The impact and relevance of techniques and fluids on lung injury in machine perfusion of lungs.

Primary graft dysfunction (PGD) is a common complication after lung transplantation. A plethora of contributing factors are known and assessment of donor lung function prior to organ retrieval is mandatory for determination of lung quality. Specialized centers increasingly perform ex vivo lung perfusion (EVLP) to further assess lung functionality and improve and extend lung preservation with the aim to increase lung utilization. EVLP can be performed following different protocols. The impact of the individual EVLP parameters on PGD development, organ function and postoperative outcome remains to be fully investigated. The variables relate to the engineering and function of the respective perfusion devices, such as the type of pump used, functional, like ventilation modes or physiological (e.g. perfusion solutions). This review reflects on the individual technical and fluid components relevant to EVLP and their respective impact on inflammatory response and outcome. We discuss key components of EVLP protocols and options for further improvement of EVLP in regard to PGD. This review offers an overview of available options for centers establishing an EVLP program and for researchers looking for ways to adapt existing protocols.

Sarcopenia and Mediastinal Adipose Tissue as a Prognostic Marker for Short- and Long-Term Outcomes after Primary Surgical Treatment for Lung Cancer.

Surgical resection remains the gold standard of treatment for early-stage lung cancer. Several risk models exist to predict postoperative morbidity and mortality. Psoas muscle sarcopenia has already successfully been used for morbidity prediction in lung transplantation and is not yet included in the available risk scores for pulmonary resections. We hypothesized that the skeletal muscle index and mediastinal adipose tissue might also have an impact on postoperative outcomes after primary surgery for primary lung cancer. The institutional database was queried for patients with primary lung cancer who were treated with primary lobectomy or segmentectomy between February 2009 and November 2018. In total, 311 patients were included for analysis. Patients receiving neo-/adjuvant chemotherapy or with a positive nodal status were excluded to rule out any morbidity or mortality due to (neo-)adjuvant treatment. Sarcopenia was defined as a skeletal muscle index of <34.4 cm2/m2 for women and <45.4 cm2/m2 for men. Mediastinal adipose tissue was defined with a radiodensity of -150 to -30 Hounsfield units. Sarcopenia was diagnosed in 78 (25.1%) of the 311 patients. Male patients were significantly more likely to suffer from sarcopenia (31.5% vs. 18.1%, p = 0.009). Comorbidities, lung function, tumour histology, pathologic tumour staging, mediastinal adipose tissue and age did not differ between groups with or without sarcopenia. Sarcopenic patients had a significantly longer length of stay, with 13.0 days vs. 9.5 (p = 0.003), and a higher rate of any postoperative complications (59.0% vs. 44.6%, p = 0.036). There was no difference in recurrence rate. Five-year overall survival was significantly better in the patient cohort without sarcopenia (75.6% vs. 64.5%, p = 0.044). Mediastinal adipose tissue showed no significant impact on length of stay, postoperative complications, recurrence rate, morbidity or survival. Sarcopenia, quantified with the skeletal muscle index, is shown to be a risk factor for postoperative morbidity and reduced survival in primary lung cancer. Efforts should be taken to pre-emptively screen for sarcopenia and start countermeasures (e.g., physical prehabilitation, protein-rich nutrition, etc.) during the preoperative workup phase.

Risk factors, complications and costs of prolonged air leak after video-assisted thoracoscopic surgery for primary lung cancer.

