Search

OBJECTIVES Patients with oligometastatic non-small-cell lung cancer (NSCLC) may benefit from therapy with curative intent. Our goal was to identify prognostic factors related to better prognosis in a multicentre analysis of patients who underwent surgery of primary tumours in combination with radical treatment of all metastatic sites. METHODS We retrospectively reviewed the records of oligometastatic patients who underwent resection of primary tumours at 4 centres (August 2001–February 2018). Oligometastasis was defined as ≤5 synchronous metastases in ≤2 organs. Radical metastatic treatment was surgery, radiotherapy or a combination. The Cox proportional hazards model was used for identification of prognostic factors on overall survival. RESULTS We treated 124 patients; 72 (58%) were men, mean age 60 ± 9.8 years, with 87 (70%) adenocarcinoma. Sixty-seven (54%) patients had positive pathologic-N stage (pN). Brain metastases were most common (n = 76; 61%) followed by adrenal (n = 13; 10%) and bone (n = 12; 10%). Systemic therapy was administered in 101 (82%) patients. Median follow-up was 60 months [95% confidence interval (CI) 41–86]. Thirty- and 90-day mortality rates were 0 and 2.4%, respectively. One-, 2-, and 5-year overall survival were 80%, 58% and 36%, respectively. Cox regression analysis showed that patients ≤60 years [hazard ratio (HR) 0.41, 95% CI 0.24, 0.69; P = 0.001] and patients with pN0 (HR 0.38, 95% CI 0.21–0.69; P = 0.002) had a significant survival benefit. The presence of bone metastases negatively affected survival (HR 2.53, 95% CI 1.05–6.09; P = 0.04). CONCLUSIONS Treatment with curative intent of selected oligometastatic NSCLC, including resection of the primary tumour, can be performed safely and with excellent 5-year survival rates, especially in younger patients with pN0 disease.

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.

Background: Residual pleural space after lung resection associated with air leak is a challenging issue, potentially causing serious complications. We report a new, postoperative technique to reduce the pleural space, inducing a controlled and reversible paralysis of the diaphragm. Methods: Ten patients were enrolled (7 lobectomies, 2 bilobectomy, 1 wedge resection). Inclusion criteria were: digitally detected air flow >200 mL/min at post-op day 3, presence of empty pleural space at chest x-ray, absence of restrictive lung disease, absence of known arrhythmias. A 22G nerve-block catheter was place under ultrasound guidance in proximity to the phrenic nerve, between the sternocleidomastoid muscle and the anterior scalene muscle at the level of 6 th cervical vertebra. Continuous infusion of ropivacaine 0.2%3 mL/h was started. Fluoroscopy was used to confirm significant reduction in hemidiaphragm movements. Monitoring of vital signs and intense respiratory physiotherapy were enhanced. The infusion was stopped at air leak cessation and the catheter was removed along with the chest drain. Results: No peri- and post-procedural complications occurred. In all patients, we observed an immediate reduction of the empty pleural space and resolution of the air leak within few days (3±1.16 days). After suspension of local anaesthetic, complete restoration of the hemidiaphragm function has been documented. Conclusions: This is an effective and minimally invasive method to reduce the residual pleural space after lung resections. Narrowing of the pleural space facilitates the contact between the lung and the chest wall promoting the resolution of the air leak. Diaphragm paralysis is controlled and temporary with no residual disabilities.

Background Indication for postdrain removal imaging after lung resection is debated. Chest roentgenogram (CR) is widely used to confirm lung expansion but not evidence based. We propose to introduce lung ultrasound (LUS) as alternative to exclude significant pneumothorax (PTx) in this setting. Methods The study enrolled 50 patients undergoing lung resections. Inclusion criteria were complete expansion of the lung at postoperative CR, pleural effusion of less than 300 mL/24 h, air leak of 10 to 20 mL/min for 6 hours. Two hours after chest drain removal, LUS was performed at the second and third intercostal spaces to assess pleural sliding. Patients with no detected PTx or with apical PTx were considered for discharge. The same patients were blindly evaluated with CR by a second operator, and a comparison between the two methods was performed. Clinical decisions were taken based on CR results. Results LUS confirmed large PTxs in 7 patients, apical PTxs in 10 patients, and no PTx in 33 patients. CR confirmed 5 of 7 significant PTxs (1 chest drain reinserted, 4 patients observed), and 2 of 7 PTx were considered irrelevant. Apical PTxs were confirmed in 8 of 10 patients, and in 2 patients there was no PTx at CR. The 33 patients with no PTx at LUS had full lung expansion at CR. LUS has a negative predictive value of 100% in excluding large PTxs and a positive predictive value of 71%. Conclusions In this subgroup of patients with air leak of 10 to 20 mL/min, performing an imaging study to verify the absence of PTx is desirable; however, when LUS confirms lung expansion or the presence of apical PTx, CR does not seem to be needed.

