Search

BACKGROUND: 60% of patients diagnosed with lung cancer are older than 65 years and are at risk for substandard treatment due to a reluctance to recommend surgery. Pneumonectomy remains a high risk procedure especially in elderly patients. Nevertheless, the impact of age and neoadjuvant treatment on outcomes after pneumonectomy is still not well described. METHODS: We performed a multicentric retrospective study, analyzing outcomes of patients older than 70 years who underwent pneumonectomy for central primary lung malignancy between January 2009 and June 2019 in 7 thoracic surgery departments: Lucerne and Bern (Switzerland), Hamilton (Canada), Alicante (Spain), Monza (Italy), London (UK), Leuven (Belgium). Survival was estimated with Kaplan-Meier, and differences in survival were determined by log-rank analysis. We investigated pre- and post-operative prognostic factors using Cox proportional hazards regression model; multivariable analysis was performed only with variables, which were statistically significant at the invariable analysis. RESULTS: A total of 136 patients were included in the study. Mean age was 73.8 years (SD 3.6). 24 patients (17.6%) had an induction treatment (chemotherapy alone in 15 patients and chemo-radiation in 9). Mean length of stay (LOS) was 12.6 days (SD 10.39) and 74 patients (54.4%) had experienced a post-operative complication: 29 (21.3%) had a pulmonary complication, 33 (24.3%) had a cardiac complication and in 12 cases (8.8%) patients experienced both cardiac and pulmonary complications. 16 patients were readmitted [median LOS 13.7 days (range, 2-39 days)] and of those 14 (10.3%) required redo surgery. Median overall survival (OS) of the entire cohort was 38 months (95% CI: 29.9-46.1 months); in-hospital mortality was 1.5%, 30-day mortality rate was 3.7%, while 90-day mortality was 8.8% accounting for 5 and 12 patients respectively. Patients receiving neo-adjuvant therapy did not experience a higher incidence of postoperative complications (P=0.633), did not have a longer postoperative course (P=0.588), nor did they have an increased mortality rate (P=0.863). CONCLUSIONS: Age should not be considered an absolute contraindication for pneumonectomy in elderly patients even after neoadjuvant treatment. It has become apparent that especially in these patients, a patient-tailored approach with a careful selection should be used to define the risk-benefit balance. ispartof: JOURNAL OF THORACIC DISEASE vol:13 issue:10 pages:5835-5842 ispartof: location:China status: published

Objective The presence of micropapillary and solid adenocarcinoma patterns leads to a worse survival and a significantly higher tendency to recur. This study aims to assess the impact of pT descriptor combined with the presence of high-grade components on long-term outcomes in early-stage lung adenocarcinomas. Methods We retrospectively collected data of consecutive resected pT1-T3N0 lung adenocarcinoma from nine European Thoracic Centers. All patients who underwent a radical resection with lymph-node dissection between 2014 and 2017 were included. Differences in Overall Survival (OS) and Disease-Free Survival (DFS) and possible prognostic factors associated with outcomes were evaluated also after performing a propensity score matching to compare tumors containing non-high-grade and high-grade patterns. Results Among 607 patients, the majority were male and received a lobectomy. At least one high-grade histological pattern was seen in 230 cases (37.9%), of which 169 solid and 75 micropapillary. T1a-b-c without high-grade pattern had a significant better prognosis compared to T1a-b-c with high-grade pattern (p = 0.020), but the latter had similar OS compared to T2a (p = 0.277). Concurrently, T1a-b-c without micropapillary or solid patterns had a significantly better DFS compared to those with high-grade patterns (p = 0.034), and it was similar to T2a (p = 0.839). Multivariable analysis confirms the role of T descriptor according to high-grade pattern both for OS (p = 0.024; HR 1.285 95% CI 1.033–1.599) and DFS (p = 0.003; HR 1.196, 95% CI 1.054–1.344, respectively). These results were confirmed after the propensity score matching analysis. Conclusions pT1 lung adenocarcinomas with a high-grade component have similar prognosis of pT2a tumors.

Background: Lung cancer is the worldwide leading oncological cause of death in both genders combined and accounts for around 40–50% of brain metastases in general. In early-stage lung cancer, the incidence of brain metastases is around 3%. Since the early detection of asymptomatic cerebral metastases is of prognostic value, the aim of this study was to analyze the incidence of brain metastases in early-stage lung cancer and identify possible risk factors. Methods: We conducted a retrospective multicentric analysis of patients with Stage I (based on T and N stage only) Non-Small Cell Lung Cancer (NSCLC) who had received preoperative cerebral imaging in the form of contrast-enhanced CT or MRI. Patients with a history of NSCLC, synchronous malignancy, or neurological symptoms were excluded from the study. Analyzed variables were gender, age, tumor histology, cerebral imaging findings, smoking history, and tumor size. Results were expressed as mean with standard deviation or median with range. Results: In total, 577 patients were included in our study. Eight (1.4%) patients were found to have brain metastases in preoperative brain imaging. Tumor histology was adenocarcinoma in all eight cases. Patients were treated with radiotherapy (five), surgical resection (two), or both (one) prior to thoracic surgical treatment. Other than tumor histology, no statistically significant characteristics were found to be predictive of brain metastases. Conclusion: Given the low incidence of brain metastases in patients with clinical Stage I NSCLC, brain imaging in this cohort could be avoided.

OBJECTIVES Lung cancer is increasingly diagnosed as a second cancer. Our goal was to analyse the characteristics and outcomes of early-stage resected lung adenocarcinomas in patients with previous cancers (PC) and correlations with adenocarcinoma subtypes. METHODS We retrospectively reviewed data of patients radically operated on for stage I–II lung adenocarcinoma in 9 thoracic surgery departments between 2014 and 2017. Overall survival (OS) and time to disease relapse were evaluated between subgroups. RESULTS We included 700 consecutive patients. PC were present in 260 (37.1%). Breast adenocarcinoma, lung cancer and prostate cancer were the most frequent (21.5%, 11.5% and 11.2%, respectively). No significant differences in OS were observed between the PC and non-PC groups (P = 0.378), with 31 and 75 deaths, respectively. Patients with PC had smaller tumours and were more likely to receive sublobar resection and to be operated on with a minimally invasive approach. Previous gastric cancer (P = 0.042) and synchronous PC (when diagnosed up to 6 months before lung adenocarcinoma; P = 0.044) were related, with a worse OS. Colon and breast adenocarcinomas and melanomas were significantly related to a lower incidence of high grade (solid or micropapillary, P = 0.0039, P = 0.005 and P = 0.028 respectively), whereas patients affected by a previous lymphoma had a higher incidence of a micropapillary pattern (P = 0.008). CONCLUSIONS In patients with PC, we found smaller tumours more frequently treated with minimally invasive techniques and sublobar resection, probably due to a more careful follow-up. The impact on survival is not uniform and predictable; however, breast and colon cancers and melanoma showed a lower incidence of solid or micropapillary patterns whereas patients with lymphomas had a higher incidence of a micropapillary pattern.