Background: Prolonged air leak (PAL) represents a common complication after lung resection. This study aims to analyze the risk factors for the development of a PAL, its impact on the postoperative outcome and to estimate additional treatment costs. Methods: A single center database was queried for all patients scheduled for video-assisted thoracoscopic surgery for primary lung cancer. In total, 957 patients between 2009 and 2021 were analyzed. Exclusion criteria was pneumonectomy. Collected data included demographics and perioperative data (e.g., duration of surgery, postoperative infections, air leak duration etc.). PAL was defined as an air leak lasting for 5 days or longer. The PAL cohort included 103 patients, the non-PAL included 854 patients. Univariate analysis and binomial logistic regression were performed. Cost calculation was performed using available data from prior publications to estimate treatment costs. Results: Male sex, chronic obstructive pulmonary disease (COPD) and low body mass index (BMI) showed to be risk factors for the development of postoperative PAL (P<0.001). Using these risk factors, a risk prediction score for PAL has been established. A subgroup analysis showed a significantly higher rate of sarcopenia in patients with PAL (P<0.001). The mean duration until removal of chest drains and length of stay (LOS) was significantly longer in the PAL cohort (14.2 vs. 4.4 days, P<0.001; 19.8 vs. 9.3 days, P<0.001). Also, the duration of the operation was longer in PAL patients (179.1 vs. 161.2 minutes, P=0.001). Patients with PAL had an elevated risk for postoperative infections [odds ratio (OR) 3.211, 31.1% vs. 12.3%, P<0.001]. As a result of a prolonged LOS, estimated treatment costs were significantly higher for PAL, ranging from 2,888.2 to 12,342.8 € depending on available cost bases compared to the non-PAL cohort, which ranged from 1,370.5 to 5,856.8 € (P<0.001). Conclusions: PAL is a frequent complication that prolongs the LOS after thoracic surgery and, according to the literature, results in elevated readmission rates, leading to excess health care costs. Risk factors for PAL are well established. Preoperative treatment of sarcopenia and dismal nutritional status might alter the risk. As measures to prevent PAL are otherwise limited, guidelines for effective management of PAL need to be established.

External validation of risk prediction scores in patients undergoing anatomic video-assisted thoracoscopic resection.

BACKGROUND: EuroLung Risk scores were established to predict postoperative morbidity and mortality in patients undergoing anatomic lung resections. We aimed to perform an external validation of the EuroLung scores, which were calculated from data of the European Society of Thoracic Surgeons database, in our video-assisted thoracoscopic surgery cohort. METHODS: All available EuroLung scores were calculated for 718 patients scheduled for anatomic video-assisted thoracoscopic surgery resections between 2009 and 2019. Morbidity and mortality according to the definitions of the EuroLung scores were analyzed in a prospectively maintained database. RESULTS: Overall observed complication rate was 10.45%. Scores showed weak individual correlation (η = 0.155-0.174). The EuroLung1 app score showed the biggest area under the receiver operative characteristic (ROC) curve with 0.660. Binary logistic regression analysis showed that predicted postoperative forced expiratory volume in 1 s was associated with increased complications in both EuroLung1 and parsimonious EuroLung1 scores. Thirty-day mortality was 0.7% (predicted 1.10-1.40%) and was associated with predicted postoperative forced expiratory volume in 1 s for both EuroLung2 and parsimonious EuroLung2 scores. The EuroLung2 (2016) showed the biggest area under the ROC curve with 0.673. Only a very weak eta correlation between predicted and observed mortality was found for both aggregate EuroLung2, EuroLung2 (2016), EuroLung2 (2019), and parsimonious EuroLung2 (2016) (η = 0.025/0.015/0.011/0.009). CONCLUSION: EuroLung scores help to estimate postoperative morbidity. However, even with the highest aggregate EuroLung scores possible only 50% suffer from postoperative morbidity. Although calibration of the scores was acceptable, discrimination between predicted and observed events was poor. Therefore, individual correlation between predicted and observed events is weak. Therefore, EuroLung scores may be best used to compare institutional quality of care to the European Society of Thoracic Surgeons database but should not be used to preclude patients from surgical treatment.

Analysis of Pain Management after Anatomic VATS Resection in Austrian Thoracic Surgery Units.

