Our experience with robotic-assisted thymic surgery.

Thoracic surgery is increasingly influenced by the development of minimally invasive approaches which have also influenced surgery in the area of the anterior mediastinum. The previously standard approach to the thymus via partial sternotomy was gradually replaced by the videothoracoscopic approach in most cases. In recent years, robotically assisted surgery has been gaining ground worldwide in this area, as well. The aim of our paper is to provide a comprehensive overview of procedures in the field of the thymus, including their indications, and to share our first experience with robot-assisted thymus surgery. At the 3rd Department of Surgery, since the start of the robot-assisted thymus surgery program, 23 thymectomies have been performed using this approach, of which 17 were performed for thymoma, 3 for myasthenia gravis, and 3 for parathyroid adenoma localized in thymus tissue. From our experience and the available data, it follows that the length of hospitalization, the rate of complications and the resulting effect of robot-assisted procedures is comparable to VTS procedures; however, the robot-assisted surgery also allows for mini-invasive treatment even in significantly obese patients and in patients with advanced thymic tumors who would otherwise be indicated for open thymectomy.

Robotic pulmonary segmentectomy, initial experience in the Czech Republic.

INTRODUCTION: The initiation of lung cancer screening in Czechia and diagnosis in earlier stages has been reflected by an increasing demand for anatomical lung segmentectomy. The purpose of this study was to describe early results of the first robotic-assisted thoracoscopic segmentectomies performed in the country. METHODS: Our institution has performed 151 robotic anatomical lung resections since the initiation of the screening program in August 2020, which enabled us to attain the status of a proctoring and case observation centre. The robotic segmentectomy program was initiated after completing 70 robotic lobectomies. We performed a retrospective analysis of the results of our first 20 patients indicated for robotic segmentectomy. RESULTS: Median age of the patients was 60, with 11 females and 7 males. The most common indications included primary lung malignancy (n=13), pulmonary metastasis (n=2) and benign lesions (n=3). We performed 11 simple segmentectomies, 6 complex (S2, S3, S1a+2, S10 on the right) and one right S6 segmentectomy with bronchoplasty. The mean number of harvested lymph nodes for NSCLC was 20, the mean blood loss was 25 mL (from 10 mL to 100 mL), and the mean operative time was 200 minutes. All resection margins were tumour-free. There was no conversion to thoracotomy. Two patients were excluded as they required conversion to robotic lobectomy given that their lesions were localized close to the intersegmental plane. One complication (recurrent laryngeal nerve paralysis) occurred in 1 patient. Mean chest tube duration was 1.9 days and length of stay 3.9 days. CONCLUSION: Our experience suggests that implementation of the robotic segmentectomy program after completion of the robotic learning curve provides promising outcomes. Robotic technology and preoperative planning facilitate this technically demanding procedure especially when bronchoplasty is required.

Biportal robotic pulmonary lobectomy, initial experience - case report.

INTRODUCTION: Thanks to perfect visualization and high maneuverability of instruments, the robotic technique is a preferable type of lung resection, even though the number of required incisions is usually higher compared to the video-assisted approach. This case report presents our initial experience with the reduced-port approach in performing robotic biportal lobectomy. CASE REPORT: The 72-years-old female, examined for hemoptysis, was diagnosed with a carcinoid tumor of the left lower lobe bronchus based on bronchoscopy. The patient underwent a biportal fully robotic left lower lobectomy. The time of operation was 235 minutes, longer compared to the average time of multiportal procedures, i.e. 190±52 minutes, and the blood loss of 100 mL was higher compared to 43±54 mL. The patient was discharged without complications on the third postoperative day. Histological analysis confirmed the diagnosis of a typical carcinoid with tumor free margins and seven tumor free lymph nodes. The patient continues to be followed at the Department of Pneumology, showing no signs of disease recurrence for eight months. CONCLUSION: The robotic biportal approach offers a reduction in chest wall traumatization while maintaining oncological radicality. Although this approach is safe and feasible, limitations in instrument movements necessitate specific training.

Video-assisted and robotic-assisted thoracoscopic pulmonary lobectomies, our experience.