In thoracic outlet syndrome (TOS) the narrowing between bony and muscular structures in the region of the thoracic outlet/inlet results in compression of the neurovascular bundle to the upper extremity. Venous compression, resulting in TOS (vTOS) is much more common than a stenosis of the subclavian artery (aTOS) with or without an aneurysm. Traditional open surgical approaches to remove the first rib usually lack good exposure of the entire rib and the neurovascular bundle. Between January 2015 and July 2021, 24 consecutive first rib resections for venous or arterial TOS were performed in 23 patients at our institutions. For our completely portal approach we used two 8mm working ports and one 12/8 mm camera port. Preoperatively, pressurized catheter-based thrombolysis (AngioJet®) was successfully performed in 13 patients with vTOS. Operative time ranged from 71–270 min (median 128.5 min, SD +/− 43.2 min) with no related complications. The chest tube was removed on Day 1 in all patients and the hospital stay after surgery ranged from 1 to 7 days (median 2 days, SD +/− 2.1 days). Stent grafting was performed 5–35 days (mean 14.8 days, SD +/− 11.1) postoperatively in 6 patients. The robotic approach to first rib resection described here allows perfect exposure of the entire rib as well as the neurovascular bundle and is one of the least invasive surgical approaches to date. It helps improve patient outcomes by reducing perioperative morbidity and is a procedure that can be easily adopted by trained robotic thoracic surgeons. In particular, patients with a/vTOS may benefit from careful and meticulous preparation and removal of scar tissue around the vessels.

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.

Objective: To evaluate the influence of lung adenocarcinoma second predominant pattern on the maximal standard uptake value (SUVmax) and its prognostic effect in different histologic groups. Methods: We retrospectively collected surgically resected pathologic stage I and II lung adenocarcinoma from nine European institutions. Only patients who underwent preoperative PET-CT and with available information regarding SUVmax of T (SUVmaxT) and N1 (SUVmaxN1) component were included. Results: We enrolled 344 patients with lung adenocarcinoma. SUVmaxT did not show any significant relation according to the second predominant pattern ( p = 0.139); this relationship remained nonsignificant in patients with similar predominant pattern. SUVmaxT influenced the disease-free survival in the whole cohort ( p = 0.002) and in low- and intermediate-grade predominant pattern groups ( p = 0.040 and p = 0.008, respectively). In the high-grade predominant pattern cohort and in the pathologic N1 cases, SUVmaxT lost its prognostic power. SUVmaxN1 did not show any significant correlation with predominant and second predominant patterns and did not have any prognostic impact on DFS. Conclusions: SUVmaxT is influenced only by the adenocarcinoma predominant pattern, but not by second predominant pattern. Concurrently, in high-grade predominant pattern and pN1 group the prognostic power of SUVmaxT becomes nonsignificant.

Objective This study aimed to provide an extensive overview of clinical and pathological findings along with various therapeutic options analyzing in addiction, retrospectively, the surgical outcomes of a single center cohort. Background Thymic neoplasms are rare thoracic tumors which commonly are located in the anterior mediastinum and are associated with a wide spectrum of clinical presentations. They may run an indolent course or could present a very aggressive biologic progression with infiltration of mediastinal structures and presence of distant metastases. The pathogenesis of these tumors is so far not completely clear. Several treatment modalities in a multidisciplinary setting have to be considered in order to provide the best treatment for patients affected by thymic tumors. Methods We conducted a retrospective cohort analysis of all patients who underwent surgery due to thymic tumor in a university hospital located in Switzerland (Bern University Hospital) and then we performed a narrative review of the English literature using PubMed, Embase, Cochrane Database of Systematic Reviews and Scopus. Conclusions Minimally invasive techniques play an important role in the treatment of thymic tumors. A careful patients selection in a multidisciplinary setting is mandatory in order to offer the best treatment for patients affected by thymic tumors.

Background and objectives Adenocarcinoma patterns could be grouped based on clinical behaviors: low- (lepidic), intermediate- (papillary or acinar), and high-grade (micropapillary and solid). We analyzed the impact of the second predominant pattern (SPP) on disease-free survival (DFS). Methods We retrospectively collected data of surgically resected stage I and II adenocarcinoma. Selection criteria anatomical resection with lymphadenectomy and pathological N0. Pure adenocarcinomas and mucinous subtypes were excluded. Recurrence rate and factors affecting DFS were analyzed according to the SPP focusing on intermediate-grade predominant pattern adenocarcinomas. Results Among 270 patients, 55% were male. The mean age was 68.3 years. SPP pattern appeared as follows: lepidic 43.0%, papillary 23.0%, solid 14.4%, acinar 11.9%, and micropapillary 7.8%. The recurrence rate was 21.5% and 5-year DFS was 71.1%. No difference in DFS was found according to SPP (p = .522). In patients with high-grade SPP, the percentage of SPP, age, and tumor size significantly influenced DFS (p = .016). In patients with lepidic SPP, size, male gender, and lymph-node sampling (p = .005; p = .014; p = .038, respectively) significantly influenced DFS. Conclusions The impact of SPP on DFS is not homogeneous in a subset of patients with the intermediate-grade predominant patterns. The influence of high-grade SPP on DFS is related to its proportion in the tumor.

Fungal osteomyelitis is a rare disease that can occur in immunocompromised patients. We report a case of a patient with a primary rib osteomyelitis after a blunt trauma of the chest wall. Aggressive surgical debridement along with antifungal therapy was the cornerstone of the disease management in this patient.

Chronic obstructive pulmonary disease (COPD) is a very heterogeneous disease characterised by an obstructive lung pattern that constitutes worldwide a major cause of high morbidity and mortality. In the last decades, lung volume reduction surgery (LVRS) has demonstrated to be a potential good alternative to transplantation in patients affected by COPD. The trend toward minimally invasive techniques resulted not only in surgical procedures better tolerated by the patients but also in several endoscopic treatments modality that are rapidly gaining ground.

