Artificial intelligence (AI)-assisted chest computer tomography (CT) insights: a study on intensive care unit (ICU) admittance trends in 78 coronavirus disease 2019 (COVID-19) patients.

Background: The global coronavirus disease 2019 (COVID-19) pandemic has posed substantial challenges for healthcare systems, notably the increased demand for chest computed tomography (CT) scans, which lack automated analysis. Our study addresses this by utilizing artificial intelligence-supported automated computer analysis to investigate lung involvement distribution and extent in COVID-19 patients. Additionally, we explore the association between lung involvement and intensive care unit (ICU) admission, while also comparing computer analysis performance with expert radiologists' assessments. Methods: A total of 81 patients from an open-source COVID database with confirmed COVID-19 infection were included in the study. Three patients were excluded. Lung involvement was assessed in 78 patients using CT scans, and the extent of infiltration and collapse was quantified across various lung lobes and regions. The associations between lung involvement and ICU admission were analysed. Additionally, the computer analysis of COVID-19 involvement was compared against a human rating provided by radiological experts. Results: The results showed a higher degree of infiltration and collapse in the lower lobes compared to the upper lobes (P<0.05). No significant difference was detected in the COVID-19-related involvement of the left and right lower lobes. The right middle lobe demonstrated lower involvement compared to the right lower lobes (P<0.05). When examining the regions, significantly more COVID-19 involvement was found when comparing the posterior vs. the anterior halves and the lower vs. the upper half of the lungs. Patients, who required ICU admission during their treatment exhibited significantly higher COVID-19 involvement in their lung parenchyma according to computer analysis, compared to patients who remained in general wards. Patients with more than 40% COVID-19 involvement were almost exclusively treated in intensive care. A high correlation was observed between computer detection of COVID-19 affections and the rating by radiological experts. Conclusions: The findings suggest that the extent of lung involvement, particularly in the lower lobes, dorsal lungs, and lower half of the lungs, may be associated with the need for ICU admission in patients with COVID-19. Computer analysis showed a high correlation with expert rating, highlighting its potential utility in clinical settings for assessing lung involvement. This information may help guide clinical decision-making and resource allocation during ongoing or future pandemics. Further studies with larger sample sizes are warranted to validate these findings.

From Voxels to Prognosis: AI-Driven Quantitative Chest CT Analysis Forecasts ICU Requirements in 78 COVID-19 Cases.

Background: The aim of the current study was to investigate the distribution and extent of lung involvement in patients with COVID-19 with AI-supported, automated computer analysis and to assess the relationship between lung involvement and the need for intensive care unit (ICU) admission. A secondary aim was to compare the performance of computer analysis with the judgment of radiological experts. Methods: A total of 81 patients from an open-source COVID database with confirmed COVID-19 infection were included in the study. Three patients were excluded. Lung involvement was assessed in 78 patients using computed tomography (CT) scans, and the extent of infiltration and collapse was quantified across various lung lobes and regions. The associations between lung involvement and ICU admission were analyzed. Additionally, the computer analysis of COVID-19 involvement was compared against a human rating provided by radiological experts. Results: The results showed a higher degree of infiltration and collapse in the lower lobes compared to the upper lobes (p < 0.05) No significant difference was detected in the COVID-19-related involvement of the left and right lower lobes. The right middle lobe demonstrated lower involvement compared to the right lower lobes (p < 0.05). When examining the regions, significantly more COVID-19 involvement was found when comparing the posterior vs. the anterior halves of the lungs and the lower vs. the upper half of the lungs. Patients, who required ICU admission during their treatment exhibited significantly higher COVID-19 involvement in their lung parenchyma according to computer analysis, compared to patients who remained in general wards. Patients with more than 40% COVID-19 involvement were almost exclusively treated in intensive care. A high correlation was observed between computer detection of COVID-19 affections and expert rating by radiological experts. Conclusion: The findings suggest that the extent of lung involvement, particularly in the lower lobes, dorsal lungs, and lower half of the lungs, may be associated with the need for ICU admission in patients with COVID-19. Computer analysis showed a high correlation with expert rating, highlighting its potential utility in clinical settings for assessing lung involvement. This information may help guide clinical decision-making and resource allocation during ongoing or future pandemics. Further studies with larger sample sizes are warranted to validate these findings.