BACKGROUND: Postoperative pain influences rehabilitation, postoperative complications and quality of life. Despite its impact, there are no uniform treatment guidelines. Different centers seem to use various strategies. This study aims to analyze pain management regimens used after anatomic VATS resections in Austrian thoracic surgery units, with a special interest in opioid usage and strategies to avoid opioids. METHODS: A questionnaire was designed to assess the use of regional anesthesia, postoperative pain medication and characteristics of individual pain management regimens. The questionnaire was sent to all thoracic surgery units in Austria, with nine out of twelve departments returning them. RESULTS: All departments use regional anesthesia during the procedure. Four out of nine centers use epidural analgesia or an intercostal catheter for postoperative regional anesthesia in at least 50% of patients. Two departments follow an opioid restrictive regimen, five depend on the visual analogue scale (VAS) and two administer opioids on a fixed schedule. Three out of nine departments use NSAIDs on a fixed schedule. The most used medication is metamizole (eight out of nine centers; six on a fixed schedule, two depending on VAS) followed by piritramide (six out of nine centers; none as a fixed prescription). CONCLUSIONS: This study reflects the heterogeneity in postoperative pain treatment after VATS anatomic lung resections. All departments use some form of regional anesthesia in the perioperative period; prolonged regional anesthesia is not utilized uniformly to reduce opioid consumption, as suggested in enhanced recovery after surgery programs. More evidence is needed to optimize and standardize postoperative pain treatment.

Duration of extracorporeal life support bridging delineates differences in the outcome between awake and sedated bridge-to-transplant patients.

OBJECTIVES: Traditionally, patients on bridge-to-transplant extracorporeal membrane oxygenation were kept sedated and intubated. However, awake bridging strategies have evolved during recent years. This study aims to elaborate differences in physical activity and postoperative outcomes after lung transplantation (LTx), depending on bridging strategy and duration. METHODS: Bridged patients receiving LTx between March 2013 and April 2021 were analysed. Awake bridging was defined as a Richmond Agitation-Sedation Scale score of ≥-1 until 24 h before transplantation. Patients were grouped in awake and sedated cohorts. RESULTS: A total of 88 patients (35 awake, 53 sedated bridging) were included. After LTx, mobilization to standing position was achieved earlier in awake bridged patients (7 vs 15 days, P < 0.001). Postoperative ventilation time (247 vs 88 h, P = 0.005) and intensive care unit stay (30 vs 16 days, P = 0.004) were longer in the sedated cohort. Awake patients with bridging duration >6 days showed shorter postoperative ventilation time (108 vs 383 h, P = 0.003), less intensive care unit days (23 vs 36, P = 0.003) and earlier mobilization to standing position (9 vs 17 days, P < 0.001). In contrast, postoperative ventilation time and days in intensive care unit in patients with bridge-to-transplant duration ≤6 days were comparable between cohorts. Mobilization to standing position was achieved faster in the awake (≤6 days) bridged cohort (5 vs 9 days, P = 0.024). CONCLUSIONS: Despite the complex management of bridged patients, excellent survival rates after LTx can be achieved. Especially in patients with more than 1 week on extracorporeal membrane oxygenation, awake bridging concepts are associated with significantly faster recovery.

Long-term outcome after chronic anastomotic leakage following surgery for low rectal cancer.

PURPOSE: This study analyzed the prevalence and factors influencing the history of chronic anastomotic leakage following low anterior resection for rectal cancer. Furthermore, the treatment of a persisting presacral sinus and the impact of stoma reversal on outcome were evaluated. METHODS: The institutional database was scanned for all patients with anastomotic leakage, who were primarily treated for low rectal cancer between January 1995 and December 2019. Patients with rectovaginal and rectovesical fistula or an inadequate follow-up were excluded (n = 5). After applying the exclusion criteria, 71 patients remained for analysis. RESULTS: A total of 39 patients out of 71 patients with anastomotic leakage (54.9%) developed a persisting presacral sinus. Neoadjuvant radiochemotherapy or chemotherapy showed a significant impact on the formation of a chronic anastomotic leakage (radiochemotherapy: p = 0.034; chemotherapy: p = 0.050), while initial surgical treatment showed no difference for anastomotic healing (p = 0.502), but a significantly better overall survival (p = 0.042). Multiple therapies and surgical revision had a negative impact on patients' rate of natural bowel continuity (p = 0.006/ < 0.001). In addition, the stoma reversal cohort showed improved overall 10-year survival (p = 0.004) and functional results (bowel continuity: p = 0.026; pain: p = 0.031). CONCLUSION: Primary surgical therapy for chronic anastomotic leakage should consist of surgical treatment. Furthermore, the reversal of a protective stoma should be considered a viable option in treating chronic presacral sinus to improve pain symptoms and bowel continuity.

A Dual-Lumen Extracorporeal Membrane Oxygenation Cannulation Technique Using a Mobile X-Ray Device.