OBJECTIVESVenous thromboembolic events (VTE) after thoracic surgery (TS) can be prevented with mechanical and chemical prophylaxis. Unlike other surgical specialties, TS lacks evidence-based guidelines. In the process of developing these guidelines, an understanding of the current prophylaxis methods practiced internationally is necessary and is described in this article.METHODSA 26-item survey was distributed to members of the European Society of Thoracic Surgeons (ESTS), American Association of Thoracic Surgery (AATS), Japanese Association for Chest Surgery (JACS) and Chinese Society for Thoracic and Cardiovascular Surgery (CSTCS) electronically or in person. Participants were asked to report their current prophylaxis selection, timing of initiation and duration of prophylaxis, perceived risk factors and the presence and adherence to institutional VTE guidelines for patients undergoing TS for malignancies.RESULTSIn total, 1613 surgeons anonymously completed the survey with an overall 36% response rate. Respondents were senior surgeons working in large academic hospitals (≥70%, respectively). More than 83.5% of ESTS, AATS and JACS respondents report formal TS thromboprophylaxis protocols in their institutions, but 53% of CSTCS members report not having such a protocol. The regions varied in the approaches utilized for VTE prophylaxis, the timing of initiation perioperatively and the use and type of extended prophylaxis. Respondents reported that multiple risk factors and sources of information impact their VTE prophylaxis decision-making processes, and these factors vastly diverge regionally.CONCLUSIONSThere is little agreement internationally on the optimal approach to thromboprophylaxis in the TS population, and guidelines will be helpful and vastly welcomed.

Introduction Treatment of malignant pleural mesothelioma (MPM) remains a clinical challenge. The aim of this study was to identify selection factors for allocation of MPM patients to multimodal therapy based on survival data from 12 years of experience. Methods Eligible patients had MPM of all histological subtypes with clinical stage T1–3 N0–2 M0. Induction chemotherapy consisted of cisplatin/gemcitabine (cis/gem) or cisplatin/pemetrexed (cis/pem), followed by extrapleural pneumonectomy (EPP). Multivariate analysis was performed to assess independent prognosticators for overall survival (OS). A Multimodality Prognostic Score was developed based on clinical variables available before surgery. Results From May 1999 to August 2011, 186 MPM patients were intended to be treated with induction chemotherapy followed by EPP. Hematologic toxicity was significantly less frequent after cis/pem compared to cis/gem, but there was no difference in response or OS between the regimens. One hundred and twenty-eight patients underwent EPP with a 30-day mortality of 4.7%. Fifty-two percent of the patients received adjuvant radiotherapy. The median OS of patients undergoing EPP was significantly longer with 22 months (95% confidence interval: 20–24) when compared to 11 months (9–12) for patients treated without EPP. A prognostic score was defined considering tumor volume, histology, c-reactive protein level, and response to chemotherapy that identified patient groups not benefitting from multimodality treatment which was confirmed in an independent cohort. Conclusion Patients receiving induction chemotherapy followed by EPP for MPM of all histological subtypes and irrespective of nodal status showed a median survival of 22 months. A prognostic score is proposed to help patient allocation for surgery after validation in an independent cohort.

PURPOSE The objective of this study was to determine the diagnostic value of computed tomography (CT) and positron emission tomography (PET)/CT for staging of malignant pleural mesothelioma (MPM) in patients undergoing induction chemotherapy. METHODS Sixty-two patients (median age, 61 years; female: n = 9) with proven MPM underwent CT after induction chemotherapy. Of these, 28 underwent additional PET/CT. Extrapleural pneumonectomy was performed for pathological TNM staging. Clinical TNM stage was assessed by 3 independent readers. Relative and absolute underestimation and overestimation were compared with pathological tumor stage. Sensitivity, specificity, and accuracy for differentiation between stages T2 and T3 were assessed. Interobserver agreement between the readers was analyzed (κ). RESULTS Positron emission tomography/CT and CT underestimated T stage in up to 30% of the cases. Positron emission tomography/CT had a higher accuracy for tumor extent compared with CT (PET/CT: 0.92; CT: 0.84). The accuracy for nodal staging was higher for CT than for PET/CT (PET/CT: 0.78; CT: 0.87). Concerning International Mesothelioma Interest Group classification, PET/CT improved the accuracy of preoperative staging compared with CT (PET/CT: 0.91; CT: 0.82). Interobserver agreement was moderate for CT (0.48-0.62) and good for PET/CT (0.64-0.83) for T staging. For nodal staging, interobserver agreement was fair to moderate for CT and good for PET/CT (CT: 0.37-0.51; PET/CT: 0.73-0.76). CONCLUSIONS Positron emission tomography/CT is more accurate and has a lower interobserver variability for clinical intrathoracic staging of MPM compared with CT. Nevertheless PET/CT underestimated tumor stage in a substantial number of cases, showing the need for a more accurate imaging technology or approach.