Extended resection for potentially operable patients with stage III non-small cell lung cancer after induction treatment.

OBJECTIVE: Surgical treatment of locally advanced non-small cell lung cancer including single or multilevel N2 remains a matter of debate. Several trials demonstrate that selected patients benefit from surgery if R0 resection is achieved. We aimed to assess resectability and outcome of patients with locally advanced clinical T3/T4 (American Joint Committee on Cancer 8th edition) tumors after induction treatment followed by surgery in a pooled analysis of 3 prospective multicenter trials. METHODS: A total of 197 patients with T3/T4 non-small cell lung cancer of 368 patients with stage III non-small cell lung cancer enrolled in the Swiss Group for Clinical Cancer Research 16/96, 16/00, 16/01 trials were treated with induction chemotherapy or chemoradiation therapy followed by surgery, including extended resections. Univariable and multivariable analyses were applied for analysis of outcome parameters. RESULTS: Patients' median age was 60 years, and 67% were male. A total of 38 of 197 patients were not resected for technical (81%) or medical (19%) reasons. A total of 159 resections including 36 extended resections were performed with an 80% R0 and 13.2% pathological complete response rate. The 30- and 90-day mortality were 3% and 7%, respectively, without a difference for extended resections. Morbidity was 32% with the majority (70%) of minor grading complications. The 3-, 5-, and 10-year overall survivals for extended resections were 61% (95% confidence interval, 43-75), 44% (95% confidence interval, 27-59), and 29.5% (95% confidence interval, 13-48), respectively. R0 resection was associated with improved overall survival (hazard ratio, 0.41; P < .001), but pretreatment N2 extension (177/197) showed no impact on overall survival. CONCLUSIONS: Surgery after induction treatment for advanced T3/T4 stage including single and multiple pretreatment N2 disease resulted in 80% R0 resection rate and 7% 90-day mortality. Favorable overall survival for extended and not extended resection was demonstrated to be independent of pretreatment N status.

Surgical Outcomes After Neoadjuvant Chemoradiation Followed by Curative Surgery in Patients With Esophageal Cancer: An Intergroup Phase III Trial of the Swiss Group for Clinical Cancer Research (SAKK 75/08).

OBJECTIVE: To assess the impact of surgical technique in regard to morbidity and mortality after neoadjuvant treatment for esophageal cancer. BACKGROUND: The SAKK trial 75/08 was a multicenter phase III trial (NCT01107639) comparing induction chemotherapy followed by chemoradiation and surgery in patients with locally advanced esophageal cancer. METHODS: Patients in the control arm received induction chemotherapy with cisplatin and docetaxel, followed by concomitant chemoradiation therapy with cisplatin, docetaxel, and 45Gy. In the experimental arm, the same regimen was used with addition of cetuximab. After completion of neoadjuvant treatment, patients underwent esophagectomy. The experimental arm received adjuvant cetuximab. Surgical outcomes and complications were prospectively recorded and analyzed. RESULTS: Total of 259 patients underwent esophagectomy. Overall complication rate was 56% and reoperation rate was 15% with no difference in complication rates for transthoracic versus transhiatal resections (56% vs 54%, P = 0.77), nor for video assisted thoracic surgeries (VATS) versus open transthoracic resections (67% vs 55%, P = 0.32). There was a trend to higher overall complication rates in squamous cell carcinoma versus adenocarcinoma (65% vs 51%, P = 0.035), and a significant difference in ARDS in squamous cell carcinoma with 14% versus 2% in adenocarcinoma (P = 0.0002). For patients with involved lymph nodes, a lymph node ratio of ≥0.1 was an independent predictor of PFS (HR 2.5, P = 0.01) and OS (HR 2.2, P = 0.03). CONCLUSIONS: This trial showed no difference in surgical complication rates between transthoracic and transhiatal resections. For patients with involved lymph nodes, lymph node ratio was an independent predictor of progression free survival and overall survival.

Pathologic femur fractures following surgery and radiotherapy for soft tissue sarcomas: A case series.

