Reply to Kawasaki et al. Comment on "Manole et al. Primary Pericardial Synovial Sarcoma: A Case Report and Literature Review. Diagnostics 2022, 12, 158".

Thank you for your comment; it adds value to the article and highlights the importance of molecular testing [...].

Percutaneous tracheostomy using the Seldinger technique.

Patients with acute respiratory failure who are anticipated to have a significant recovery and require prolonged mechanical ventilation, defined as ventilation lasting 7 days or longer, should be evaluated for the potential need for a tracheostomy. A tracheostomy reduces the necessity for sedation and aids in the process of weaning patients. The popularity of percutaneous tracheostomy techniques, which can be carried out at the patient's bedside, has increased due to their ability to save costs associated with time in the operating room. This video tutorial provides a comprehensive guide comprising 10 sequential steps, demonstrating the process of performing a percutaneous tracheostomy. The technique highlighted in the tutorial uses the Seldinger method alongside serial dilators, while also covering the essential anatomical aspects and necessary equipment.

Indwelling pleural catheter insertion technique.

This video tutorial is a step-by-step demonstration of the indwelling pleural catheter insertion technique in a patient who was diagnosed with malignant pleural effusions due to multiple metastases. Placing an indwelling pleural catheter is a novel method to treat chronic pleural effusions, especially secondary to malignancies. This method is particularly useful in patients with a trapped lung or with reduced life expectancy in whom more-invasive procedures are contraindicated. Indwelling pleural catheters are well tolerated.

Obesity Impact on SARS-CoV-2 Infection: Pros and Cons "Obesity Paradox"-A Systematic Review.

BACKGROUND: During the last years, the COVID-19 pandemic meets the pandemic generated by obesity, raising many questions regarding the outcomes of those with severe forms of infection. METHODS: The present systematic review summarises and analyses the data providing evidence for or against the "obesity-paradox" in COVID-19 patients. After applying the inclusion and exclusion criteria, 23 studies were included. We also analysed the presumably underlying basic mechanisms. RESULTS: The patients with a body mass index (BMI) of 30-40 kg/m2 presented severe symptoms that led to intensive care unit (ICU) admission but not increased death rate. Those with a higher degree of obesity, with a BMI higher than 40 kg/m2, led to a rise in the death rate, particularly in young patients. Obesity was associated with a higher rate of ICU admission but was not determined as an independent predictor of increased mortality. In contrast, some studies suggest a strong association between obesity or morbid obesity and the risk of death. CONCLUSIONS: The existence of "obesity-paradox" cannot be stated; our study presents obesity as a critical risk factor in the evolution of COVID-19.

Gender Differences in Coping, Depression, and Anxiety in Patients with Non-Metastatic Lung Cancer.

Background: Depression and anxiety are prevalent issues amongst individuals suffering from thoracic cancer. Gender differences in coping with thoracic cancer have a serious impact upon the management of emotional distress. The purpose of our study has been to assess sex variations in handling anxiety and depression, including the use of coping mechanisms and their relationship with respect to anxiety and depression. Methods: This cross-sectional study registered 18 women and 22 men with non-metastatic lung cancer and operated upon. Pre-operatively and at one month post-operatively, the patients were assessed by means of scales (COPE, GAD-7 and PHQ-9). Results: Post-operatively, the intensity of depression and anxiety was substantially greater in males than in females (p = 0.049, p = 0.042). Male individuals tended to use coping mechanisms of humour (p = 0.009) and restraint (p = 0.029) significantly more frequently than women. Moreover, in women, depression correlated significantly with denial and behavioural deactivation (rho = 0.465, p = 0.029, respectively, rho = 0.562, p = 0.006); whilst anxiety, similarly, correlated with positive interpretation, behavioural deactivation, and use of social-emotional support (rho = 0.484, p = 0.022, respectively, rho = 0.590, p = 0.004 and rho = 0.502, p = 0.017). Furthermore, in males, depression correlated significantly with mental deactivation, use of social-instrumental and social-emotional support (rho = 0.702, p = 0.001, respectively, rho = 0.505, p=0.033, and rho = 0.773 with p < 0.001), whilst anxiety correlated significantly with mental deactivation, denial, and use of social-emotional support (rho = 0.597, p = 0.009, respectively, rho = 0.553 with p = 0.017 and rho = 0.755, p < 0.001). Conclusion: There were gender divergences in the use of coping mechanisms and the level of post-surgical anxiety and depression. We found significant positive relationships between some coping mechanisms and depression/anxiety. The patient's gender governs the coping style, which in turn has bearing upon the post-operative evolution.