Objective: Lung transplantation is the ultimate treatment option for patients with end-stage cystic fibrosis (CF) lung disease. Despite poorer reports on survival benefit for CF patients undergoing lung transplantation, several centers, including ours were able to show a survival benefit. This study compares our center’s experience with 100 consecutive recipients in two different eras. Methods: All CF patients who underwent lung transplantation at our center were included (1992—2009). Survival rates were calculated and compared between the earlier era (before 2000) and later era (since 2000). Results: CF patients constituted 35% of all transplantations performed at our institution. Mean age at transplantation was 27 years (range 12—52). Fifty-one percent of the patients were female. Waiting list time was lower in the earlier era compared to the later era ( p = 0.04). Lobar transplantation was performed in 10 cases. Thirty-four percent of the cases required downsizing of the graft. In 33% of the cases, transplantations were done on cardiopulmonary bypass. There were no anastomotic complications. Total intensive care unit stay was significantly lower in the later era compared to earlier era ( p = 0.001). The other parameters such as C-reactive protein at the time of transplantation, total cold ischemic time, and total operation time were comparable between the two eras. Overall 30-day mortality was 5%. The 30-day mortality was significantly lower in the second period ( p = 0.006). In the earlier era, 3-month, 1-year, and 5-year survival were 85 6%, 77 8%, and 60 9%, respectively, and in the later era improved to 96 2%, 92 3%, and 78 5% ( p = 0.03). Conclusion: Improved results obtained in the early postoperative period since 2000 is most likely due to change in surgical management approach. Improved surgical outcome for CF patients can be obtained, especially in experienced transplant centers. # 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Objective: Pulmonary sequestration is a rare congenital malformation and may be the cause of recurrent infections or hemoptysis. It has been shown in case reports that resection by video-assisted thoracic surgery (VATS) is feasible despite the possible technical difficulties due to inflammatory changes, but its role has not been evaluated yet in a larger series of consecutively treated patients. Methods: Retrospective analysis of all consecutively thoracoscopically treated patients (between January 1991 and January 2005) with pulmonary sequestration in a single center. We included 14 patients in the study who fulfilled the criteria; seven were women. Median age was 33 years (20—64 years). The following data were analyzed for all patients: major symptoms, diagnostic procedures, treatment, and outcome. Operative parameters and findings including operating time, blood loss, anatomical location of the sequestration, and feeding vessels were evaluated. Results: Leading symptoms were recurrent infections (10), hemoptysis (3), and chest discomfort (1). The diagnosis was made by CT scan. Additionally, an arteriography or an angio-MRI was done in three patients and one patient, respectively. Thirteen intralobar (all lower lobes, eight on the right) and one left-sided extralobar pulmonary sequestration were resected. We performed eight lobectomies, four atypical segmentectomies, one extralobar resection, and one occlusion of the aberrant artery. One case had to be converted to a thoracotomy due to bleeding from the aberrant artery. There was no mortality. Complications included pneumonia in three cases, one hemothorax, one pneumothorax after removing the chest tube, and one wound infection. All were treated conservatively. Conclusion: Thoracoscopic treatment of pulmonary sequestration is feasible in experienced hands. The aberrant systemic artery can be freed and dissected safely despite the frequently occurring inflammatory changes. Conversion rate to thoracotomy is low.

Objective: The limited number of available grafts is one of the major obstacles of lung transplantation. Size-reduced lung transplantation allows the use of oversized grafts for small recipients. Optimal lung size matching is vital to achieve best functional outcome and avoid potential problems when using oversized grafts. We hypothesise that donor-predicted postoperative forced expiratory volume in 1 s (ppoFEV1) correlates with the recipient best FEV1 after size-reduced lung transplant, being useful for the estimation of function outcome. Methods: All patients undergoing size-reduced or standard bilateral lung transplantation were included (1992—2007). Donor ppoFEV1 was calculated and corrected with respect to size reduction and correlated with recipient measured best FEV1 post-transplant. In addition, pre- and postoperative clinical data including surgical complications and outcome of all size-reduced lung transplant recipients were compared with standard lung transplant recipients. Results: A total of 61 size-reduced lung transplant recipients (lobar transplants, n = 20; anatomic or non-anatomic resection, n = 41) were included and compared to 145 standard transplants. The mean donor—recipient height difference was statistically significant between the two groups (p = 0.0001). The mean donor ppoFEV1 was comparable with recipient best FEV1 (2.7 0.6 vs 2.6 0.7 l). There was a statistically significantcorrelation betweendonorppoFEV1andrecipientbestFEV1(p = 0.01,r = 0.688).The30-daymortalityrateand3-month,1-and5-year survival rates were comparable between the two groups. Conclusions: In size-reduced lung transplantation, postoperative recipient best FEV1 could be predicted from donor-calculated and corrected FEV1 with respect to its size reduction. Compared to standard lung transplantation, equivalent morbidity, mortality and functional results could be obtained after size-reduced lung transplantation. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Chest wall trauma along with resulting pulmonary complications are associated with considerable morbidity and mortality. Non-surgical treatment of rib fractures has represented the gold standard for the past few decades but a new trend towards operative management has been encouraged by many surgeons who aimed to reduce morbidity, mortality and hospital length of stay (LOS). Indications, patient selection and timing of surgical stabilization of rib fractures (SSRF) remains still debated and the results of international conducted surveys show a large variability in decision-making. In this article, we discuss the state of the art of surgical management of traumatic rib fractures.

Blunt and penetrating trauma in children are uncommon but nevertheless remain a major source of morbidity and mortality. The peculiarity of some anatomic and physiologic factors makes the management and the treatment of pediatric thoracic trauma very difficult. A thorough evaluation of the patient along with a proper management are key factors in order to obtain excellent short- and long-term outcomes. Our review focuses on clinical presentation, diagnostic pathways and treatment options in pediatric chest trauma patients.

OBJECTIVES Lung volume reduction surgery (LVRS) improves dyspnoea, quality of life and may even prolong survival in carefully selected patients with end-stage emphysema. The benefit may be sustained for several years and vanishes with the natural progression of the disease. Data on repeated surgical treatment of emphysema are scarce. The aim of this study was to evaluate the safety, effects and outcomes of repeated LVRS (Re-LVRS) in patients no longer benefiting from their initial LVRS. METHODS Between June 2002 and December 2013, 22 patients (9 females) with advanced emphysema underwent Re-LVRS at a median of 60 months (25–196) after their initial LVRS. While initial LVRS was performed thoracoscopically as a bilateral procedure, Re-LVRS was performed unilaterally by a video-assisted thoracoscopic technique in 19 patients and, due to adhesions, by thoracotomy in 3 patients. Pulmonary function test (PFT) was performed at 3 and 12 months postoperatively. RESULTS Lung function at Re-LVRS was similar to that prior to the first LVRS. The 90-day mortality rate was 0%. The first patient died 15 months postoperatively. The median hospitalization time after Re-LVRS was significantly longer compared with the initial LVRS [14 days, interquartile range (IQR): 11–19, vs 9 days, IQR: 8–14; P = 0.017]. The most frequent complication was prolonged air leak with a median drainage time of 11 days (IQR: 6–13); reoperations due to persistent air leak were necessary in 7 patients (32%). Five patients (23%) had no complications. Lung function and Medical Research Council (MRC) score improved significantly for up to 12 months after Re-LVRS, with results similar to those after initial bilateral LVRS. The average increase in the forced expiratory volume in 1 s (FEV1) was 25% (a 7% increase over the predicted value or 0.18 l) at 3 months, and the mean reduction in hyperinflation, assessed by relative decrease in RV/TLC (residual volume/total lung capacity), was 12% at 3 months (a decrease of 8% in absolute ratios). The mean MRC breathlessness score decreased significantly after 3 months (from 3.7 to 2.2). CONCLUSIONS Re-LVRS can be performed successfully in carefully selected patients as a palliative treatment. It may be performed as a bridge to transplantation or in patients with newly diagnosed intrapulmonary nodules or during elective cardiac surgery. Morbidity is acceptable and outcomes may be satisfactory with significantly improved lung function and reduced dyspnoea for at least 12 months postoperatively.