OBJECTIVES Recent evidence shows that permissive anaemia strategies are safe in different surgical settings. However, effects of variations in haemoglobin (Hb) levels could have a negative impact in high-risk patients. We investigated the combined effect of postoperative Hb concentration and cardiac risk status on major cardiopulmonary complications after anatomical lung resections. METHODS We retrospectively analysed the records, collected in a prospective clinical database, of 154 consecutive patients undergoing anatomical lung resections at our institution (February 2017–February 2019). Hb levels were displayed as preoperative concentration, nadir Hb level before onset of complications and delta Hb (ΔHb). Cardiac risk was stratified according to the Thoracic Revised Cardiac Risk Index (ThRCRI). Univariable and multivariable logistic regression analyses were used to test the associations between patients, surgical variables and cardiopulmonary complications according to the European Society of Thoracic Surgeons definitions. RESULTS Cardiopulmonary complications occurred in 63 patients (17%). In the fully adjusted multivariable model, higher values of ΔHb were associated with increased risk of complications [odds ratio (OR) 1.07; P CONCLUSIONS In our series, ΔHb, rather than nadir Hb, was associated with an increased risk of complications, particularly in patients with higher cardiac risk. Restrictive transfusion strategies should be carefully applied in patients undergoing lung resections and balanced according to individual clinical status.

Surgical stabilization of flail chest decreases mortality, complications and costs. A 48-year-old male sustained a cardiac arrest followed by successful cardio-pulmonary resuscitation. An anterior flail chest due to bilateral rib fractures and a sternal fracture led to respiratory failure. A surgical stabilization of the flail chest was indicated, and a minimally invasive approach was preferred. A titanium plate for the sternum and a Nuss bar for rib fractures were successfully placed, followed by full and prompt recovery. It is an effective and safe procedure since minimizes the surgical trauma with benefits of chest wall stabilization.

The pleura connect the lungs and the chest wall. This interaction is therefore very important for appropriate breathing mechanics. There is a logical association between the pleura’s physiology and physical attributes and its anatomic and functional construction. The pressure difference between the two pleural sheets is essentially important in regard to the physiology and pathophysiology of the pleural space and its organs. The difference in pressure from the outer side of the lung and heart to the inner side of the chest wall is regulated by that pressure. The intrapleural pressure influences the regulation of two clinically relevant processes: the first is breathing and the second is the production, consistency, and amount of pleural fluid produced.The pathophysiologic changes in pleural fluid are produced as a consequence of changes in the complex pleural pressure relationships. The consistency of the pleural fluid has a crucial impact on clinical symptoms and course of any resultant disease states.

Trans-esophageal endoscopic ultrasound with fine-needle aspiration (EUS-FNA) is widely used to assess mediastinal masses. Common complications are self-limiting bleeding or pain, but occasionally, more serious accidents have been reported. A 54-year-old woman with a huge mass located in the left middle mediastinum presented 2 days after an EUS-FNA with dyspnea and chest pain. Computed tomography scan showed a massive left pleural effusion. A chest tube was inserted revealing a chylothorax (1800 ml). Over the following days, the pleural effusion did not diminish, requiring a left mini-thoracotomy. Intraoperative findings showed a pedunculated mass arising from the upper lobe. A wedge resection and a ligation of a large lymphatic vessel were performed. Postoperative course was regular. Histology showed a solitary fibrous tumor of the pleura. To our knowledge, the case we describe is the first reported chylothorax after EUS-FNA. Despite the demonstrated safety, particular care is mandatory in case of large, vascular, and heterogeneous masses.

Bei Patienten mit chronischem, therapierefraktarem Pleuraerguss ist eine dauerhafte Entlastung auf ambulanter Basis sinnvoll und wunschenswert.