Diagnostic Challenges in Rare Causes of Arrhythmogenic Cardiomyopathy-The Role of Cardiac MRI.

Arrhythmogenic right ventricular dysplasia (ARVD) is a rare genetic condition of the myocardium, with a significantly high risk of sudden death. Recent genetic research and improved understanding of the pathophysiology tend to change the ARVD definition towards a larger spectrum of myocardial involvement, which includes, in various proportions, both the right (RV) and left ventricle (LV), currently referred to as ACM (arrhythmogenic cardiomyopathy). Its pathological substrate is defined by the replacement of the ventricular myocardium with fibrous adipose tissue that further leads to inadequate electrical impulses and translates into varies degrees of malignant ventricular arrythmias and dyskinetic myocardium movements. Particularly, the cardio-cutaneous syndromes of Carvajal/Naxos represent rare causes of ACM that might be suspected from early childhood. The diagnostic is sometimes challenging, even with well-established rTFC or Padua criteria, especially for pediatric patients or ACM with LV involvement. Cardiac MRI gain more and more importance in ACM diagnostic especially in non-classical forms. Furthermore, MRI is useful in highlighting myocardial fibrosis, fatty replacement or wall movement with high accuracy, thus guiding not only the depiction, but also the patient's stratification and management.

Primary Pericardial Synovial Sarcoma: A Case Report and Literature Review.

We report a case of a 52-year-old woman who was referred to our institution with a superior vena cava syndrome and was investigated through echocardiography, CT and MRI revealing a well-defined, encapsulated pericardial mass. The pathology, correlated with the immunohistochemical analysis, concluded it was an extremely rare primary pericardial synovial sarcoma. The patient underwent surgery and chemotherapy with a 16-month disease-free survival and passed away after a contralateral aggressive relapse. Moreover, we discuss the role of each imaging modality together with their pericardial synovial sarcoma reported features.

Cardiac sympathetic denervation in patients with nonischemic cardiomyopathy and refractory ventricular arrhythmias: a single-center experience.

INTRODUCTION: Cardiac sympathetic denervation (CSD) is an effective therapy for selected patients with drug refractory ventricular arrhythmias (VA). Data about the role of CSD in patients with structural heart disease and VAs are sparse. We herein present our experience of CSD in patients with nonischemic cardiomyopathy and VAs despite prior ablation procedure and/or antiarrhythmic drug (AAD) therapy. METHODS: A total of ten patients (mean age 61.6 ± 19.6, mean LVEF 29.5 ± 12.1%) with nonischemic dilated cardiomyopathy (NICM) (n = 9) and hypertrophic cardiomyopathy (HCM) (n = 1) underwent CSD (left sided in six and bilateral in four patients) due to refractory VA despite multiple AADs (mean number of AADs was 1.6 ± 0.7) and prior VT ablation (mean number of procedures per patient was 1.5 ± 1.3). RESULTS: Mean follow-up was 10.1 ± 6.9 months. The median number of VA and ICD shocks decreased significantly from 9.0 and 2.5 episodes 6 months prior to CSD to 0 and 0 episodes within 6 months after CSD (p = 0.012 and p = 0.011). Five patients remained free from sustained VA recurrences. Two patients experienced single ICD shock due to a polymorphic VT (triggered by severe hypokalemia in one patient) and one patient a single shock due to monomorphic VT. One patient had five episodes of slow VT under amiodarone therapy (three of them terminated by antitachycardia pacing) and underwent endo- epicardial re-ablation. Two patients died 1 month after CSD. One of them due to electrical storm and cardiogenic shock and the second one due to refractory cardiogenic shock, without recurrence of VAs though. No major complications of CSD occurred. No patient suffered from Horner syndrome. CONCLUSION: In this study, CSD was effective for treatment of VAs in patients with structural heart disease refractory to antiarrhythmic drugs and catheter ablation. Further larger studies are required to confirm these findings.