OBJECTIVES: Lobar lung transplantation is an option that provides the possibility of transplanting an urgent listed recipient of small size with a size-mismatched donor lung by surgically reducing the size of the donor lung. We report our short- and long-term results with bilateral lobar lung transplantation (BLLT) and compare it with the long-term outcomes of our cohort. METHODS: Retrospective analyses of 75 lung transplant recipients who received downsized lungs with a special focus on 23 recipients with BLLT performed since January 2000. Postoperative surgical complications, lung function tests, late complications and survival were analyzed. The decision to perform lobar transplantation was considered during allocation and finally decided prior to implantation. RESULTS: Cystic fibrosis was the most common indication (43.5%) followed by pulmonary fibrosis (35%). Median age at transplantation was 41 (range 13–66) years. Fifteen were females. Nineteen of the transplantations (83%) were done with extracorporeal membrane oxygenation (ECMO) support; 3 of them were already on ECMO prior to transplantation. There was no 30-day or in-hospital mortality. No bronchial complications occurred. The most common early complication was haematothorax (39%), which required surgical intervention. The rate of postoperative atrial arrhythmias was 30%. Forced expiratory volumes in 1 s (% predicted) at 1 and 2 years were 76 ± 23 and 76 ± 22, respectively (mean ± standard deviation). By 2-year follow-up, bronchiolitis obliterans syndrome was documented in 3 patients with a median follow-up of 1457 days. Overall survivals at 1 and 5 years were 82 ± 8 and 64 ± 11%, respectively and were comparable with those of 219 other recipients who received bilateral lung transplantation during the same period (log rank test, P= 0.56). CONCLUSIONS: This study demonstrates that BLLT has short- and long-term outcomes comparable with those of standard bilateral lung transplantation. The limitation of lung transplantation due to size-mismatch, particularly in smaller recipients, could be overcome by utilizing lobar lung transplantation.

The resection of thymic tumours requires completeness and may be technically challenging due to the anatomical proximity of the delicate mediastinal structures. An open approach by sternotomy is still recommended in all cases with locally extended disease. Video-assisted thoracoscopic surgery is feasible, but limited by the two-dimensional vision and the impaired mobility of the instruments. We evaluated the da Vinci® Surgical System for the resection of various mediastinal pathologies, particularly thymomas.Among 105 patients operated on by robotic assisted thoracoscopic surgery (RATS) for mediastinal tumours between 27 August 2004 and 12 July 2011, 20 patients with thymomas were studied prospectively. Of these, 10 males with a median age of 53 years, with a well-circumscribed thymic lesion on computed tomography (CT) and a diameter of6 cm were resected by RATS alone, and selected ones (n = 3), with a diameter of6 cm, underwent a hybrid procedure with a contralateral thoracotomy on the side of the main tumour extension. A regular follow-up with chest CT scans was performed every 6 months.Thymoma resection was complete in all patients. Partial pericardial resection was needed in five and pulmonary resection in two patients. Eighty-five percent of patients had an R0 resection. Histological classifications included thymoma WHO type A (n = 3), AB (n = 8), B1-2 (n = 5) and B3 (n = 4). All B3 thymomas received adjuvant radiotherapy. No intraoperative complications occurred. The median hospitalization time was 5 days (range 2-14 days). There were no local, but two pleural, recurrences. After a median observation time of 26 months, 19 patients (95%) are alive.Well-circumscribed thymomas can be safely and completely resected with the da Vinci® Surgical System with excellent short- and mid-term outcomes. Selected tumours with large diameters may be resectable using a hybrid procedure combining RATS with a thoracotomy.

Video-assisted thoracic surgery (VATS) represents nowadays the standard for the treatment of the majority of benign and malignant lung diseases. Even if the learning curve brings per se an increase in the number of post-operative complications, more and more surgeons have gained experience and can perform also complex cases thoracoscopically getting good outcomes without increasing morbidity and mortality. Nevertheless, the only surgeon without intraoperative complications is the one who performs no surgery.

Background: We assessed longevity and complications of totally implantable venous access devices in oncology patients. Methods: 197 patients received a total of 201 port devices via the subclavian vein for delivery of chemotherapy between January 1, 2005, and December 31, 2006. We reviewed the patient charts for port-related complications and risk factors until July 31, 2007. Results:A total of 47,781 catheter days were analyzed (median, 175 days; range, 1–831). Forty-six different complications occurred (0.96 complications/1,000 catheter days). The only risk factor significantly associated with a higher complication rate was younger age. Older patients had a lower risk for developing complications with a risk reduction of 2.4% for each year. There were no differences regarding underlying tumor, gender, access side, method of placement (subclavian/cephalic vein) or implanting team (thoracic versus visceral surgery). A trend was seen for shorter port longevity in hematologic patients compared to oncologic patients (p = 0.059). The former developed significantly more port-associated infections than solid tumor patients [11/53 cases (21%) versus 2/148 cases (1.4%); p < 0.0001]. Conclusions: Port-associated infections were mostly observed in younger patients with hematologic neoplasms. Prospective trials should be performed to evaluate the benefit of a prophylactic antimicrobial lock in these selected patients.

Objective: Solitary fibrous tumours of the pleura (SFTP) are rare and can histologically be differentiated into benign and malignant forms. The aim of this study is to present new cases, and discuss up-to-date preoperative examinations, the role of video-assisted thoracic surgery and longterm outcome. Methods: Between 1993 and 2006, 27 SFTPs were diagnosed (14 females, mean age SD, 62.3 9.6 years) at our institution. Medicalrecordswere reviewed,and follow-up was obtained byrepeated examinations orcontactwith generalpractitioners.Results:SFTPswere associated with symptoms in 63% of all cases. In the six patients in which positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) was performed preoperatively, malignant lesions were all found to be positive. Complete resection was achieved by video-assisted thoracic surgery in 15 and anterolateral thoracotomy in 12 patients. Mean hospital stay was shorter for patients operated by video-assisted thoracic surgery compared to thoracotomy, 4.5 (range 3—6) versus 7.5 (range 4—25) days, respectively (p < 0.01). Histology revealed 17 benign and 10 malignant SFTP. Mean SD tumour diameter of malignant SFTPs was larger than in benign forms, 11.9 7.1 versus 6.1 3.5 cm, respectively (p < 0.01). Tumour recurrence was recognised in four patients with malignant SFTPs at a median time interval after surgery of 38 (range 6—122) months, two late deaths occurred resulting from tumour recurrences. Conclusions: SFTPs can be treated minimally invasively by video-assisted thoracic surgery with short hospital stay. Large SFTPs with increased FDG-uptake have a high likelihood for malignancy. Long-term follow-up is mandatory in malignant SFTPs because of late recurrences associated with death. # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