INTRODUCTION: Combined limb-sparing surgery and radiation therapy are considered the standard of care for higher grade soft tissue sarcomas (STS) of the extremities. The risk of post-radiation fracture after this treatment modality is well known, but still underestimated, and can end in serious long-term secondary problems years later. PRESENTATION OF CASE: We reviewed the records of three patients with pathological femur fractures years after wide local excision of an STS of the proximal lower extremity. All patients received more than 50 Gy (Gy) to the entire femur circumference. During surgery, all patients had bone exposure, and in two patients with stripping of the periosteum. The median time from surgery to fracture was 116 months (range from 84 to 156 months). The median age at the time of diagnosis was 66 years old. Despite standard operative fracture treatment, all three patients developed a non-union. One patient later died due to uncontrolled pulmonary metastasis independent from the femoral non-union. In the second case, an exarticulation at hip level due to an uncontrolled infected non-union had to be performed. The third patient finally achieved fracture union after two years of treatment. DISCUSSION: Our study confirms the high occurrence rate of postoperative complications and difficulties one encounters in treating these pathologic fractures. Only in one patient, following several revisions with intramedullary nailing, the fracture healed. In pathologic femur shaft fractures we recommend a minimal invasive procedure using intramedullary nailing devices. CONCLUSION: The risk of pathological fractures at the former treatment site is high, even years later. The rate of non-unions after a difficult fracture treatment in this particular clinical situation seems to be very high and may be associated with severe complications.

Stage III N2 non-small cell lung cancer treatment: decision-making among surgeons and radiation oncologists.

BACKGROUND: Stage III N2 non-small cell lung cancer (NSCLC) is a very heterogeneous disease associated with a poor prognosis. A number of therapeutic options are available for patients with Stage III N2 NSCLC, including surgery [with neoadjuvant or adjuvant chemotherapy (CTx)/neoadjuvant chemoradiotherapy (CRT)] or CRT potentially followed by adjuvant immunotherapy. We have no clear evidence demonstrating a significant survival benefit for either of these approaches, the selection between treatments is not always straightforward and can come down to physician and patient preference. The very heterogeneous definition of resectability of N2 disease makes the decision-making process even more complex. METHODS: We evaluated the treatment strategies for preoperatively diagnosed stage III cN2 NSCLC among Swiss thoracic surgeons and radiation oncologists. Treatment strategies were converted into decision trees and analysed for consensus and discrepancies. We analysed factors relevant to decision-making within these recommendations. RESULTS: For resectable "non-bulky" mediastinal lymph node involvement, there was a trend towards surgery. Numerous participants recommend a surgical approach outside existing guidelines as long as the disease was resectable, even in multilevel N2. With increasing extent of mediastinal nodal disease, multimodal treatment based on radiotherapy was more common. CONCLUSIONS: Both, surgery- or radiotherapy-based treatment regimens are feasible options in the management of Stage III N2 NSCLC. The different opinions reflected in the results of this manuscript reinforce the importance of a multidisciplinary setting and the importance of shared decision-making with the patient.

Recurrence Patterns and Long-term Results After Induction Chemotherapy, Chemoradiotherapy, and Curative Surgery in Patients With Locally Advanced Esophageal Cancer.

OBJECTIVE: The long-term follow up data of 2 prospective phase II trials is reported (NCT00072033, NCT00445861), which investigated neoadjuvant chemoradiation followed by surgery in patients with esophageal carcinoma. Postoperative complications as well as prognostic factors and patterns of relapse during long-term observation are shown. SUMMARY OF BACKGROUND DATA: Long-term follow-up is often missing in the complex setting of multimodal treatments of esophageal carcinoma; this leads to rather undifferentiated follow-up guidelines for this tumor entity. METHODS: In the first trial, patients received induction chemotherapy followed by chemoradiation and surgery. In the second trial, cetuximab was added to the same neoadjuvant treatment concomitant with induction chemotherapy and chemoradiation. RESULTS: Eighty-two patients underwent surgery; the median follow-up time was 6.8 and 6.4 years, respectively. Fifty-five percent were diagnosed with adenocarcinoma, 80% clinically node-positive, 68% received transthoracic esophagectomy, and 32% transhiatal or transmediastinal resection. Five patients died postoperatively in-hospital due to complications (6%). The median overall survival was 4.3 years, and the median event-free survival was 2.7 years. Patients with adenocarcinoma rarely relapsed after a 3-year event-free survival. Whereas patients with residual tumor cells after neoadjuvant therapy primarily experienced relapse within the first 2 postoperative years, this in contrast to several patients with complete remission who also experienced late relapses 4 years after surgery. CONCLUSION: After curative surgery in a multimodal setting, the histological type and the response to neoadjuvant therapy predicted the time frame of relapse; this knowledge may influence further follow-up guidelines for esophageal carcinoma.