Dissimilarity of Airway and Lung Tissue Microbiota in Smokers undergoing Surgery for Lung Cancer.

Human airways are continuously colonized by microaspiration of microbiota. Less is known about the presence, origin and composition of microbiota in the lung parenchyma. In a study of 13 patients undergoing surgery for peripheral lung cancer microbiota composition was comparatively evaluated in upper airway, lower airway and lung tissue samples using 16S rDNA analysis. Bacterial density decreased stepwise from upper to lower airways and tissue. On a taxonomic level upper and lower airway microbiota were similar whereas lung tissue showed marked dissimilarities compared to lower airways that may reflect different environmental conditions shaping local microbiota and host immunity.

Morbidity, mortality and long-term outcome of lung cancer resections performed in palliative intent.

BACKGROUND: Surgery is seldom used for palliation in advanced lung cancer and the published data on this issue are very limited. We aimed to assess the results of palliative lung resections and identify criteria to guide surgical therapy in this situation. METHODS: This is a retrospective single-institution analysis of patients with palliative intended lung cancer resection. Survival analysis was performed by Kaplan-Meier method, log-rank test and Cox proportional hazards regression at a statistical significance level of P=0.05. RESULTS: Forty-eight patients received palliative intended lung resections (31 lobectomies, 4 bilobectomies, 13 pneumonectomies) with acceptable rates of severe complications (Clavien-Dindo >IIIa 29%) and 30-day mortality (4%). The most frequent indications were infection and hemoptysis. The median survival for the entire group was 12 months (95% CI: 6.9-17.1 months). Due to unexpectedly favorable histopathologic tumor stage, a switch to curative treatment in 17 completely resected patients resulted in a 2-year survival rate of 46%. In a subgroup of 20 patients with favorable prognostic factors as identified by uni- and multivariable analysis, a median survival of 26 months was observed. CONCLUSIONS: In well selected patients with lung cancer, resection in palliative intent can offer symptom relief and even a survival benefit with acceptable morbidity and low mortality. Prognostic factors were identified and can be used to guide operative treatment. Due to the low specificity of CT and FDG-PET/CT in the presence of inflammation or centrally located lung tumors, a large proportion of patients with lung resection in palliative intent experience a down-staging and frequently also a switch from palliative to curative treatment with additional survival benefit. Factors like expected complete resection, a squamous cell type and the ability to receive adjuvant therapy are useful to support the decision to perform palliative tumor resection.

Actinomyces Meyeri Empyema Necessitatis-A Case Report and Review of the Literature.

Pleural empyema necessitatis caused by Actinomyces meyeri is a rare but severe infection. A. species predominantly A. meyeri and A. israelii represent the second most common pathogen for empyema necessitans after mycobacteria. The incidence is reported in the literature to be 1:300,000. Men are thrice more likely to be affected than women. Pathogenetically, an infection can be triggered by aspiration in immunocompromised individuals which leads to an atelectasis with pneumonitis. In two cases, a 38-year-old construction worker and a 61-year-old woman with ulcerative breast carcinoma, who presented to the local emergency department with a painful swelling of the left chest, diagnostic workup revealed a pleural empyema necessitatis of the left chest. An antibiotic treatment was initiated with piperacillin/tazobactam and sulbactam/ampicillin, respectively. Temporally vacuum-dressing therapy was initiated after surgical debridement. In the course of the procedure, a reconstruction of tissue damage was feasible. The patients were recovered completely and discharged with an oral antibiotic treatment (amoxicillin) for 6 and 12 months, respectively. Thoracic actinomycosis is a relatively uncommon and traditionally chronic, indolent infection secondary to pulmonary infection with A. species . Surgical treatment is generally reserved for cases failing to resolve with antibiotic therapy. Early diagnosis, prompt debridement, and narrow spectrum ß-lactam antibiotics can result in complete resolution of infection and good prognosis.

An Unexpected Endobronchial Mass Appearing During Bronchoscopy.

