A Diaphragmic Traction Suture Increases Pleural Cavity Volume and Surgical Field Overview During Video-Assisted Thoracoscopic Surgery.

OBJECTIVES: An elevated hemidiaphragm may impair surgical field overview during video assisted thoracoscopic surgery (VATS) and may consequently jeopardize a safe surgical procedure or prolong the duration of surgery. The aim of this study was to evaluate if tension applied to a diaphragmatic suture improves the surgical field overview. METHODS: Following informed consent and at the surgeon's discretion during elective VATS procedures, a single stitch was placed at the posterior tendinous border of the diaphragm and retracted through the camera port. The surgical field overview was evaluated using a numeric rating scale (1-10) by the surgeon before and after applying tension during the procedure, and later by 9 VATS surgeons (> 10 years' experience) using video recordings. RESULTS: During a 4-month period, 43 patients scheduled for elective VATS by two surgeons gave informed consent to participate. The hemidiaphragm was elevated to such an extent in 27 patients that the surgeon placed a diaphragmatic stitch suture. When tension was applied to the suture, surgical field overview improved significantly (p < 0.001). CONCLUSION: A diaphragmatic traction suture improves surgical field overview in selected patients with elevation of the hemidiaphragm. This simple procedure may facilitate VATS in patients with impaired surgical field overview and consequently improve safety during VATS. CLINICAL TRIAL NUMBER: http://ClinicalTrials.gov (No. NCT04837950).

New Chest Drainage Unit with Integrated CO2-Detector Demonstrates False Air Leak.

BACKGROUND: Postoperative observed air leakage does not always originate from parenchymal defects but may arise from defects in the chest drainage unit, connections or reverse airflow in water seals. We investigated such false air leakage using a new chest drainage unit with a built-in CO2-detector and an electronic chest drainage unit. METHODS: Two types of chest drainage units were tested in a simple porcine model: A well-known electronic chest drainage unit and a new chest drainage unit with integrated CO2-detector. We created a setup of true air leakage-a parenchymal lesion, and false air leakage-allowing air to flow into the thoracic cavity alongside the chest drain. RESULTS: We demonstrated that the new chest drainage unit with a built-in CO2-detector can distinguish between experimentally induced true air leakage and false air leakage. CONCLUSION: Available chest drainage systems do not allow direct assessment of true or false air leakage, which may increase chest drain duration unnecessarily. The integration of a CO2-sensitive color indicator into a chest drainage unit allows simple distinction between false air leak and true air leak, which may improve postoperative management.

A Newly Developed Chest Drainage Unit with an Integrated CO2 Detector.

PURPOSE: Postoperative air leakage does not always originate from parenchymal defects. In some cases, it may arise from defects in the chest drainage unit itself or connections, or from reverse airflow in water seals. The aim of the present study was to test a new chest drainage unit in the clinic, where an integrated CO2-sensitive colour indicator helps to distinguish false air leakage from true air leakage. METHODS: Over a 3-week period, 14 consecutive patients were operated upon using either an open approach (for bilobectomies) or VATS (for diagnostic procedures or lobectomies). All patients received general anaesthesia with double-lumen intubation. All patients had a 24-Fr chest tube connected to a chest drainage unit with a built-in CO2-detector. RESULTS: In all patients with air leakage after surgery, we found a colour change in the CO2-sensitive colour indicator, confirming "true air leakage". One patient had prolonged air leakage. None of the patients had pneumothorax after removal of the chest tube and no patients had wound infections or any other complications. CONCLUSION: The chest drainage unit described here was easily implemented in the clinic and clearly confirmed true air leakage in all patients with air leakage after lung surgery. It allowed safe and appropriate timing for chest tube removal with no need for reinsertion in a broad cohort of patients referred for thoracic surgery.

Platelet function in lung cancer patients undergoing lobectomy.

