative pain following this procedure is still a constant clinical challenge. Serratus anterior plane (SAP) block is one of the regional analgesic techniques with promising outcomes. However, due to the limited duration of action, optimal analgesia is often not achieved with a single injection. We tested whether in patients who have been subjected to routine SAP block under preoperative anesthesia, the addition of a second SAP block 24 hours after surgery, improves quality of recovery, lowers postoperative opioid consumption, and reduces the prevalence of chronic pain. Methods: The present study is a single institutional, prospective, randomized, triple-blinded, placebo-controlled study. Ninety patients undergoing VATS from January 2022 to April 2022 were randomized at 1:1 ratio to receive ultrasound-guided second SAP block with 15 mL 0.375% ropivacaine (SAP block group) or 15 mL normal saline (control group) 24 hours after both groups received routine SAP block with 15 mL 0.375% ropivacaine. The primary outcome was quality of patient recovery, measured using 40-item quality of recovery questionnaire (QoR-40) at postoperative day 2 (POD 2). Secondary outcomes included: postoperative pain scores at rest, postoperative opioid consumptions, number of times that patient controlled analgesia (PCA) pump button was pressed, perioperative complications and adverse effects, prevalence of chronic pain at 2nd and 3rd month postoperatively, and length of hospital stay (LOS). Results: A total of 83 patients completed the study: 43 patients in SAP block group and 40 patients in the control group. The global QoR-40 scores on POD 2 and POD 3 were significantly higher among SAP block group patients (180.07±11.34, 182.09±8.20) compared with the control group (172.18±6.15, 177.50±6.94) (P=0.01, P=0.008) respectively. Postoperative pain scores, opioid consumptions and incidence of postoperative nausea and vomiting were significantly lower among patients in SAP block group versus control group. There were no statistically significant differences in perioperative complications and LOS between the two groups. The prevalence of chronic pain at the 2nd and 3rd month postoperatively for patients in SAP block group and control group was 16.3%, 14%, and 32.5%, 27.5% respectively. Conclusions: In patients undergoing VATS, application of ultrasound-guided second SAP block 24 hours after surgery improved postoperative quality of life, reduced opioid consumption and related side effects, and lowered the prevalence of chronic pain.

Surgical management of the diaphragmatic defect in congenital diaphragmatic hernia: a contemporary review.

Worldwide, 150 children are born each day with congenital diaphragmatic hernia (CDH), a diaphragmatic defect with concomitant abnormal lung development. Patients with CDH with large defects are particularly challenging to treat, have the highest mortality, and are at significant risk of long-term complications. Advances in prenatal and neonatal treatments have improved survival in high-risk patients with CDH, but surgical treatment of large defects lacks standardization. Open repair by an abdominal approach has long been considered the traditional procedure, but the type of defect repair (patch or muscle flap) and patch material (non-absorbable, synthetic or absorbable, biological) remain subjects of debate. Increased experience and improved techniques in minimally invasive surgery (MIS) have expanded selection criteria for thoracoscopic defect repair in cardiopulmonary stable patients with small defects. However, the application of MIS to repair large defects remains controversial due to increased recurrence rates and unknown long-term effects of perioperative hypercapnia and acidosis resulting from capnothorax and reduced ventilation. Current recommendations on the surgical management rely on cohort studies of varying patient numbers and data on the long-term outcomes are sparse. Here, we discuss surgical approaches for diaphragmatic defect repair highlighting advancements, and knowledge gaps in surgical techniques (open surgery and MIS), patch materials and muscle flaps for large defects, as well as procedural adjuncts and management of CDH variants.