INTRODUCTION: The use of video-assisted (VATS) and robotic-assisted (RATS) thoracoscopic surgery for anatomical pulmonary resections has been rapidly increasing. This study aimed to analyze our results of minimal invasive lobectomies to safely introduce these techniques to our practice. METHODS: Starting these new programs we followed the recommended steps including case observations and a proctoring. We retrospectively analyzed the data of our 7-year experience with VATS lobectomies and 1-year experience with RATS lobectomies. RESULTS: 128 minimal invasive lobectomies were performed between 4/2015 and 4/2021 in our center. The mean age of our patients was 64.7±10.5 years; 61 (47.7%) were women and 67 (52.3%) were men. Pulmonary malignancy was the main indication in 116 (90.6%) patients, including 2 patients with localized small cell lung cancer (SCLC). In 12 (9.4%) cases we operated for bronchiectasis and benign lung lesions. Stage I lung cancer was found in 57 (66.3%), stage II in 22 (25.6%) and stage III in 7 (8.1%) patients. We performed 110 VATS and 18 RATS lobectomies with a clear shift from triportal VATS to uniportal VATS and RATS in the last years. The mean operative time was 166±55.5 minutes and a conversion was approached in 8 (6.2%) cases (4 bleedings - less than 300 ml in all cases, 3 oncological cases, 1 case for a technical reason). The median postoperative length of stay was 4 days. CONCLUSION: VATS and RATS lobectomy has become a standard approach for early stages of lung cancer. Respecting the rules of introducing VATS and RATS including proctoring offers safety without any negative impact on survival or oncological radicality.

Treatment of anastomotic leak after Ivor Lewis esophagectomy.

INTRODUCTION: Anastomotic leak (AL) is one of the most serious surgical complications after esophagectomy. Endoscopic, radiological and surgical methods are used in the treatment of AL. The aim of this study was to retrospectively evaluate our therapeutic procedures and results of AL treatment after Ivor Lewis esophagectomy (ILE). METHODS: Retrospective audit of all ILEs performed in the years 20052019. Evaluation of AL treatment results according to Esophagectomy Complication Consensus Group (ECCG) classification and according to the primary therapeutic procedure with a focus on the treatment with esophageal stent. RESULTS: Out of 817 patients with ILE, AL was detected in 80 patients (9.8%): ECCG type I 33 (41%), type II 23 (29%) and type III 24 (30%) patients. Some 33 patients (41%) were treated conservatively. Esophageal stents were used in 39 patients (49%), of which 18 (23%) had concomitant percutaneous drainage and 17 (21%) were reoperated. Reoperation without a stent insertion was performed in 7 patients (9%). Esophageal diversion with cervical esophagostomy was performed in a total of 16 patients (20%). Esophageal stent treatment was successful in 24/39 patients (62%). Airway fistula occurred in 4 patients treated with stent (10%). Endoscopic vacuum therapy was successfully used in three patients after stent failure. Eight patients (10%) died as a result of AL. Mortality of AL type I, II and III was 0%, 4% and 29%. CONCLUSION: Successful treatment of AL requires an individual and multidisciplinary approach. The primary effort should aim to preserve anastomosis using endoscopic and radiological methods. In case of insufficient clinical effect, we recommend not to hesitate with reoperation. If primary therapy fails, the life-saving procedure is a cervical esophagostomy.

[Pulmonary contusion]. / Plicní kontuze.

Pulmonary contusion is a common finding after blunt chest trauma. It occurs in 23-35% of all cases. Alveolar capillaries are injured due to the trauma, which results in accumulation of blood and other fluids within lung tissue. The fluids interfere with gas exchange, leading to hypoxemia. The consequences of pulmonary contusion include ventilation/perfusion mismatching, increased AV shunts and loss of compliance of lung parenchyma. These physiological consequences are manifested within hours from injury and usually resolve in 7 days. Computed tomography (CT) is a sensitive and main diagnostic tool. Clinical symptoms include hypoxemia and hypercapnia, manifested predominantly during 72 hours from injury. Patients are treated primarily conservatively; surgery may be needed due to haemothorax associated with lung contusion or progression of AV shunts due to localized pulmonary contusion.Key words: pulmonary contusion blunt chest trauma computed tomography.

[Ruptures of the diaphragm]. / Ruptury bránice.