Palliative thoraxchirurgische Eingriffe zielen auf die Sicherung oder Wiederherstellung einer möglichst umfassenden Lebensqualität des betroffenen Patienten. Die chirurgischen Grundlagen dazu basieren einesteils auf gesicherten, statistischen Ergebnissen, andererseits setzen sie profunde, klinische Erfahrung in onkologischer Chirurgie voraus. Um so mehr, als Palliation nicht Heilung als Ziel fordern kann, setzen derartige Operationen eine präzise Information und den partnerschaftlichen Einbezug des betroffenen Patienten voraus. Die Operabilität hängt vom Allgemeinzustand des Kranken und von der Invasivität des geplanten Eingriffes ab. Wird Tumorgewebe reseziert, ist auch in der palliativen Situation die lokale Radikalität grundsätzliches Ziel; multimodale Therapiestrategien gestatten chirurgisch-anatomisch bedingte Modifikationen. Zu den zentralen Indikationen der pallativen Thoraxchirurgie gehören die Lungenmetastasenresektionen. Dank neuen, lasertechnischen Verfahren lässt sich der Parenchymverlust minimieren und die Lobektomierate von 25% auf 4% senken. Bei Mortalitäts- und Morbiditätsraten unter 1% beträgt die 5-Jahres-Überlebensrate nach kompletter Metastasenentfernung über 30%. Brustwandtumoren verursachen Schmerzen und neigen zur Exulzeration; zudem bewirken sie durch ihre stete Präsenz Angst. Ihre Entfernung, kombiniert mit der plastischen Defektdeckung, ist deshalb auch in fortgeschrittenem Stadium sinnvoll. Bei mediastinalen Tumoren stellt die Chirurgie kurativ und palliativ – nebst der Aufgabe zur Histologiesicherung – einen der plurimodalen Behandlungspfeiler dar. Die thorakoskopische Talkpleurodese weist bei malignen Pleuraergüssen eine Erfolgsrate von über 90% aus, wenn die Lunge nach Ergussdrainage noch entfaltbar ist.

In a prospective study (June 1990 to June 1993), 79 patients were treated for spontaneous pneumothorax by video-assisted thoracoscopic methods with regular follow-up. The observation time was from 3 to 36 months (mean 19.6 months) and was more than 24 months in 27 patients. In 57 patients spontaneous pneumothorax was primary and in 22 secondary. The 53 male and 26 female patients were aged between 17 and 87 years (mean 37 years). Twenty-one patients were treated thoracoscopically for first episode, 22 for persistent pneumothorax (>7 days), and 36 for a recurrence. Endoscopic examination failed to reveal any lung alteration in four patients (5.1 %), and treatment then consisted of simple drainage. Leaks were sealed 26 times by means of a Roeder loop with local anesthesia and 14 times by wedge resection with endotracheal anesthesia and one-lung ventilation; 34 patients were treated by pleurectomy. No deaths occurred. Surgical morbidity was 3.8%, and the postoperative complication rate was 5.1 %. One patient was excluded from the follow-up study after conversion to a thoracotomy for control of arterial bleeding. We noted six recurrences; four occurred in the first 21 days and three after ligation of the leak with a Roeder loop. We conclude that video-assisted thoracoscopic treatment of spontaneous pneumothorax by wedge resection and pleurectomy has a recurrence-free rate of 93.8 % (45/48) and is therefore an effective treatment for all forms of spontaneous pneumothorax.

The patient, surgeon and hospital must meet a number of requirements before an perative thoracoscopy can be performed with acceptable risk factors.

In patients aged over 60 years, malignant disease is the cause of exudative pleural effusions in more than 50% of cases [118]. The formation of malignant pleural effusions can be expected during the course of the disease in 26%-49% of patients with carcinoma of the breast, 10%–24% with bronchial carcinoma, 16%–17% with ovarian carcinoma and 7%–15% with malignant lymphomas [35, 75]. The pleural cavity is almost always infiltrated by tumour cells, which in can be confirmed diagnostically in more than half the cases by the cytological examination of aspirated fluid. The effusion results either from increased capillary permeability owing to distended or destroyed capillary endothelium or is caused by tumorous lymph drainage [75]. It is also not uncommon for a hypalbuminaemia in cachectic patients to be the sole or contributive cause of pleural effusions. In over 80% of cases, both pleural membranes are involved in the exudation [75, 100, 146].

Large control series reported in the considerable body of literature dealing with diagnostic and interventional thoracoscopy confirm the low mortality and morbidity of the method. Viskum [173] found only one fatality in over 8000 recorded cases. In a review of the literature by Boutin et al. [19], the mortality rate was 0.09% in more than 4300 cases. It must, however, be pointed out that these figures primarily involved conventional thoracoscopic interventions for biopsy or to perform pleurodesis in cases of malignant effusions and spontaneous pneumothorax. These interventions are normally performed under local anaesthesia combined with intravenous sedation via one and more seldom two incisions.