A growing interest concerns arterial thromboembolic disease in cancer patients. As platelets may be key players in this process, investigation of platelet aggregation in cancer patients is of importance. We aimed to investigate platelet aggregation in patients with lung cancer prior to surgery and during video-assisted thoracoscopic surgery (VATS) lobectomy compared with lobectomy performed through a thoracotomy. We included 93 patients (VATS + low molecular weight heparin (LMWH), n = 32; VATS no LMWH, n = 31; thoracotomy + LMWH, n = 30). Data obtained from 121 healthy individuals were used for comparison prior to surgery. Platelet aggregation was analysed by impedance aggregometry using adenosine diphosphate 6.5 µM (ADPtest) and collagen 3.2 µg/mL (COLtest) as agonists. Prior to surgery, platelet aggregation was significantly increased in both VATS-patients (ADPtest, p < .0001; COLtest, p = .0002) and patients undergoing thoracotomy (ADPtest, p < .0001; COLtest, p < .0001) compared with healthy individuals. Platelet aggregation did not differ between VATS-patients and thoracotomy patients prior to surgery (p-values >.11). At the first postoperative day, VATS-patients demonstrated significantly higher collagen-induced platelet aggregation than preoperatively (p = .001), but the increase in platelet aggregation did not differ significantly between VATS and thoracotomy patients (p-values ≥.24). At the second postoperative day, platelet aggregation was significantly reduced in thoracotomy patients compared with the preoperative level (ADPtest, p = .002; COLtest, p = .05). In conclusion, platelet aggregation was significantly increased in patients with primary lung cancer prior to surgery compared with healthy individuals. At the first postoperative day, platelet aggregation was significantly higher than the preoperative level in VATS-patients; however, this increase did not differ between patient groups.

The Influence of Suction on Chest Drain Duration After Lobectomy Using Electronic Chest Drainage.

BACKGROUND: Management of chest drains after thoracic surgery remains an area with little consensus. To optimize chest drainage algorithms with electronic chest drainage systems, a randomized controlled trial comparing low variable suction (-5 cm H2O) versus high variable suction (-20 cm H2O) was conducted. METHODS: This was a prospective open label randomized trial in patients undergoing lobectomy. Sample size was calculated from a clinical relevant difference in chest drain duration as 1 full day. End points were chest drain duration and length of hospitalization. Data were analyzed by Kaplan-Meier survival analysis and multivariate Cox proportional hazards regression. RESULTS: The study randomized 106 patients. There was no statistical significant difference in chest drain duration and length of stay between the low-suction and the high-suction groups: Median chest drain duration and hospitalization were 25 hours (interquartile range [IQR] 21 to 55 hours) versus 28 hours (IQR 23 to 77 hours; p = 0.97) and 5 days (IQR 3 to 6 days) versus 5 days (IQR 3 to 7 days; p = 0.75), respectively. Multivariate analysis demonstrated that the diffusing capacity of the lung for carbon monoxide was the only significant predictor of chest drain duration (p = 0.015) and length of hospitalization (p = 0.003). Complications requiring reinsertion of the chest drain were significantly more frequent in the low-suction group (p = 0.03). CONCLUSIONS: There was no clinically relevant difference in chest drain duration or length of hospitalization, but reinsertions of chest drains were significantly more frequent in the low-suction group, a finding suggesting that low suction levels should not be used after lobectomy. Trial registry number is ISRCTN10408356.

From acute to chronic pain after thoracic surgery: the significance of different components of the acute pain response.

PURPOSE: Acute postoperative pain is a strong predictor for postthoracotomy pain syndrome (PTPS), but the mechanism is unknown. Even though thoracic pain is usually considered the dominating acute pain after thoracic surgery, up to 45% of patients consider shoulder pain to be dominating pain and often this shoulder pain is referred visceral pain. This study aims to examine which components of the acute pain response after thoracic surgery were associated with PTPS and if any signs of a generalized central hypersensitivity could be identified in patients with PTPS. PATIENTS AND METHODS: In a prospective cohort study, 60 consecutive patients for lobectomy were included and examined preoperatively and 12 months postoperatively for pain and signs of hypersensitivity using a comprehensive protocol for quantitative sensory testing. Thoracic pain, shoulder pain, referred pain, and overall pain were assessed five times daily during the first four postoperative days. RESULTS: Sixteen patients (31% of the 52 patients who completed the study) developed PTPS. Thoracic pain was the only pain component that was associated with PTPS and was a stronger predictor for PTPS than overall pain. There were no signs of hypersensitivity before or after the operation in patients with PTPS, but patients with PTPS more often suffered from preoperative pain. CONCLUSION: Thoracic pain was the only component of the acute pain response that predicted PTPS and was a stronger predictor than overall pain.

