The role of thoracic surgery in the management of complicated acute and post-acute COVID-19 pneumonia (PASC).

INTRODUCTION: COVID-19 is considered a respiratory virosis in its classic form, although it may present with heterogeneous symptoms. Thoracic complications occur in a small percentage of patients. Our objective was to evaluate existing experience with this disease and its thoracic manifestations and to determine the real-world status of care of these patients. METHODS: This study is a retrospective, single-institution analysis of a group of patients hospitalized with acute and post-acute COVID-19 pneumonia at Thomayer Hospital in Prague in the period from December 2020 to March 2022 and indicated for a thoracic surgical procedure. RESULTS: During the peak of COVID-19 pandemic, a thoracic intervention was performed in 46 admitted patients. Thoracic drainage (due to pneumothorax in 18 cases, fluidothorax in 3 cases, CT-guided lung abscess drainage in 2 cases, and CT-guided pneumatocele drainage in 2 cases) were the most common thoracic surgical procedures. Pleurectomy/decortication surgery was done in 10 cases. Additionally, 12 lung parenchyma-sparing resections were performed, while lobectomy was required in 2 cases. Resection of postintubation tracheal stenosis due to a severe course of COVID-19 pneumonia was indicated in 2 patients. CONCLUSION: Even mild COVID-19 may cause a considerable morphological a functional alteration of the respiratory system. The most common complications of COVID-19 pneumonia that require a thoracic surgical intervention include pathologies associated with an air leak and accumulation of air (pneumothorax, pneumomediastinum and subcutaneous emphysema). The development of pulmonary necrosis, symptomatic bronchiectasis, pneumatocele, and bullous-fibrotic formations may result in pneumothorax, hemothorax or thoracic empyema in sporadic cases. An early thoracic surgical intervention to treat thoracic complications of COVID-19 pneumonia can improve the survival of COVID-19 patients.

Association of the postoperative white blood cells (WBC) count in peripheral blood after radical surgical treatment of left upper lobe non-small cell lung cancer (NSCLC) with overall survival - single center results.

INTRODUCTION: The individual patient prognosis after radical surgery for Non-small cell lung cancer (NSCLC) of left upper lobe remains still unclear. The purpose of this study is to evaluate the predictive value of elevated white blood cell count in peripheral blood as early indicator of postoperative NSCLC prognosis. METHODS: A retrospective statistical analysis was performed studying patients subject to radical treatment of left upper lobe NSCLC in period of five years with subsequent one to three-year monitoring of morbidity and mortality of the patient population. The statistical ROC (Receiver Operating Characteristic) analysis of the WBC count in peripheral blood third day after the operation was used to evaluate the relationship with overall survival, with respect to patients surviving for at least 24 months. RESULTS: Based on the results of the ROC analysis with a total area under the curve (AUC) of 0.67, it is possible to confirm that the WBC count established third day after the operation allows us to classify patients into groups according to the 24-month overall survival. CONCLUSION: Our findings confirm the potential of using WBC count to improve current protocols to establish postoperative prognosis for NSCLC of the upper left lobe (Tab. 2, Fig. 1, Ref. 11).

VATS lobectomy, history, indication, contraindication and general techniques.

VATS lobectomy is a respected modality of anatomic lung resections nowadays. Video-assisted lobectomies without rib extractor fulfil all current requirements for minimally invasive lung resections. This type of an anatomic pulmonary resection with a targeted treatment of hilar structures doesn't traumatize the intercostal space by using rib retractor. Videothoracoscope serves to visualize the surgical field on the screen. Assisted VATS (aVATS) lobectomy is a procedure using 3-5 cm working incision. Fully endoscopic resection (VTS) or complete VATS lobectomy (cVATS) are operations performed only through ports, without working incision. The authors supplement the article with a videorecord of VATS lobectomy general technique (Fig. 4, Ref. 11).

Our own method of fixation of biodegradable tracheal stent.

The authors present their own unique original method of fixation polydioxan biodegradable stents in the treatment of tracheal stenosis documented by pictures and video (Fig. 3, Ref. 12).

Importance of histological verification of mediastinal lymphadenopathy in exact staging of non-small cell bronchogenic carcinoma.