PURPOSE: Dual-lumen extracorporeal membrane oxygenation (ECMO) cannulation is considered technically challenging and harbors the risk of potential life-threatening complications during cannulation. Dual-lumen cannula insertion is performed under either ultrasound or fluoroscopy guidance. Both techniques have significant disadvantages, such as examiner dependence or the necessity for transportation of the patient from the intensive care unit to the operating room. DESCRIPTION: Digital, mobile x-ray devices provide a novel, examiner-independent imaging modality for bedside dual-lumen ECMO cannulation. EVALUATION: From November 2019 to November 2021, 23 dual-lumen cannulations were performed in 20 patients at the Department of Thoracic Surgery, Medical University of Vienna. Twelve of 23 (52.2%) were inserted in the intensive care unit using a mobile x-ray device. The remaining patients (47.8%) were cannulated in the operating room with conventional fluoroscopy guidance. In none of the procedures did cardiovascular injuries occur. Insertion site bleeding was the most common ECMO-related complication (n = 2). CONCLUSIONS: Dual-lumen cannulation using sequential x-rays can be performed safely. Especially for infectious patients or patients who require an awake ECMO, this technique overcomes disadvantages of established imaging modalities.

Delay to surgical treatment in lung cancer patients and its impact on survival in a video-assisted thoracoscopic lobectomy cohort.

Patient pathways from first suspicious imaging until final surgical treatment vary and in some instances cause considerable delay. This study aims to investigate the impact of this delay on survival of lung cancer patients. The institutional database was queried to identify patients with primary lung cancer who were treated with primary surgery. Time intervals were defined as date of first suspicious medical images until date of surgical treatment. All patients received PET-CT staging and tissue confirmation prior to treatment planning in a multidisciplinary tumor board. Patients with unknown date of first contact, follow-up CT-scans of pulmonary nodules, or neoadjuvant therapy were excluded. In total, 287 patients treated between 2009 and 2017 were included for further analysis. Median time between first suspicious medical imaging and surgical therapy was 62 (range 23-120) days and did not differ between male and female patients. Patients were then classified into two groups according to the duration of the medical work-up: group A up to 60 days, and group B from 61 to 120 days. Clinical T and N stages were comparable between the groups. There was no difference in overall survival between the two groups. In the subgroup of cT2 tumors (87 patients), there was a significant survival benefit for patients in group A (p = 0.043), while nodal stages, stage migration, lymphatic vessel invasion, grading and other potentially survival-influencing clinical parameters were comparable between the groups. Delay between diagnosis and treatment of lung cancer may result in dismal outcome. Efforts need to focus on improving and streamlining patient pathways to shorten the delay until surgical treatment to a minimum. Process improvement might be achieved by stringent interdisciplinary work-up and a patient-centered approach.

Intercostal Catheters for Postoperative Pain Management in VATS Reduce Opioid Consumption.

BACKGROUND: Postoperative pain after video-assisted thoracoscopic surgery (VATS) affects patients' recovery, postoperative complications, and length of stay (LOS). Despite its relevance, there are no guidelines on optimal perioperative pain management. This study aims to analyse the effects of an additional intercostal catheter (ICC) in comparison to a single shot intraoperative intercostal nerve block (SSINB). METHODS: All patients receiving an anatomic VATS resection between June 2019 and May 2020 were analysed retrospectively. The ICC cohort included 51 patients, the SSINB cohort included 44 patients. RESULTS: There was no difference in age, gender, comorbidities, or duration of surgery between cohorts. Pain scores on the first postoperative day, after chest drain removal, and highest pain score measured did not differ between groups. The overall amount of opioids (morphine equivalent: 3.034 mg vs. 7.727 mg; p = 0.002) as well as the duration of opioid usage (0.59 days vs. 1.25 days; p = 0.005) was significantly less in the ICC cohort. There was no difference in chest drain duration, postoperative complications, and postoperative LOS. CONCLUSIONS: Pain management with ICC reduces the amount of opioids and number of days with opioids patients require to achieve sufficient analgesia. In conclusion, ICC is an effective regional anaesthesia tool in postoperative pain management in minimally invasive thoracic surgery.