BACKGROUND: Extracorporeal life support (ECLS) as a bridge to lung transplantation (LuTx) is a promising option for patients with end-stage lung disease on the transplant waiting list. We investigated the outcome of patients bridged to lung transplantation on ECLS technologies, mainly extracorporeal membrane oxygenation (ECMO). METHODS: Between January 2007 and October 2013, ECLS was implanted in 30 patients with intention to bridge to LuTx. Twenty-six patients (26/30) were successfully bridged to LuTx on ECLS. The most common diagnosis was cystic fibrosis (N = 12). Venovenous ECMO was used in 10, venoarterial in 4, interventional lung assist in 5, and stepwise combination of them in 7 recipients. RESULTS: Two patients weaned from ECMO, and 2 patients died on ECMO on the waiting list. Median duration of ECLS was 21 days (1-81 years). Six patients were awake and spontaneously breathing during ECLS support. Thirty-day, 1-year, and 2-year survivals were 89%, 68%, and 53%, respectively, for bridged patients and 96%, 85%, and 79%, respectively, for control group (P = 0.001). Three months conditional survivals were 89% and 69% at 1 and 2 years for ECLS group, compared to 92% and 86% for control group (P = 0.03). Cystic fibrosis recipients had 82% survival rate at 1 and 2 years. All recipients bridged to LuTx on awake ECLS (N = 6) are alive with a median follow-up of 10.8 months (range, 6-21 months). CONCLUSIONS: Our data show significantly lower survival in this high-risk group compared to patients transplanted without preoperative ECLS. Awake and ambulatory ECLS provides the best prognosis for these high-risk patients.

Objective: To investigate the incidence and management of postoperative complications after neoadjuvant chemotherapy followed by extrapleural pneumonectomy for malignant pleural mesothelioma. Methods: Patients with histologically proven mesothelioma of clinical stages T1—3, N0—2, M0 and considered to be completely resectable received neoadjuvant chemotherapy (cisplatin + gemcitabine or cisplatin + pemetrexed) followed by extrapleural pneumonectomy and postoperative radiotherapy. The incidence and management of postoperative complications in general and of bronchopleural fistula and postpneumonectomy-empyema in particular were analyzed. Univariate analysis was performed toidentifyprognosticfactors[sex,age,sideofoperation,weightloss,smoking,chemotherapy, EORTC-score(EuropeanOrganizationforResearch and Treatment of Cancer-classification) and duration of operation]. Results: Between 1st May 1999 and 15th August 2005, 63 patients underwent complete extrapleural pneumonectomy after neoadjuvant chemotherapy. Postoperative complications were observed in 39 cases (62%) and 2 patients died within 30 days (3.2%). Postpneumonectomy-empyema occurred in 15.8% of the patients (n = 10), six with a bronchopleuralfistula on the right side. All empyemas were treated successfully. Five patients developed chylothorax (7.9%) and four patients had complications due to a patch failure: cardiac herniation (n = 2), restriction of cardiac output (n = 1) or gastric herniation (n = 1). Patients with higher EORTC-score presentedsignificantly morepostoperativecomplications (p = 0.03). A longer duration of surgery tended to be associatedwith a higher incidence of postoperative complications, especially of empyemas. Conclusions: Extrapleural pneumonectomy after neoadjuvant chemotherapy can be performed with mortality rates comparable to standard pneumonectomies. Complications are frequent but can be successfully managed; the EORTC-score seems to be a predictor for postoperative complications.

We report a 57-year-old female with severe airway obstruction who underwent resection of a tumor of unknown dignity during lung volume reduction surgery. The nodule consisted of a well-differentiated neuroendocrine tumor (carcinoid), and severe chronic obstructive lung disease was due to diffuse idiopathic pulmonary neuroendocrine cell hyperplasia, a very rare cause of obliterative bronchiolitis. Radionuclide ablative therapy of the neuroendocrine tissue was considered but not found to be feasible due to a low lung/background ratio of the radiotracer.

Background Resection for localized bronchiectasis is a well established therapy. However, there is little information on the role of surgery in non-localized bronchiectasis. Methods Between January 1992 and April 2001, 55 patients without cystic fibrosis underwent resection. Forty-eight patients (mean age 45 (range 23–74) years; 32 women) were available for long-term follow-up. Twenty-five patients underwent resection for localized disease (group 1) and 23 had bronchiectasis in at least two different lobes (group 2). Results Thirty-one of the 48 patients were treated by Video Assisted Thoracoscopic Surgery (VATS) resection. There was no 30-day mortality. Mean duration of hospital stay was 10·9 (range 6–31) days in group 1 and 11·1 (range 5–19) days in group 2. Three of 25 patients in group 1 required reoperation. Only minor complications occurred in group 2 (three patients). Mean follow-up for both groups was 37 (range 6–97) months. Twenty-three of 25 patients in group 1 and 16 of 23 in group 2 reported satisfaction at 6 months after the operation. Recurrent infection was noted in three patients in each group. Haemoptysis recurred in only one patient in group 2. Conclusion The surgical treatment of selected patients with non-localized bronchiectasis was safe and most patients were satisfied with the outcome.