BACKGROUND: Diagnostics and treatment of bronchogenic non-small cell lung carcinoma is a severe clinical problem. Radical surgery is the major treatment modality with the highest chance for a long-time survival. The aim of the study was to map metastasizing of bronchogenic non-small cell lung carcinoma into homolateral mediastinal lymph nodes and to assess the importance of histological verification of mediastinal lymphadenectomy for exact staging and treatment. METHODS: Study of 29 patients with non-small cell lung carcinoma in stage IIIa, IIIb and IV (TNM classification) diagnosed from September 2006 to March 2007, with mediastinal lymph nodes invasion according to CT, and with subsequent mediastinal lymph node dissection during autopsy. RESULTS: 50% of the right upper lobe tumors metastasized into group 1 nodes (N1-N4) and 50% into group 3 (N7). 66% of the right lower lobe tumors metastasized into group 3 nodes (N7) and 33.3% into group 1 (N1-4). 20.0% of the left upper lobe tumors metastasized into group 1 nodes (N1-4), 33.0% into group 2 (N5-6), 25.0% into group 3 (N7) and 16.7% into group 4 (N8-9). 23.5% of the left lower lobe tumors metastasized into group 1 nodes (N1-4), 23.5% into group 2 (N5-6), 23.5 % into group 4 (N8-9) and 29.5% into group 3 (N7). 27.6% of examined patients had false positivity of lymph node metastasis according to CT. CONCLUSION: Histological verification of suspect mediastinal lymph nodes via Endobronchial Ultrasound Biopsy (EBUS) or mediastinoscopy or thoracoscopy is crucial for determining the stage of the disease according to the TNM classification. False positivity of imaging methods in diagnostics of non-small cell brochogenic carcinoma can contraindicate up to quarter of potentially operable patients (Tab. 3, Ref. 11).

Importance of systemic mediastinal lymphadenectomy in exact staging of bronchogenic carcinoma.

BACKGROUND: Constituent part of radical lung resection for lung cancer is a dissection of mediastinal lymph nodes. Lymphadenectomy is a standard procedure in an assessment of clinical stage of the disease. The aim of the study was to map metastasizing of bronchogenic non-small cell lung carcinoma into homolateral mediastinal lymph nodes and to assess the importance of mediastinal lymphadenectomy for exact staging and survival. METHODS: Study of 31patients with lung resection and systematic mediastinal lymphadenectomy operated from August 2004 to January 2007, with pre-operative stage Ia to IIb (TNM classification) - according to CT without mediastinal lymph nodes invasion and with positive histological finding after systematic mediastinal lymphadenectomy. RESULTS: Tumors in right upper lobe metastasized in 45.5 % into group 1 nodes (stages N1-N4) and group 3 nodes (stages N7) and in 9 % into group 4 nodes (stages N8-N9). Tumors of the right middle lobe metastasized in 100 % into group 3 nodes (stage N7).Tumors of the right lower lobe metastasized in 87.5 % into group 3 nodes (N7) and in 12.5 % into group 4 nodes (stages N8-N9). Tumors of the left upper lobe metastasized in 9.0 % in group 1 nodes (stages N1-N4), in 82 % into group 2 nodes (stages N5-N6) and in 9.0 % were found skip metastases into group 4 nodes (stages N8-N9). Tumors of the left lower lobe metastasized in 26.7 % in group 4 nodes, 46.6 % into group 3 nodes, in 20,0 % into group 2 nodes and in 6,7 % into group 1 nodes. CONCLUSION: Systematic mediastinal lymphadenectomy is crucial for determining the stage of the disease according to the TNM classification. Systematic lymphadenectomy is essential for the diagnosis of stage IIIa disease and setting of additional therapy that prolongs survival (Ref. 17).

[Lung sequestration as an accidental finding in adulthood. Surgical therapy]. / Plicní sekvestrace jako náhodný nález v dospelém veku a její operacní terapie.

Authors present case-reviews of three patients, 33 years old, with finding of pulmonary sequestration and indicated for surgical therapy, it means lung resection. It was an accidental finding in all three case-reviews. Standard examination methods in pneumology as a X-ray of the chest, bronchoscopy with cytology, spirometry and chest CT, were used for diagnosis. If the suspicion of pulmonary sequestration was expressed from chest CT scans, then CT angiography was indicated. The patients underwent surgery revision, ligation of atypically leading artery followed by lung resection with pulmonary seqestration. In the postoperative course there were no complications.

The role of neoadjuvant chemotherapy in marginally resectable or unresectable stage III non-small cell lung cancer.

The study was undertaken to test whether marginally resectable or unresectable stage IIIa-IIIb non-small cell lung cancer (NSCLC) patients could reach complete resectability after induction chemotherapy. Fifty six patients were included into the study and treated either by vinorelbine 35 mg/m2 day 1 and cisplatin 75 mg/m2 day 1 (n=28) or by vinorelbine 30 mg/m2 day 1 and 8 and cisplatin 80 mg/m2 day 1 (n=28). Cycles were repeated every 21 days. At the completion of induction therapy patients assessed to be resectable underwent thoracotomy. Radiation therapy was applicated in nonresected cases. The minimal follow up was 24 months. 32% of patients with marginally resectable or unresectable stage IIIa-IIIb NSCLC could reach a complete resectability after induction chemotherapy. Survival of patients stage IIIa was comparable to stage IIIb. Responders and resected patients survived significantly longer comparing to the patients with stable disease and progression, respectively to the incompletely resected plus nonresected patients. Perioperative complications were rare and there were no treatment-related deaths in our study. The main surgery-related complication was late bronchopleural fistula.