INTRODUCTION: The diaphragm is a flat muscle that divides the thoracic and abdominal cavities, and it is one of the most important muscles involved in respiration. Traumas of the diaphragm include its rupture caused by an external force, resulting in blunt or penetrating injuries. Diaphragmatic rupture is associated with the risk of a prolapse (i.e. not a typical hernia) of abdominal organs into the pleural cavity. The rupture may occur due to a blunt injury of the chest or abdomen, or due to penetrating injuries (gunshots, stab wounds, foreign bodies) in the lower part of the chest and epigastrium. Ruptures never heal spontaneously and always require suture of the diaphragmatic defect. Most acute rupture cases are managed using laparotomy; thoracotomy is preferred for lately recognised ruptures to facilitate the removal of adhesions in the thoracic cavity developed between the diaphragmatic defect and a lung. Thirty one patients with diaphragmatic rupture were operated at the 3rd Department of Surgery of the 1st Faculty of Medicine, Charles University and University Hospital Motol between 2006 and 2016. Acute rupture was present in 60% of the cases and chronic in 40%. Right-sided rupture was found in 20% and left-sided in 80%. CONCLUSION: The authors describe surgical treatment of diaphragmatic ruptures. They recommend an early surgical treatment if diaphragmatic rupture is recognized. Generally, the prognosis of the patients depends on availability of professional health care; ideally, these patients should be treated at specialised traumacentres with specialists for abdominal and thoracic surgery. The authors advise against establishing injudicious thoracic drainage in cases where diaphragmatic rupture with herniation of abdominal organs into the thorax may be present.Key words: polytrauma - acute rupture of diaphragm - chronic rupture - suture - patch.

[Surprising findings during thoracic revision due to gunshot injury - a case report]. / Prekvapivý nález pri revizi hrudníku pro strelné poranení - kazuistika.

INTRODUCTION: Gunshot thoracic injuries are not very common in our geographical location, occurring most frequently in the context of criminal activity or as a result of suicidal behavior. CASE REPORT: The authors report the case of a patient who, in a suicidal attempt, caused himself a combined penetrating gunshot injury of the chest with laceration of the lung and a heart gunshot hole, which was diagnosed peroperatively. CONCLUSION: Therapy of gunshot injuries in the era of modern medicine should be comprehensive in multidisciplinary cooperation.Key words: thoracic trauma gunshot injury lung injury heart injury thoracotomy.

[The role of rotational thromboelastometry (ROTEM) in the perioperative period in a warfarinized patient (case report)]. / Význam rotacnej tromboelastometrie (ROTEM) v perioperacnom období u warfarinizovaného pacienta.

UNLABELLED: Warfarin overdose with unmeasurable values of the prothrombin time (PT-INR) is a significant problem in the preoperative preparation of the patient for acute invasive surgery. In contrast to conventional blood clotting assays, rotational thromboelastometry (ROTEM) evaluates the coagulation profile of the whole blood and provides a more complex view of the coagulation status of the patient. Thromboelastometry results are available within about 10 minutes and help us to provide targeted "bedside" therapy of coagulopathy in a bleeding patient. In our case report we describe a case of a patient with warfarin overdose and unmeasurable PT-INR values. The patient was indicated for urgent gastroscopy because of haematemesis and abdominal surgery because of ileus. Haematemesis was stopped by ROTEM targeted treatment of coagulopathy and the operation was performed without bleeding complications with normal ROTEM despite the prolongation of PT-INR to 1.8. Finally, we would like to say that ROTEM method can be used for rapid management of warfarin-induced coagulopathy and that surgery may be performed safely without any correction of PT-INR in case of normal ROTEM. KEY WORDS: prothrombin time - bleeding - surgery thromboelastometry (ROTEM) warfarin.

[Development of tracheal resection technique - our experience]. / Vývoj techniky resekcí trachey - nase zkusenosti.

INTRODUCTION: Tracheal resections are very frequent interventions on the trachea in general. In borderline cases where the tracheal resection length is too high, the situation can be resolved by inserting a stent or Montgomerys T cannula. Tracheal stenoses are of benign origin in 94%, and malignant in 6% of cases. We present a summary of tracheal resection interventions for the last 21 years. METHOD: 235 tracheal resections were performed at the authors institution in 1993-2013. In total 221 benign stenosis cases (85 % developed after tracheostomy, 15% developed after intubation) and 14 malignant cases were treated. The patients were divided into two groups: A resection in years 19932002 and B - resection in years 20032013. The comparison of these two time periods is presented with focus on surgical procedures development and recommendations based on experienced complications. RESULTS: Restenosis (early or late) is the most common complication during the process of tracheal resection treatment. Tiny fistulas in the suture can be diagnosed easily by minor air leaking and are treated conservatively without intervention. Fortunately, suture insufficiency is relatively rare. In some cases the restenoses can be resected or treated by stent application or by Montgomerys T-cannula application. Complications were observed in 2% of the treated patients, which is a number presented also by international studies. CONCLUSION: Tracheal resection is definitely an optimal solution for patients suffering from tracheal stenosis. As presented in our study, in the hands of experienced thoracic surgeons tracheal resections is a safe and final solution of tracheal stenosis. KEY WORDS: trachea - stenosis resection.