If there are no special risks or indications involved, we base our measures for preventing thrombosis on those of open thoracic surgery in patients undergoing thoracoscopy under general anaesthesia. These patients are given s.c. lowmolecular heparin perioperatively. Preoperatively the patients are instructed to perform physiotherapeutic exercises to flex and extend the calf muscles and to systematically exercise their lower extremities. Postoperative mobilization begins on the day of the operation. When we perform thoracoscopies under local anaesthesia, we do not give any special prophylactics. Up to now we have seen no clinically manifest deep vein thrombosis. We have also had no case of clinically detectable pulmonary embolism.

The aim of minimally invasive surgery is to maintain the physical integrity of the patient as far as possible by reducing operative trauma. The resulting expectations such as the reduction in the time required for medical care and the patient’s earlier reintegration in everyday life should be considered under two aspects: firstly as an undoubted benefit for the patient, but also as a way of encouraging the patient to play a more responsible role in his or her own therapy. Promoting the patient’s insight into his or her own illness on the one hand, and minimizing the operative invasiveness on the other are the therapeutic aims which should determine the further development of this method.

A shadow found by chance on the chest X-ray is cause for concern for both doctor and patient, even when the location, form and extent strongly suggest a benign lesion. If growth of the tumour can be determined retrospectively or in the period following the discovery, not only verification by biopsy is indicated but also resection of the process. Surgical thoracoscopy is a suitable, definitive therapeutic method, which allows not only verification of the diagnosis by biopsy but also resection and evacuation.

The possibility of exploring the thoracic cavity and its structures directly and of obtaining biopsies from specific areas, swabs and specimens of effusion followed up by histological, cytological, microbiological, immunological and chemical analysis, makes thoracoscopy a valuable addition to the diagnostic arsenal of the practising pneumologist [41, 115, 174]. The most common indications and the results obtained can be seen in Table 8. In addition to the diagnostic thoracoscopies listed, in six patients with histologically verified bronchial carcinoma, oncological staging included the thoracoscopic dissection of a suspicious aorto-pulmonary lymph node (N2) which was followed by a planned mini-thoracotomy to verify the thoracoscopic findings.

Thanks to electronic transmission and storage facilities, the possibilities of documenting endoscopic findings and operative procedures are almost unlimited. Video recorders allow the whole operation to be recorded on tape. If questions arise, the tape can be reviewed and evaluated. Various types of video printers can provide hard copies of the main pathological findings, interesting anatomical variations and specific steps in the operation. The postoperative information for the physicians involved and for the patient is both simplified and far more objective. Including this pictorial information in the operation report adds a new precision to the case history. Slides, photographs and apes support and illustrate the spoken word in a teaching situation.

Eine zufallig entdeckte Verschattung im Thoraxrontgenbild ist fur den Arzt und den Patienten auch dann Anlas zur Beunruhigung, wenn Lokalisation, Form und Ausdehnung des Befundes eine benigne Lasion als wahrscheinlich erscheinen lassen. Ist retrospektiv oder im weiteren Verlauf eine Grosenzunahme feststellbar, wird deshalb oft nicht nur eine bioptische Verifizierung, sondern auch eine Resektion des Prozesses angestrebt. Die chirurgische Thorakoskopie bietet sich dazu als definitives Behandlungsverfahren an, welches uber eine bioptische Diagnosesicherung hinaus die definitive Resektion und Evakuation gestattet.

Durch die Moglichkeit der direkten Exploration des Thoraxraumes und seiner Strukturen sowie durch gezielte Biopsie-, Abstrich- und Ergusgewinnung und die nachfolgende histologische, zytologische, mikrobiologische, immunologische und chemische Analyse bildet die Thorakoskopie eine wertvolle Erganzung im diagnostischen Arsenal des pneumologisch tatigen Arztes [41, 115, 174]. Die haufigsten Indikationen und die erzielten Resultate sind Tabelle 8 zu entnehmen. Zusatzlich zu den aufgefuhrten diagnostischen Thorakoskopien wurde bei 6 Patienten im Rahmen des onkologischen Stagings bei histologisch verifiziertem Bronchuskarzinom im Anschlus an die thorakoskopische Praparation eines suspekten Lymphknotens aortopulmonal (N2) geplant eine Minithorakotomie zur Uberprufung der thorakoskopischen Befunddarstellung vorgenommen.

Der Patient sollte auf einem rontgenstrahlendurchlassigen Operationstisch liegen. Auch wenn selten notwendig, ist damit die Moglichkeit einer intraoperativen Darstellung des thorakalen Situs mittels Bildverstarker gewahrleistet.