[Endoscopic wedge-shaped lung biopsy--initial experience]. / Endoskopická klínovitá plicní biopsie--první zkusenosti.

The authors publish their initial experience with wedge-shaped pulmonary biopsy by the endoscopic route. The group is formed by 18 patients who were indicated for the operation on account of a disseminated pulmonary process in order to assess the micromorphological appearance of the affected lung tissue. Two patients developed a complication during operation which therefore was completed by minor thoracotomy. In who patients the authors observed after operation slow expansion of the pulmonary parenchyma. No death after the operation was recorded. The authors assume, based on their initial experience, that this operation will soon be included among common diagnostic operations and will help to facilitate the diagnosis and selection of treatment in patients with disseminated lung disease.

[Complications of mediastinoscopy examinations]. / Komplikace mediastinoskopického vysetrení.

In 1970-1990 in the Institute of Lung Diseases in Prague a total of 180 mediastinoscopies were performed. In the submitted paper the authors discuss 169 of these examinations. In this group 20 examinations were associated with a peroperative or postoperative complications, i.e. a total of 12% of the examinations. However, only in three patients, i.e. cca 1.8% from the total number serious complications were involved which were unequivocally specific for mediastinoscopy. In two instances massive haemorrhage occurred from lacerated mediastinal vessels associated with superior vena cava syndrome and in one case pneumothorax developed. All these complications were controlled by surgical intervention made in time. The most frequent complication after mediastinoscopic examination was retention of a serohaematoma in the wound--this was recorded 11 times. The cause of its development is the method of preparation and anatomical conditions in the pre- and paratracheal space. The percentage of this complication can be reduced by using active drainage of the mediastinum.

[Extended pulmonary resection in non-small cell lung cancer]. / Rozsírené plicní resekce pro nemalobunecný typ plicní rakoviny.

The authors give an account of their experience with extensive pulmonary resections on account of an extensive non-small-cell carcinoma of the lungs. During a 13-year period (1976-1988) they made 140 extensive resections of the lungs. As to histological characteristics, the epidermoid type of tumour predominated. The tumour spread most frequently to mediastinal nodes and the thoracic wall. The mean age of the patients was 54.9 years, the mortality within 30 days after operation 5.7%. The five-year survival of patients after operation was evaluated in patients operated between 1976 and 1988 when 90 operations were performed. The majority of patients (32.5%) survived combined surgery. Two patients survive after 10 years. Due to the small number of patients and their difficult comparability it is not possible to evaluate the effectiveness of different types of treatment statistically. In the literature views on combined postoperative treatment differ, a randomized study would be useful. In the conclusion the authors advocate continuation of the hitherto used trend of therapy, they recommend introduction of new chemotherapeutic agents in close collaboration with oncologists and concentration of patients in specialized departments.

[Hemothorax as a complication of thoracotomy]. / Hemotorax jako komplikace torakotomie.

In 1969 to 1989 in the Research Institute of Tuberculosis and Respiratory Diseases in Prague a total of 3583 thoracotomies were performed. Of these during the postoperative period 29 patients were re-operated on account of continuing haemorrhage into the pleural cavity. This is approximately 0.8% of all thoracotomies. Sixteen patients had to be re-operated within 12 hours after operation, 12 patients were re-operated later than 12 hours after operation but within 24 hours, one patient was re-operated later than 24 hours after operation. The cause of haemothorax was in the first place capillary haemorrhage from a lacerated pleura, in the second place haemorrhage from a severe intercostal artery at the very site of the thoracotomy. Other causes of haemorrhage such as haemorrhage from the bronchial artery and its branches are not frequent. None of the patients had to be re-operated on account of haemorrhage from the major arteries of the pulmonary hilus. Administration of small doses of heparin before and after operation did not influence the number of re-operations on account of haemothorax.

[Bronchopleural fistula as a complication of pulmonary resection]. / Bronchopleurální pístel jako komplikace plicní resekce.

During a 15-year period, when in the department for thoracic surgery in the Research Institute for Tuberculosis and Respiratory Diseases 1612 resections of the lungs were performed, the authors recorded 18 patients with bronchopleural fistulae. After pneumonectomies and lobectomies the incidence of this complication was recorded in 1.4%. The majority of fistulae was observed after resection on the lungs on account of bronchogenic carcinoma, in two patients after resection on account of a pulmonary aspergilloma. After resection on account of TB and bronchiectas is the authors did not observe bronchopleural fistulae. Treatment of the fistula was in two thirds of the patients of the investigated group conservative with a 33% lethality. In six patients on account of the fistula rethoracotomy was performed with a lethality of 66.6%. The total lethality during treatment of bronchopleural fistulae was 44.4%. The purpose of the present work is to draw attention to the serious character of this post-resection complication and to its possible prevention by preoperative preparation and surgical technique.