Long-term outcomes and prognostic factors of patients with pulmonary carcinoid tumors.

The aim of the study was to evaluate type of surgery, long-term survival and factors influencing outcome of pulmonary carcinoid tumors. We reviewed our database of 137 patients surgically treated for typical or atypical carcinoid tumors at our department between 1998 and 2013. There were 95 (69%) patients with typical carcinoid (87 N0, 6 N1, 2 N2) and 42 (31%) with atypical carcinoid (26 N0, 8 N1, 8 N2). Patients with atypical carcinoid were older than those with typical carcinoid (median age of 57±8.1 and 50.5±15.8 years, respectively, p<0.00001). The resection performed consisted of 6 (4.4%) pneumonectomies, 110 (80.1%) lobectomies and bilobectomies, 15 (11%) sleeve lobectomies, 2 (1.5%) resections of main bronchus and 4 (3%) wedge resections. Overall 5- and 10-year survival rates for different tumors were as follows: typical carcinoid: 97.2% and 89.9%, respectively; atypical carcinoid 71.1% and 62.2%, respectively. Statistical analyses indicated that histology (typical carcinoid, p<0.00001), age (less than 45 years, p=0.004) and nodal status (N0, p=0.0002) were significant prognostic factors for better prognosis. Histological sub-type and nodal involvement appear as the most important factors influencing the prognosis. Systemic lymphadenectomy is recommended and should always be performed.

Pneumonectomy for non-small cell lung cancer: predictors of early mortality and morbidity.

BACKGROUND: The aim of this study was to determine independent risk factors affecting postoperative morbidity and mortality after pneumonectomy for non-small cell lung cancer (NSCLC). METHODS: A review of 329 patients having pneumonectomy for NSCLC between January 1, 1998 and July 31,2012 was undertaken. Factors affecting morbidity and mortality were analyzed by univariate and multivariate analyses. RESULTS: The overall 30-day mortality rate was 5.1%. Smoking habits, chronic obstructive pulmonary disease (COPD) status, neoadjuvant therapy and obesity had no statistical influence on the short-term outcome. Coronary artery disease and respiratory failure were identified as risk factors for increased 30-day mortality (p < 0.01). Right pneumonectomy and presence of respiratory failure with mechanical ventilation increased the incidence of bronchopleural fistula (p < 0.01). CONCLUSIONS: Pneumonectomy for NSCLC carries an acceptable operative morbidity and mortality. Coronary artery disease, right pneumonectomy and respiratory failure adversely affect morbidity and mortality after this procedure.

[Timeline trends in surgery of bronchogenic carcinoma]. / Casové trendy chirurgické terapie bronchogenního karcinomu.

BACKGROUND: The aim of our study was to determine how patient preoperative status and outcomes of resection have changed over last 12 years. MATERIAL AND METHODS: This retrospective study of prospective database included 1412 patients operated from January 1,1998 through December 31,2009. Patient characteristics and outcomes were compared for two time periods (1998-2003 and 2004-2009). RESULTS: We performed 985 lobectomies with 30-days mortality 1.8% and 300 pneumonectomies with 30-days mortality 5.7%. Median of survival of all 1412 patients was 4.3 year and 5-year survival was 45%. The percentage of female patients, lobectomies and adenocarcinoma increased over time, as well as age of our patients. Outcome improved over time, with significant decrease in 30-days mortality after pneumonectomy (8.2% vs. 2.3%, p = 0.029). The overall 3-year survival improved in patients with III. stage (30 % vs. 40%, p = 0.012). CONCLUSION: Our study identified time trends which are in-line with increased incidence of lung cancer among women and with improvement of preoperative evaluation, preoperative and postoperative care

Risk factor analysis for early mortality and morbidity following pneumonectomy for non-small cell lung cancer.