Objectives: Pneumonectomy in chronic pulmonary infection with empyema is associated with a high mortality rate and an increased risk of recurrent empyema. The surgical resection is technically demanding, and successful management continues to be a challenge. Methods: We evaluated a concept which combines (pleuro-)pneumonectomy or completion pneumonectomy with surgical debridement of the pleural cavity and packing with povidine–iodine soaked dressings. The debridement and packing is repeated in the operating theater after 48 h until the chest cavity is macroscopically clean. Finally, the pleural space is obliterated with antibiotic solution. Results: Between February 1997 and October 2000, 11 patients (average age of 59 years, ranging from 25 to 84) with destroyed lung caused by tuberculosis (six), aspergilloma (two), bronchiectasis (one), esophago-pleural fistula (one) or broncho-pleural fistula after lobectomy for bronchial carcinoma (one) and ongoing chronic infection with acute empyema (ten) (25–2500 days between first and definitive therapy) were treated. Pleural culture findings showed Aspergillus in four, Mycobacterium in two, Enterococcus in two, Candida in one and Staphylococcus in one, respectively. The mean number of interventions was 2.9 (2–4). The chest was definitively closed in all patients within 1 week. The mean hospitalization time was 19 days (9–31 days).In the follow-up (10–54 months), there was no recurrence of empyema. One patient (84 years) died at day 31, due to sepsis. Conclusions: Pneumonectomy combined with repeated surgical debridement and antimicrobial therapy enables the successful treatment of chronic pulmonary infection with empyema within a short time period. q 2002 Published by Elsevier Science B.V.

Tuberculosis affects pulmonary and extra-pulmonary sites with a multitude of differing presentations. The involvement of thoracic wall is a rare entity. We report the case of a patient who had a tumefaction on the right chest wall 6 months after a right breast mastectomy. After an initial radiological suspicion of malignancy, we detected intraoperatively an abscess in which histologic examination revealed granulomas with multinucleated giant cells.

Background Solitary fibrous tumors of the pleura (SFTP) are rare and their long-term outcome is difficult to predict, as there are insufficient data which allow accurate characterization of the malignant variant. Thus the aim of this study was to describe the outcome and possible determinants of malignant behavior of SFTPs. Methods Data were collected retrospectively from medical records of patients treated at the University Hospital Zurich from 1992 to 2012. Kaplan-Meier and Cox regression analysis were performed to define disease-free survival time (defined as survival without tumor-recurrence or tumor-related death) using the classical histo-morphological criteria (tumor size, localization, pedunculation, tumor necrosis or hemorrhage, mitotic activity and nuclear pleomorphism) and immunohistochemical parameters. Results 42 patients (20 males) with SFTP (median (IQR) age 62 (56–71) years) could be identified. SFTP were associated with symptoms in 50% of all cases. Complete resection was achieved by video-assisted thoracic surgery or thoracotomy in 20 and 22 patients, respectively. Three SFTP-related deaths (7.1%) and four tumor recurrences (9.5%) were observed. Mean disease-free survival time was 136.2 (±13.1) months, and 2-, 5- and 10-year disease-free survival was 91%, 84%, and 67%, respectively. Mean disease-free survival inversely correlated with the mean tumor diameter, number of mitotic figures and proliferation rate (Ki-67 expression). Other criteria (tumor necrosis, atypical localization, sessile tumor, and pleomorphism) were not statistically significant prognostic parameters. Conclusions Patients with large SFTP with a high mitotic index and high proliferation rate should be followed-up closely and over a prolonged time period in order to recognize recurrence of the SFTP early and at a treatable stage. Future research on this topic should focus on the prognostic role of immunohistochemistry including Ki-67 expression and molecular parameters.

Lung transplantation is an accepted therapy in selected patients with end-stage lung disease. However, there is a shortage of suitable donor organs, in particular for small or pediatric patients. Simultaneous bilateral lobar lung transplantation derived from one large donor into two small recipients is reported. The upper lobes were transplanted into the smaller female recipient, and the middle and right lower lobe and left lower lobe were transplanted into the male recipient.

Introduction Patients with stage IV metastatic non-small cell lung cancer (NSCLC) are generally not considered for surgery due to their poor median survival ranging from 4 to 11 months. However published results suggested that carefully selected patients with oligometastatic disease may benefit from resection of both the primary and metastatic sites in a multidisciplinary treatment approach. The aim of the study was to analyze and detect prognostic factors in surgically treated patients with synchronous single-organ metastasis from NSCLC. Methods This is a retrospective single-center study including 29 patients with synchronous single-organ metastatic NSCLC who underwent lung resection and local treatment of the metastasis between 2002 and 2008. Overall survival was estimated from the date of lung surgery until last follow-up. The impact on survival of nine variables (age, pT, pN, site of metastasis, presence of solitary metastasis, R-resection status, presence of neoadjuvant or adjuvant treatment, tumor histology) were further assessed. Results Twenty-nine patients (20 males, 69%) with a median age of 62 (from 44 to 77) were included. Site of metastatic disease was the brain in 19, the lung in 8 and the adrenal glands in 2 patients. Histology was adenocarcinoma in 21, large-cell carcinoma in 3, squamous-cell carcinoma in 2 and other in 3 patients. Type of lung resection performed for primary tumors were pneumonectomy in 3, bilobar resection in 3, lobar resection in 17 and sublobar resection in 6 patients. Survival at 1 and 5 years for the overall population reached 65% and 36%, respectively. Median survival was 20.5 months. Univariate regression model analysis identified pathologic T stage as a predictor of survival. Patients with pT1–2 behaved statistically significantly better (p = 0.007) compared to patients with pT3–4 tumors. No impact on survival for the other 8 variables has been shown. Conclusions The 5-year survival rate of 36% confirms that multimodality treatment including surgical lung resection should be considered in the therapy of single-site metatastatic NSCLC for selected patients. Pathologic T stage appeared to have significant impact on predicting patient survival.

OBJECTIVES: Sleeve resection is the operation of choice in patients with centrally located tumours, in order to avoid a pneumonectomy. Most surgeons protect the bronchial anastomoses with tissue to prevent insufficiencies. The purpose of this study is to report on outcome of unwrapped bronchial anastomoses, especially after neoadjuvant chemo- or chemoradiotherapy. METHODS: Between 2000 and 2010, 103 patients [59 years (range 16–80), 40 females] underwent bronchial sleeve resections without coverage of the anastomosis with a tissue flap. We retrospectively reviewed the data for morbidity, mortality and survival, especially with regard to the type of resection, neoadjuvant therapy and stage. RESULTS: Sleeve lobectomy was performed in 88, sleeve bilobectomy in 8, sleeve pneumonectomy in 4 and sleeve resection of the main bronchus in 3 patients. Twenty-seven patients had a combined vascular sleeve resection. Neoadjuvant chemotherapy was performed in 20 and radiochemotherapy in 5 patients. Non-small cell lung cancer (NSCLC) was present in 76 patients (squamous cell carcinoma in 44, adenocarcinoma in 24, large cell carcinoma in 6 and mixed cell in 2) and neuroendocrine tumour in 20 and other histological types in 7 patients. The pathologic tumour stage in NSCLC was stage I in 26, stage II in 26, stage IIIA in 16, stage IIIB in 7 and stage IV in 1 patient. There were no anastomotic complications, especially no fistulas. One patient developed narrowing of the intermediate bronchus without need for intervention. Twenty-four patients had early postoperative complications, including 11 surgery-related complications (air leakage, nerve injury, haemothorax or mediastinal emphysema). The 30-day mortality was 3% (one patient died due to heart failure and two with multiorgan failure). The 5-year survival rate was 63% in NSCLC patients and 86% in neuroendocrine tumour patients. CONCLUSIONS: Sleeve resection without wrapping the bronchial anastomoses with a tissue flap is safe even in patients who underwent neoadjuvant chemo- or chemoradiotherapy. Therefore, wrapping of the bronchial anastomoses is not routinely mandatory.