Postoperative morbidity of complete mesocolic excision and central vascular ligation in right colectomy: a retrospective comparative cohort study.

BACKGROUND: To investigate morbidity and mortality following complete mesocolic excision (CME) and central vascular ligation (CVL) in patients undergoing right colectomy. METHODS: Data from consecutive patients undergoing elective right colectomy at a university-affiliated referral centre were retrospectively analysed. Patients who underwent conventional right-sided colonic cancer surgery (January 2001-April 2009, n = 84) were compared to patients who underwent CME/CVL (May 2009-January 2015, n = 71). The primary end point was anastomotic leak. Secondary end points were delayed gastric emptying, severe respiratory failure, mortality and length of hospital stay. RESULTS: No significant difference was found in the rate of anastomotic leak (1.2% in the conventional versus 5.6% in the CME/CVL group, p = 0.108). Patients in the CME/CVL group had a higher 90-day mortality rate (7.0% versus 0.0%, p = 0.019). Four out of five deceased patients suffered from aspiration with consecutive respiratory failure. There was a tendency towards delayed gastric emptying in the CME/CVL group (12.7% versus 7.1%, p = 0.246). Clavien-Dindo complication grades ≥ 2 were similar in both groups with 16 (19%) in the conventional and 15 (21.1%) in the CME/CVL group (p = 0.747). CME/CVL patients had a shorter mean length of stay with 11 versus 14 days (p <  0.001). CONCLUSIONS: Complete mesocolic excision with central vascular ligation in right colectomy seems to have a higher aspiration rate leading to severe respiratory failure and to higher mortality compared to conventional resection methods. Patient selection for this procedure may therefore be crucial.

Operative Stabilization of Chest Wall Trauma: Single-Center Report of Initial Management and Long-Term Outcome.

BACKGROUND: Conservative treatment of even severe thoracic trauma including flail chest was traditionally the standard of care. Recently, we reported possible benefits of surgical chest wall stabilization in accordance with other groups. The aim of this study was to critically review our indications and results of internal fixation of rib fractures in the long-term course. METHODS: We retrospectively analyzed the data of a consecutive series of patients with internal rib fracture fixation at our institution from 8/2009 until 12/2014, and we retrospectively studied the late outcome through clinical examination or personal interview. RESULTS: From 1398 patients, 235 sustained a severe thoracic trauma (AIS ≥3). In 23 of these patients, 88 internal rib fixations were performed using the MatrixRIB® system. The median age of these operated patients was 56 years [interquartile range (IQR) 49-63] with a median ISS of 21 [IQR 16-29]. From 18 local resident patients, follow-up was obtained after an average time period of 27.6 (12-68) months. Most of these patients were free of pain and had no limitations in their daily routine. Out of all implants, 5 splint tips perforated the ribs in the postoperative course, but all patients remained clinically asymptomatic. Plate osteosynthesis showed no loss of reduction in the postoperative course. No cases of hardware prominence, wound infection or non-union occurred. CONCLUSIONS: In our carefully selected thoracic trauma patients, locked plate rib fixation seemed to be safe and beneficial not only in the early posttraumatic course, but also after months and years, patients remain asymptomatic and complete recovery as a rule. Trial registration number KEK BASEC Nr. 2016-01679.

Tutorial Assistance for Board Certification in Surgery: Frequency, Associated Time and Cost.