A 60-year-old man was admitted to the hospital with productive cough and yellowish sputum, severe fatigue, and weight loss of 4 kg over the past month; furthermore, he reported a slowly progressive shortness of breath on exertion over the past 6 months. Before admission, he received ampicillin/sulbactam (750 mg) orally twice daily for 7 days without significant clinical improvement.

Experiences with LESS-appendectomy in Children.

PURPOSE: To evaluate the outcome of laparoendoscopic single-site (LESS-A) through one transumbilical port vs. 3-port laparoscopic (3TA) appendectomy in children. METHODS: We reviewed the records of 309 children (65 LESS-A, 244 3TA) operated on between 2008 and 2012. One hundered forty-nine patients had acute catarrhalis (CA), 133 phlegmonous (PLA), and 27 perforated appendicitis (PA). We compared the duration of operation (DO) the incidence of abdominal abscesses (AA) and wound infections (WI), as well as the degree of appendiceal inflammation (DI) among surgeons with and without board certification. RESULTS: For all DI, LESS-A resulted in a shorter DO than 3TA (CA 57.9 ± 22.8 vs. 68.5 ± 23.2, P = 0.014; PLA 51.5±16.5 vs. 68.4±33.0, P = 0.006; PA 66.0 ± 29.0 vs. 97.3 ± 41.8, P = 0.039). LESS-A was not used for less complicated cases when compared to 3TA (CA 50.8% vs. 47.5%; PLA 33.8% vs. 45.5%; PA 15.4% vs. 7.0%; CA vs. PLA, P = 0.292; CA vs. PA, P = 0.142; PLA vs. PA, P = 0.031). Surgeons without board certification were assigned to a similar percentage to perform both techniques for any DI (CA 30.3% vs. 37.1%, P = 0.541; PLA 31.8% vs. 40.5%, P= 0.484; PA 40% vs. 35.3%, P = 1.0). We found no significant differences concerning AA (1.5% vs. 1.2%, P = 1.0) and WI (3.1% vs. 1.6%, P = 0.61). CONCLUSIONS: LESS-A can be done by surgeons with and without board certification for all DI, with shorter DO and similar complication rates as compared to 3TA.

Clinical Case Discussion: Isolated Lung Metastases After Radical Nephrectomy for Clear Cell Carcinoma: The Case for Surgery.

In a stable patient with metastatic renal cell carcinoma, metastasectomy is an option when all the lesions can be resected. Individual informed consent from the patient is most important.

Bronchus anastomosis after sleeve resection for lung cancer: does the suture technique have an impact on postoperative complication rate?

OBJECTIVES: Bronchoplastic resections emerged as an alternative to pneumonectomy for patients with impaired pulmonary function and have gained popularity due to a marked decrease in morbidity and at least similar oncological outcome. Actual guidelines recommend sleeve resections whenever technically feasible, even in cases with adequate pulmonary reserve for pneumonectomy, in order to maximally preserve functional lung parenchyma. Various suture techniques were described; the existing evidence, however, is insufficient to recommend one of them as standard. The aim of this study was to compare two suture techniques for bronchus repair after sleeve resection. METHODS: Two groups of patients from two separate institutions were retrospectively analysed. In Group A (n = 20), the anastomosis was performed with a running suture at the membranous part and an interrupted suture for the rest of the circumference. In Group B (n = 40), a telescoping continuous suture was used. Intra- and postoperative findings directly related to the anastomosis were compared. The parameters were assessed as absolute numbers and percentages; the statistical significance was determined using Pearson's χ(2) test for categorical variables and Student's t-test for continuous data (P < 0.05 considered as significant). RESULTS: Other than tumour location and resection type (predominance of the right upper lobe for Group B), the groups were comparable regarding patient characteristics. The intraoperative anastomotic assessment revealed: patency 100% in both groups, initial air tightness (100 vs 82.5%; P = 0.047) and buttressing 85 vs 5%. No suture revision was necessary in both groups. The analysis of anastomosis-related morbidity revealed no significant difference: atelectasis (1 in Group A and 2 in Group B; P = 1), reversible anastomotic changes (0 vs 2; P = 0.309), early stenosis (0 vs 0), bronchopleural fistula (1 vs 0; P = 0.154), bronchovascular fistula (0 vs 0), late stenosis (1 vs 0; P = 0.119) and reoperations (15 vs 5%; P = 0.186). The operative mortality rate was similar (2 vs 3; P = 0.741) without intraoperative deaths. CONCLUSIONS: Sleeve resections are technically challenging, especially concerning the tension in the suture and size mismatch. In our series, there was no significant difference between the two groups regarding parameters directly related to the anastomosis. The interrupted suture without telescoping is the most cited technique, can be performed in several variations and can universally be used with good ability to compensate size mismatch. The telescoping continuous anastomosis is less time- and material-consuming and is especially valuable for large-calibre bronchi and relevant size mismatch.