OBJECTIVES: The purpose of this report is to analyze factors affecting morbidity and mortality following pneumonectomy for non-small cell lung cancer (NSCLC). METHODS: We reviewed our institutional experience with all consecutive patients undergoing pneumonectomy for NSCLC from 1998 to 2010. Patients were analyzed with regard to hospital mortality and morbidity and long-term outcome. RESULTS: There were 310 patients following pneumonectomy. Overall 30-day mortality rate was 5.5 %. Chronic obstructive pulmonary disease, induction therapy, smoking habits and obesity had no statistical influence on short-term outcome. Coronary artery disease and respiratory failure were identified as risk factors for increased 30-day mortality (p<0.01). Right pneumonectomy and presence of respiratory failure with mechanical ventilation increases the incidence of bronchopleural fistula (p<0.01). CONCLUSIONS: Patients with right pneumonectomies are at increased risk. Coronary artery disease and respiratory failure adversely affect morbidity and mortality after this procedure (Tab. 3, Ref. 19). Full Text in free PDF www.bmj.sk.

Time trend in the surgical therapy of lung cancer.

BACKGROUND: The purpose of our study was to clarify results of surgery for non-small cell lung cancer (NSCLC) and its time trends. METHODS: We retrospectively reviewed our prospective database of patients who underwent surgery for NSCLC between 1998 and 2009 in our institution. Patients were divided into two equal 6-year periods according to the year of surgery (1998-2003 and 2004-2009). RESULTS: One thousand, four hundred and twelve patients underwent operation for NSCLC. We performed 985 lobectomies with 30-days mortality of 1.8 % and 300 pneumonectomies with 30-days mortality of 5.7 %. Median of survival of all 1412 patients was 4.3 year and 5-year survival was 45 %. The percentage of female patients, lobectomies and adenocarcinomas increased over time, as well as the age of our patients. Outcome improved over time, with significant decrease in a 30-days mortality after pneumonectomy (8.2 % vs 2.3 %, p=0.029). The overall 3-year survival improved in patients with stage III (30 % vs 40 %, p=0.012). CONCLUSION: Outcomes of lung resection for NSCLC improved over time despite a worsening of some elements of preoperative status. The shift in histological distribution was associated with an increasing proportion of patients with stage I, a lower operative mortality and better 3- and 5-year survival. These trends are due to improvement of preoperative evaluation, preoperative and postoperative care (Tab. 1, Fig. 2, Ref. 9). Full Text in free PDF www.bmj.sk.

[Lung transplantation]. / Transplantace plic.

Lung transplantation is an effective life-saving therapy for the treatment of a variety of end-stage lung diseases. However, the application of lung transplantation is hindered by multiple factors such as the shortage of organ donors, early graft failure, infection, and chronic graft dysfunction. A novel strategy for donor lung preservation--ex-vivo lung perfusion (EVLP)--that keeps the organ at physiological protective conditions, has shown great promise to increase lung utilization by reassessing, treating, and repairing injured donor lungs prior to transplantation. Infections are a major cause of early morbidity and mortality after lung transplantation. Because of the potential association of infections such as respiratory viral infections and gram-negative bacterial infections with bronchiolitis obliterans syndrome, prompt attention to these pathogens is critical. Despite marked improvements in early survival, long-term outcome after lung transplantation is still threatened by bronchiolitis obliterans syndrome. The program of lung transplantation in Czech Republic was started in University Hospital Motol in Prague in 1997. Nowadays in Czech Republic is performed about 20 transplants every year with results comparable to other advanced centers. Until September 2011, 175 transplants were carried out in Czech Republic.

[Esophageal perforation]. / Perforace jícnu.

OBJECTIVE: Evaluation of patients with acute esophageal perforations with single institution experience. MATERIAL AND METHODS: The authors evaluate the set of 64 consecutive patients with esophageal perforation treated in our department between January 2000 and December 2010. In all patients were before decision making performed CT scans and X-ray examination with contrast agent administration. For selected patients was also accompanied upper endoscopy. Excluded were patients with malignant tracheoesophageal fistula and patients with perforation of malignant stenosis treated with palliative intent. RESULTS: The mean age was 62 years (range 24-90), of which one third (34.4%) were aged 70 years or more. We received the iatrogenic perforation in 45 (70%) patients, less than one quarter (n = 15; 23%) consisted of spontaneous perforation, in three patients we have failed to determine the cause of perforation (5%) and one patient experienced perforation during removal of foreign body. Perforation of the thoracic esophagus in 41 patients, in 20 (31%) cases in the upper and middle third and 21 (33%) in the distal third of the thoracic esophagus. Cervical perforation was noted in 14 patients (22%) and abdominal of the 9 patients (14%). 92% of patients were treated surgically (n = 59). 43% (n = 27) were treated by primary suture of the perforation, esophageal resection with primary reconstruction was performed in 4 patients, esophagectomy with terminal esophagostomy and nutritional jejunostomy in 7 patients, 4 patients were treated by surgical drainage and only 7 patients, we introduced endless lavage. In 9 cases we have resected affected portion of esophagus with stapler closure in the chest. Conservative management of esophageal perforation we proceeded in 5 patients in whom a stent was introduced and the perforation successfully healed. Overall mortality in our set of patients is 23.4%. CONCLUSION: Conservative procedure in carefully selected patients could be an alternative to radical and inherently surgical procedures. Published results and our little experience are encouraging, but this topic is still under study.