External Suction and Fluid Output in Chest Drains After Lobectomy: A Randomized Clinical Trial.

BACKGROUND: Even when air leakage has ceased completely after lobectomy, chest drains are often not removed because of high fluid output. Accepted thresholds for removal vary between institutions but typically range between 200 and 500 mL/d. There is little knowledge whether external suction influences the amount of fluid. METHODS: We randomly assigned (1:1) 106 patients who underwent lobectomy to either low (-5 cm H2O) or high (-20 cm H2O) external suction using an electronic chest drainage system. Only one chest drain was allowed, and we used strict algorithms for chest drain removal, which was delegated to staff nurses: air leakage less than 20 mL/min for 6 hours regardless of fluid output, provided it was serous. The primary end point was fluid output after 24 and 48 hours. RESULTS: Mean fluid output was significantly higher with high suction after both 24 (338 ± 265 mL versus 523 ± 215 mL) and 48 hours (616 ± 366 mL versus 1067 ± 387 mL (p < 0.001). Repeated measure analysis (mixed model) demonstrated that in addition to suction level the surgical approach (video-assisted thoracoscopic surgery/thoracotomy, p = 0.04) and affected lobe (upper/lower, p = 0.001) were significant predictors of fluid production. CONCLUSIONS: Increased suction levels lead to increased fluid output. Thoracotomy and lower lobectomy are associated with increased fluid output in chest drains, which should be taken into consideration if algorithms for chest drain removal include an upper limit of fluid output.

Coagulation profile in open and video-assisted thoracoscopic lobectomies: a cohort study.

OBJECTIVES: Lung cancer patients are perceived to have a relatively high risk of venous thromboembolic events due to an activation of the coagulation system. In terms of activation of the coagulation system, the difference between video-assisted thoracoscopic surgery (VATS) and open lobectomies for primary lung cancer has not been investigated. The aim of this study was to compare the impact on the coagulation system in patients undergoing curative surgery for primary lung cancer by either VATS or open lobectomies. METHODS: In total, 62 patients diagnosed with primary lung cancer were allocated to either VATS (n = 32) or open lobectomies (n = 30). All patients received subcutaneous injections with dalteparin (Fragmin®) 5000 IE once daily. The coagulation was assessed pre- and intraoperatively, and the first 2 days postoperatively by standard coagulation blood tests, thromboelastometry (ROTEM®) and thrombin generation. RESULTS: The open lobectomies bled more than the VATS group and had a significantly lower platelet count (109/l) on postoperative Days 1 and 2 (198 vs 231 and 194 vs 243, respectively). The open group also had a higher international normalized ratio on postoperative Days 1 and 2 compared with the VATS group (1.21 vs 1.14 and 1.17 vs 1.09, respectively). There were no differences in thromboelastometry (ROTEM®) and thrombin generation parameters. None of the included patients developed venous thromboembolic events. CONCLUSIONS: In patients undergoing curative surgery for early-stage primary lung cancer, we observed a statistical non-significant difference and a similar-sized minor impact on the coagulation system.

Video-assisted Thoracoscopic surgery (VATS) lobectomy for lung cancer does not induce a procoagulant state.