Can a simplified algorithm prevent incomplete laparoscopic pyloromyotomy?

PURPOSE: The purpose of this study is to analyze an algorithm intended to prevent incomplete pyloromyotomy in 3-port laparoscopic (3TP) and laparoendoscopic single-site (LESS-P) procedures in a teaching hospital. METHODS: We defined the pyloroduodenal and pyloroantral junctions as anatomical margins prior pyloromyotomy by palpating and coagulating the serosa with the hook cautery instrument. Incomplete pyloromyotomies, mucosa perforations, serosa lacerations, and wound infections were recorded for pediatric surgical trainees (PST) and board-certified pediatric surgeons (BC). RESULTS: We reviewed the medical files of 233 infants, who underwent LESS-P (n=21), 3TP (n=71), and open pyloromyotomy (OP, n=141). No incomplete pyloromyotomies occurred. In contrast to OP, mucosa perforations did not occur in the laparoscopic procedures during the study period (6.38% vs. 0%, P=.013). OP had insignificantly more serosal lacerations (3.5% vs. 1.4%, P=.407). There was no difference in the rate of wound infections between OP and laparoscopic procedures (2.8% vs. 4.3%, P=.715). In the latter, all wound infections were associated with the use of skin adhesive. CONCLUSIONS: This algorithm helps avoiding incomplete laparoscopic pyloromyotomy during the learning curve and in a teaching setting. It is not risky to assist 3TP and LESS-P to PST as this led to a decreased rate of mucosa perforations without experiencing incomplete pyloromyotomies.

The format type has impact on the quality of pathology reports of oncological lung resection specimens.

Most pathology reports are in a narrative form without a given structure and occasionally lack important information. Here we show that the format of pathology reports of oncological lung resection specimens correlates with the quality of the reports. All pathology reports of oncological lung resection specimens between 01/02 and 04/11 (N = 878) were classified into descriptive reports (DR, N = 249), structured reports (SR, N = 415) as well as template based synoptic reports (TBSR, N = 214) and compared regarding the content of organ specific essential data (ED). The amount of recorded ED was summarized in an essential data score (EDS). Median EDS of DR was 8, of SR 9, and of TBSR 10. Only 28.7% of all reports had an EDS of 10; divided into the report types 2.6% of DR, 16.4% of SR and 88.4% of TBSR obtained an EDS of 10 (paired comparison: P < 0.0001). Traditional descriptive reports showed the lowest quality sometimes lacking important information and clarity of data layout whereas the template based synoptic reports reached the highest quality level. The broader use of structured reports is recommended for oncological lung resection specimens as they lead to a reduction of failed data transfer and therefore to an increase of quality.

Morbidity and mortality in patients with usual interstitial pneumonia (UIP) pattern undergoing surgery for lung biopsy.