BACKGROUND: Tutorial assistance is related to extra time and cost, and the hospitals' financial compensation for this activity is under debate. We therefore aimed at quantifying the extra time and resulting cost required to train one surgical resident in the operating theatre for board certification in Switzerland as an example of a training curriculum involving several surgical subspecialties. Additionally, we intended to quantify the percentage of tutorial assistance. METHODS: We analysed 200,700 operations carried out between 2008 and 2012. Median duration of procedure categories was calculated according to four different seniority levels. The extra time if the procedure was performed by residents, and resulting cost were analysed. The percentage of procedures carried out by residents as compared to more experienced surgeons was assessed over time. RESULTS: On average, residents performed about a third of all operations including typical teaching procedures like appendectomies. An increase in duration and cost of well-defined procedures categories, e.g. cholecystectomies was demonstrated if a resident performed the procedure. In less well-defined categories, residents seemed to perform less difficult procedures than senior consultants resulting in shorter durations of surgery. CONCLUSIONS: The financial impact of tutorial assistance is important, and solutions need to be found to compensate for this activity. The low percentage of procedures performed by trainees may make it difficult to fulfil requirements for board certification within a reasonable period of time. This should be addressed within the training curriculum.

Percutaneous transluminal angioplasty of infrainguinal vein graft stenosis is not a negative predictor for long-term patency.

BACKGROUND: To investigate whether maintenance percutaneous transluminal angioplasty (PTA) for significant stenosis after infrainguinal bypass grafting affects long-term patency of the bypass grafts in comparison to those not needing intervention. PATIENTS AND METHODS: The cohort includes 141 consecutive patients with 157 infrainguinal vein grafts performed from January 1996 to December 2005. Grafts occluded within three months after operation were excluded. Revascularisations needing maintenance PTA for significant stenoses of graft or adjacent in- or outflow vessels (intervention group, n = 39) were compared to those not needing intervention during follow up (non-intervention group, n = 118). Primary end point was bypass occlusion. Secondary end points were major amputation or death. Long-term patency in the intervention and non-intervention groups was estimated using Kaplan-Meier curves and compared using the Tarone-Ware test. RESULTS: In the intervention group, primary assisted patency rate after 36 and 60 months was 94.1 % and 89.4 %, respectively, whereas in the non-intervention group patency rate was 92.5 % and 91.0 %, respectively (p = 0.644). Comparing the intervention group to the non-intervention group, 1 versus 2 major amputations (p = 0.642) and 14 versus 40 deaths (p = 0.233) occurred. CONCLUSIONS: Occurrence of graft stenosis did not decrease long-term patency rate when treated by PTA in comparison to grafts not needing maintenance PTA.

[Pediatric supracondylar fractures of the humerus]. / Suprakondyläre Humerusfrakturen im Kindesalter.

Supracondylar fractures are on the of the most common injuries in paediatric patients. Therapeutic consequences depend on the one hand on the degree of the osseous displacement according to the Gartland classification. On the other hand, the diagnosis of concomitant neuro-vascular injuries is crucial to prevent long term impairment. Never the less, clinical diagnosis can be challenging. In-depth knowledge of pediatric supracondylar humerus fractures is a prerequisite to achieve a functionally and cosmetically satisfactory long-term outcome.

Interest in a national research network in surgery in Switzerland.

BACKGROUND: Networks are known to improve performance and create synergies. A research network can provide a significant advantage for all parties involved in research in surgery by systematically tracking the outcome of a huge number of patients over a long period of time. The aim of the present study was to investigate the experiences of surgeons with respect to research activities, to evaluate the opinions of surgeons with regard to the development of a national network for research in the field of surgery in Switzerland and to obtain data on how such a network should be designed. METHODS: An anonymous postal survey of board-certified surgeons practising in Switzerland was conducted during summer 2007. The questionnaire included questions related to research activities, the desire to develop a national research network and the design and potential advantages of such a network. Qualitative analyses were performed using Mayring's content analysis. RESULTS: A total of 337 out of 749 (45%) questionnaires were returned. In all, 156/337 (46.3%) surgeons were engaged in research activities. During the past five years, 212/337 (62.9%) of the participants had participated at least in one multi-centre study. Out of 337, 88 (26.1%) surgeons were members of an established research association in Switzerland. Interest in a national surgical research network was reported by 266 (78.9%) participants. The reported advantages were "power" (53.1%), "teamwork effects" (23.7%), "efficiency" (12.2%) and "quality aspects" (8.0%). The most frequently named design proposal was based on a clinic for coordinating research, while the younger participants also suggested a web-based platform. CONCLUSIONS: Due to the significant interest of participants, the establishment of a national research network should be considered. An established clinic for coordinating research alongside an additional web-based platform to target young surgeons could function as an umbrella organisation.