BACKGROUND: Changes in the coagulation system in patients undergoing surgery for lung cancer have been sparsely investigated and the impact of the surgical trauma on the coagulation system is largely unknown in these patients. An increased knowledge could potentially improve the thromboprophylaxis regimes. The aim of this study was to assess the coagulation profile evoked in patients undergoing curative surgery by Video-Assisted Thoracoscopic Surgery (VATS) lobectomy for primary lung cancer. METHODS: Thirty-one patients diagnosed with primary lung cancer undergoing VATS lobectomy were prospectively included. The coagulation profile was assessed preoperatively and in the first two days postoperatively using a wide range of standard coagulation tests, dynamic whole blood coagulation measured by rotational thromboelastometry (ROTEM®) and thrombin generation evaluated by calibrated automated thrombography. Patients did not receive thromboprophylactic treatment. Data was analyzed using repeated measures one-way ANOVA. RESULTS: The standard coagulation parameters displayed only subtle changes after surgery and the ROTEM® and thrombin generation results remained largely unchanged. CONCLUSIONS: Patients undergoing VATS lobectomy are normocoagulable in the preoperative state and a VATS lobectomy does not significantly influence the coagulation. TRIAL REGISTRATION: The trial is registered at ClinicalTrials.gov (Identifier: NCT01741506) and at EudraCTno. 2012-002409-23. Registered December 2012.

The Etiology of Primary Hyperhidrosis: A Systematic Review.

PURPOSE: Primary hyperhidrosis is a pathological disorder of unknown etiology, affecting 0.6-5% of the population, and causing severe functional and social handicaps. As the etiology is unknown, it is not possible to treat the root cause. Recently some differences between affected and non-affected people have been reported. The aim of this review is to summarize these new etiological data. METHODS: Search of the literature was performed in the PubMed/Medline Database and pertinent articles were retrieved and reviewed. Additional publications were obtained from the references of these articles. RESULTS: Some anatomical and pathophysiological characteristics (as well as enzymatic, metabolic, and neurological dysfunctions) have been observed in hyperhidrotic subjects; three main possible etiological factors predominate. A familial trait seems to exist, and genetic loci associated with hyperhidrosis have been identified. Histological differences were observed in sympathetic ganglia of hyperhidrotic subjects: the ganglia were larger and contained a higher number of ganglion cells. A higher expression of acetylcholine and alpha-7 neuronal nicotinic receptor subunit in the sympathetic ganglia of patients with hyperhidrosis has been reported. CONCLUSIONS: Despite these accumulated data, the etiology of primary hyperhidrosis remains obscure. Nevertheless, three main lines for future research seem to be delineated: genetics, histological observations, and enzymatic studies.

The influence of chest tube size and position in primary spontaneous pneumothorax.

BACKGROUND: Optimal chest tube position in the pleural cavity is largely unexplored for the treatment of primary spontaneous pneumothorax (PSP). We investigated whether type, size and position of chest tubes influenced duration of treatment for PSP. METHODS: A retrospective follow-up study of all patients admitted with PSP over a 5-year period. Traumatic, iatrogenic and secondary pneumothoraxes were excluded. Gender, age, smoking habits, type and size of chest tube used (pigtail catheter or surgical chest tube) were recorded from the patients' charts. All chest X-rays upon admittance and immediately following chest tube placement were retrieved and re-evaluated for size of pneumothorax (categorized into five groups) and location of the chest tube tip (categorized as upper, middle or lower third of the pleural cavity). All data were analysed in a Cox proportional hazards regression model. RESULTS: We identified 134 patients with PSP. Baseline characteristics were similar for patients treated with surgical chest tubes and pigtail catheters. Chest tube duration was not significantly influenced by position of the chest tube tip, but was significantly longer in females (P<0.01), patients <30 years (P=0.01), larger pneumothoraxes (P<0.01), use of surgical chest tubes (P=0.03) and a history of previous pneumothorax (P=0.04). CONCLUSIONS: Contrary to common belief and guidelines recommendation the position of a chest tube in the pleural cavity did not significantly influence chest tube duration, but it was significantly longer in patients who were treated with a surgical chest tube.

Coagulation profile in patients undergoing video-assisted thoracoscopic lobectomy: A randomized, controlled trial.