BACKGROUND: Previous studies revealed that surgical lung biopsy in usual interstitial pneumonia (UIP) patients is accompanied with higher morbidity and mortality. The aim of this retrospective analysis was to assess morbidity and mortality of patients with suspected UIP undergoing surgical lung biopsy. METHODS: We conducted a retrospective study of 45 patients with suspected UIP pattern undergoing surgical biopsy for diffuse pulmonary infiltrates in our department. Data concerning medical history, histology, and survival status were extracted from the medical database of the University Medical Center Freiburg. RESULTS: UIP was diagnosed by experienced pneumo-pathologists according to the criteria of American Thoracic Society/European Respiratory Society (ATS/ERS) consensus classification. Due to adhesions the surgeon decided in two patients to perform wedge resection via open surgery. In 43 patients lung biopsy was performed via Video-assisted thoracoscopy (VATS). No intraoperative complications were observed. Postoperative complications consisted of bradyarrhythmia (n = 1), gastrointestinal bleeding (n = 1), bacterial pneumonia (n = 1), candida pneumonia (n = 1) and acute exacerbation (n = 1). There was no 30-day mortality, but one patient was lost in follow-up and therefore censored. The intraoperative placed thoracic drain was removed at the first postoperative day in most cases (mean day of removal 1.9, ±2.6). The mean length of hospital stay was 8.1 days (±6.8). CONCLUSIONS: We conclude that surgical biopsy can be safely performed in patients with suspected UIP.

Video-assisted vs open mediastinal lymphadenectomy for Stage I non-small-cell lung cancer: results of a prospective randomized trial.

OBJECTIVES: Since the introduction of video-assisted lobectomy for non-small-cell lung cancer (NSCLC) into clinical practice, it has been discussed controversially whether mediastinal lymphadenectomy can be performed as effectively as an open procedure via thoracotomy. Therefore, we address this issue in a prospective randomized trial conducted in our institution. METHODS: In total, 66 patients with completely staged clinical Stage I NSCLC were included and randomized either into a video-assisted group (n = 34) or into the conventional lobectomy group (n = 32). The video-assisted thoracoscopic (VATS) lobectomy was performed by using a 4- to 5-cm utility incision in the fourth or fifth intercostal space and two additional 10-mm ports without rib spreading. The conventional lobectomy was done via an anterolateral thoracotomy. Lymph nodes were classified according to the International Association for the Study of Lung Cancer classification; for right-sided tumours, lymph nodes number 2R, 4R, 7, 8, 9, 10, 11 and 12 were dissected, and for left-sided tumours, lymph nodes number 5, 6, 7, 8, 9, 10, 11 and 12. For the subsequent analyses, lymph nodes were grouped into different zones consisting of Zone 1 (2R and 4R), Zone 2 (7), Zone 3 (8R and 9R), Zone 4 (10R, 11 R and 12R), Zone 5 (4 L), Zone 6 (5 and 6), Zone 7 (8L and 9L) and Zone 8 (10 L, 11 L and 12L). RESULTS: Both groups were comparable with respect to different clinical pathological parameters (age, tumour size and comorbidity). In the video-assisted group, 2 patients were excluded due to conversion to an open thoracotomy. The number of mediastinal lymph nodes removed was as follows: VATS (right side) 24.0 lymph nodes/patient, open right-sided 25.2 lymph nodes/patient, VATS (left side) 25.1 lymph nodes/patient and open left-sided 21.1 lymph nodes/patient. With respect to the zones mentioned above, we found the following results: VATS vs open (mean number of lymph nodes/patient): Zone 1: 9 vs 8.5; Zone 2: 6.3 vs 5.6; Zone 3: 2.4 vs 3.2; Zone 4: 6.5 vs 6.9; Zone 5: 0 vs 0.5; Zone 6: 3.2 vs 3.7; Zone 7: 4.6 vs 3.2 and Zone 8: 10.5 vs 8.9. There were no statistically significant differences between the procedures, either with respect to the overall number of lymph nodes or with respect to the number of lymph nodes in each zone. CONCLUSIONS: Mediastinal lymph node dissection can be performed as effectively by the video-assisted approach as by the open thoracotomy approach. Furthermore, the video-assisted approach allows a better visualization of different lymph node zones.

Venous thoracic outlet syndrome caused by a congenital rib malformation.

Venous thoracic outlet syndrome (VTOS) represents a rare disorder. Hypertrophy of the anterior scalene musculature is the cause of the compression syndrome in most cases. To our knowledge, we describe the first reported case worldwide of a venous compression syndrome caused by a congenital malformation of the 1st and 2nd ribs. Treatment by transaxillary partial rib resection was necessary and a very good postoperative result was achieved.