[Impact of neoadjuvant chemotherapy on postoperative complications following pneumonectomy]. / Vliv neoadjuvantní terapie na pooperacní komplikace po pneumonektomii.

BACKGROUND: The risks of complications in patients undergoing pneumonectomy after preoperative chemotherapy for nonsmall cell lung cancer remain controversial. We reviewed a consecutive series of patients having undergone pneumonectomy in a single centre. MATERIAL AND METHODS: This retrospective study included 292 patients operated from January 1, 1998 through December 31, 2008. Group 1 included patients those who received preoperative chemotherapy and pneumonectmy (57 patients, 19%), and group 2 included patients who underwent pneumonectomy alone (235 patients, 81%). The main objectives were 30-day and 90-day mortality rates, and major postoperative complications. RESULTS: There was no statistically significant difference in patients' age, gender, cardiovascular co morbidity, histology and side of pneumonectomy between these two groups. Overall 30-days and 90-days mortality rates were 5.5 % and 8.6%, respectively. Postoperative mortality at 30 days was 5.2% in group 1 and 5.6 % in group 2 (p = 0.16), and 10.5% for group 1 and 8.1% in group 2 at 90 days (p = 0.8). Incidence of empyema was 5.2% in group 1 and 3.0% in group 2 (p = 0.12); incidence of bronchopleural fistula was 3.5 % in group 1 and 3.0% in group 2 (p = 0.10); incidence of postoperative respiratory failure was 3.4% in group 1 and 3.0% in group 2 (p = 0.75). CONCLUSION: Preoperative chemotherapy does not significantly increase postoperative morbidity and early mortality after pneumonectomy in our experience.

[Disadvantages of unilateral videothoracoscopic thymectomy]. / Nevýhody jednostranné videotorakoskopické tymektomie.

The authors highlight disadvantages of the unilateral videothoracic approach in thymectomy procedures. They present a case-review of a young female patient, indicated for the procedure for myastenia gravis. In these patients, the primary objective is to remove all the thymus tissue and the surrounding adipose tissue within the anterior mediastinum, which, using the above approach cannot always be guaranteed. Considering the number of patients indicated for the procedure based on the above diagnosis, it is inevitable to perform the procedures in specialized centres, experienced with these conditions.

Predisposing factors of atelectasis following pulmonary lobectomy.

BACKGROUND: The aims of our study were to investigate postoperative atelectasis complicating pulmonary lobectomy, identify risk factors and evaluate its relationship to other postoperative complications. MATERIAL AND METHODS: From January 2004 to April 2007, 412 patients underwent pulmonary lobectomy. We performed a retrospective analysis of our prospective database. Post-lobectomy atelectasis (PLA) was defined as an ipsilateral opacification of the remaining lobe with an ipsilateral shift of the mediastinum on the chest radiography, requiring bronchoscopy. RESULTS: The incidence of PLA was 6.6%, comprising 29% of all postoperative pulmonary complications seen. There was no statistically significant difference in patient age, gender, ASA score, cardiovascular co-morbidity or operation time for the PLA group versus the group without this complication. Current smokers were at a higher risk for PLA, but this incidence did not reach statistical significance. Chronic obstructive pulmonary disease (COPD) was the only preoperative variable increasing the risk of PLA (p < 0.05). Patients undergoing a right upper lobectomy, either on its own or in combination with a right middle lobe resection, had a significantly higher incidence of PLA when compared with all other types of resection (p < 0.05). CONCLUSIONS: Patients with COPD and those undergoing right upper lobe resection have an increased risk of PLA. In this group of patients we should use pre-operative (cessation of cigarette smoking, treatment of airflow obstruction in patients with COPD), intra-operative (duration of operation) and postoperative (intensive physiotherapy and effective postoperative pain control) measures to decrease the risk of PLA. Although often solitary, PLA is associated with a longer hospital stay.