Spontaneous pneumothorax during chemotherapy: a case report.

BACKGROUND: Spontaneous pneumothorax (SP) associated with malignant disease is relatively infrequent but has important diagnostic and therapeutic implications. CASE REPORT: We describe a case of SP that occurred during chemotherapy with ifosfamide and doxorubicin in a patient with an advanced pleomorphic sarcoma. The pneumothorax developed secondary to the rapid regression of peripheral pulmonary metastases presumably resulting in bronchopleural fistula formation. After treatment with chest tube drainage, the patient recovered and chemotherapy could be continued without further complications. DISCUSSION: We discuss different pathophysiological mechanisms and the clinical context of SP in sarcoma patients and give an overview of the literature and different treatment options.

Arguments for and against a career in surgery: a qualitative analysis.

OBJECTIVE: To evaluate arguments given by board-certified surgeons in Switzerland for and against a career in surgery. BACKGROUND DATA: Currently, the surgical profession in most Western countries is experiencing a labor shortage because of a declining interest in a surgical career among new graduates, a changed public opinion of medicine and its representatives, and as a consequence of the increasing influence of health economists and politicians on the professional independence of surgeons. Reports that focus primarily on the reasons that board-certified surgeons remain within the surgical profession are rare. METHODS: Surgeons were asked to answer 2 questions concerning arguments for and against a career in surgery. Of 749 surgeons the arguments of 334 (44.6%) were analyzed using Mayring's content analysis. The surgeons were also asked whether they would choose medicine as a career path again. RESULTS: The 334 participating surgeons provided 790 statements for and 981 statements against a career in surgery. Fifty-nine surgeons (17.7%) would not choose medicine as a career again. Mayring's content analysis of the statements yielded 10 categories with arguments both for and against a career in surgery. "Personal Experience in Daily Professional Life" (18.7%) was the top-ranked category in favor of a career in surgery, and "Specific Training Conditions" (20%) was the top-ranked category against the choice of such a career. Ordinal logistic regression showed that the category "Personal Experience in Daily Professional Life" (OR, 2.39; 95%CI, 1.13-5.07) was independently associated with again studying medicine, and the category "Work-life Balance" (OR, 0.37; 95%CI, 0.20-0.70) was associated with not studying medicine again. CONCLUSION: This qualitative study revealed unfavorable working conditions and regulations as surgeons' main complaints. It is concluded that new organizational frameworks and professional perspectives are required to retain qualified and motivated surgeons in the surgical profession.

Locoregional therapy.

Even after complete surgical resection of pulmonary metastases, many patients develop recurrent disease in the thorax despite the use of systemic chemotherapy, dosage of which is limited because of systemic toxicity. Although subsequent operations are feasible and good long-term results have been reported, sufficient functional lung parenchyma must remain. For this reason, new treatment strategies are explored. Similar to isolated limb and liver perfusion, isolated lung perfusion (ILuP) is a promising surgical technique for the delivery of high-dose chemotherapy with minimal systemic toxicity. The use of biologic response modifiers, such as tumor necrosis factor, is also feasible. ILuP with high-dose chemotherapy has proven to be highly effective in the experimental models of pulmonary metastases with a superior survival advantage compared with systemic treatment. Lung levels are significantly higher after ILuP compared with intravenous therapy without systemic exposure. Phase I human studies have shown that ILuP is technically feasible with low morbidity and without compromising the patient's pulmonary function. Further clinical studies are necessary to determine its definitive effect on local recurrence, long-term toxicity, pulmonary function, and survival.