BACKGROUND: Knowledge about the impact of Low-Molecular-Weight Heparin (LMWH) on the coagulation system in patients undergoing minimal invasive lung cancer surgery is sparse. The aim of this study was to assess the effect of LMWH on the coagulation system in patients undergoing Video-Assisted Thoracoscopic Surgery (VATS) lobectomy for primary lung cancer. METHODS: Sixty-three patients diagnosed with primary lung cancer undergoing VATS lobectomy were randomized to either subcutaneous injection with dalteparin (Fragmin®) 5000 IE once daily or no intervention. Coagulation was assessed pre-, peri-, and the first two days postoperatively by standard coagulation blood test, thromboelastometry (ROTEM®) and thrombin generation. RESULTS: Patients undergoing potential curative surgery for lung cancer were not hypercoagulable preoperatively. There was no statistically significant difference in the majority of the assessed coagulation parameters after LMWH, except that the no intervention group had a higher peak thrombin and a shorter INTEM clotting time on the first postoperative day and a lower fibrinogen level on the second postoperative day. A lower level of fibrin d-dimer in the LMWH group was found on the 1. and 2.postoperative day, although not statistical significant. No differences were found between the two groups in the amount of bleeding or number of thromboembolic events. CONCLUSIONS: Use of LMWH administered once daily as thromboprophylaxis did not alter the coagulation profile per se. As the present study primarily evaluated biochemical endpoints, further studies using clinical endpoints are needed in regards of an optimized thromboprophylaxis approach.

Subcarinal Lymph Nodes Should be Dissected in All Lobectomies for Non-Small Cell Lung Cancer-Regardless of Primary Tumor Location.

BACKGROUND: Mediastinal staging is of paramount importance for planning of treatment in non-small cell lung cancer (NSCLC). Single institution reports recently claimed that subcarinal lymph node dissection during resection of upper lobe NSCLC could be spared. We used a complete national lung cancer registry to investigate patterns of unsuspected mediastinal lymph node involvement after lobectomy. METHODS: During an 11-year period (2004 to 2014) 5,577 consecutive patients who underwent operations for NSCLC were investigated for unsuspected mediastinal lymph node involvement (N2 disease) discovered at final histopathology. The analysis excluded patients with clinical N2 disease. We used a national registry to extract information for each patient about tumor location, histopathology, clinical and pathologic TNM stage, preoperative imaging modalities, and type of invasive mediastinal staging. RESULTS: Mediastinal lymph node dissection was performed in 5,577 patients during the operation, and unsuspected N2 disease was discovered in 612 (11.0%), and 193 (3.5%) had subcarinal metastasis. Subcarinal N2 disease was significantly more common in patients with lower-lobe or middle-lobe cancers compared with upper-lobe cancers (5.8% vs 1.6%, p < 0.01). Preoperative invasive mediastinal staging was performed in 73.4% (4,097 of 5,577) of all patients and significantly more frequently in patients who eventually had N2 disease (87.3% [534 of 612], p < 0.01) as well subcarinal N2 disease (89.6% [173 of 193], p < 0.01). CONCLUSIONS: Subcarinal lymph node metastases were common despite frequent use of preoperative invasive mediastinal staging in lower-lobe, middle-lobe, and upper-lobe NSCLC. Subcarinal lymph nodes should be dissected or sampled routinely during operations for NSCLC to avoid understaging-regardless of preoperative invasive mediastinal staging and tumor location.

European Association for Cardio-Thoracic Surgery expert consensus statement on the prevention and management of mediastinitis.

Mediastinitis continues to be an important and life-threatening complication after median sternotomy despite advances in prevention and treatment strategies, with an incidence of 0.25-5%. It can also occur as extension of infection from adjacent structures such as the oesophagus, airways and lungs, or as descending necrotizing infection from the head and neck. In addition, there is a chronic form of 'chronic fibrosing mediastinitis' usually caused by granulomatous infections. In this expert consensus, the evidence for strategies for treatment and prevention of mediatinitis is reviewed in detail aiming at reducing the incidence and optimizing the management of this serious condition.