PURPOSE: Anastomotic complications following lung transplantation (LuTx) have been described in up to 15% of patients. Challenging to treat, they are associated with high morbidity and a mortality rate of 2-5%. The aim of this study was to analyze the incidence of complications in a consecutive series of bronchial anastomosis after LuTx at our center and to delineate the potential risk factors. METHODS: Between 1992 and 2007, 441 bronchial anastomoses were performed in 235 patients. Indications for transplantation were cystic fibrosis (35.7%) emphysema (28.1%) pulmonary fibrosis (12.8%) and pulmonary hypertension (7.7%). There were 206 sequential bilateral and 28 single transplants including lobar engraftments in 20 cases. The donor bronchus was shortened to the plane of the lobar carina including the medial wall of the intermediate bronchus. Peribronchial tissue was left untouched. Anastomosis was carried out using a continuous absorbable running suture (PDS 4/0) at the membranous and interrupted sutures at the cartilaginous part. Six elective surveillance bronchoscopies were done monthly during the first half-year post-LuTx, with detailed assessment of the pre- and post-anastomotic airways. RESULTS: One-year survival since 2000 was 90.5%. In all 441 anastomoses performed, no significant dehiscence was observed. In one patient, a small fistula was detected and closed surgically on postoperative day five. Fungal membranes were found in 50% of the anastomoses at 1 month and in 14% at 6 months. Discrete narrowing of the anastomotic lumen without need for intervention was found in 4.9% of patients at 1 month and in 2.4% at 6 months. Age, cytomegalovirus status, induction therapy, immunosuppressive regimen, ischemic time, and ventilation time had no influence on bronchial healing. CONCLUSIONS: Clinically relevant bronchial anastomotic complications after LuTx can be avoided by use of a simple standardized surgical technique. Aggressive antibiotic and antifungal therapy might play an important supportive role.

Background: Postpneumonectomy syndrome (PPS) is a rare complication after pneumonectomy. It consists of an excessive mediastinal shift resulting in compression and stretching of the tracheobronchial tree and the esophagus. The aim of this study was to give a comprehensive overview of diagnosis, variety of symptoms and evaluation of surgical treatment of PPS. Methods: We retrospectively reviewed the charts of all our patients with PPS since 1994 with respect to symptomatology, treatment and outcome. Our results were compared with case reports and case seriesintheliterature.Results:Sixwomenwithamedianageof56.5years(range49—65)developedPPSafterpneumonectomyforthetreatment of lung cancer. Four presented with a right PPS and two with a left PPS, respectively. Symptomsconsisted of shortness of breath in all patients and dysphagia as well as heartburn in two patients. Correction of PPS required re-exploration of the pneumonectomy space, reposition of the mediastinum followed by the insertion of single silicone prosthesis in five patients or fixation of the mediastinum with a xenopericardial graft in one patient. We could observe an improvement of the FEV1/FVC ratio in all our patients and the clinical improvement of shortness of breath was better than we expectedby changes of lung function.Four patients returnedto theirregular activities with a follow-up of four years. We found 73 cases of PPS in the literature, on the right side in 50 patients (68%) and on the left side in 23 patients (32%). Fifty-nine patients (81%) were treated surgically. Symptoms can be suspicious for cardiogenic origin and vary from heartburn to recurrent syncopes. Conclusion: PPS is rare and not predictable.Itcanoccurafterrightorleftpneumonectomy. Symptomsaremanifoldandresult fromashift,leadingto compressionandstretching of the two conduits located within the mediastinum, the tracheobronchial tree and the esophagus and consists of shortness of breath, stridor and heartburn. Diagnosis must be made by exclusion. Implantation of prosthesis is the most commonly used and effective treatment. # 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

OBJECTIVE: Postpneumonectomy empyema remains a clinical challenge. We proposed an accelerated therapy without an open chest window 5 years ago. This concept was evaluated on a larger scale in 2 centers in 2 different countries. METHODS: Between July 1995 and October 2005, 75 consecutive patients with postpneumonectomy empyema were treated in Szczecin, Poland (n = 35), and Zurich, Switzerland (n = 40). The therapy consisted of repeated open surgical debridement of the pleural cavity after achievement of general anesthesia, a negative pressure wound therapy of the temporarily closed chest cavity filled with povidone-iodine-soaked towels, and continuous suction and systemic antimicrobial therapy. If present, bronchopleural fistulae were closed and reinforced either with a muscle flap or the omentum. Finally, the pleural space was filled with an antibiotic solution and definitively closed. RESULTS: Of 75 patients (63 men; median age, 59 years; age range, 19-82 years), postpneumonectomy empyema was present on the right in 46 patients (32 with bronchopleural fistula) and in 29 patients (12 with bronchopleural fistula) on the left. Median time between pneumonectomy and postpneumonectomy empyema was 131 days (range, 7-7200 days). Bronchopleural fistulae have been closed and additionally reinforced by means of different methods (omentum, 18; muscle, 11; pericardial fat, 5; azygos vein, 1). The chest was definitively closed within 8 days in 94.6% of patients. The median hospitalization time was 18 days (range, 9-134 days). Postpneumonectomy empyema was successfully treated in 97.3% of patients, including 10 (13%) patients who needed a second treatment cycle. Three (4%) patients died within 90 days. The median follow-up time was 29.5 moths (range, 3-107 months). CONCLUSIONS: Treatment of postpneumonectomy empyema with the accelerated treatment is effective and safe. Our results are superior compared with those in reported series using a (temporary) chest fenestration. Patients appreciate the physical integrity of the chest.