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Purpose/introduction [18F]FDG-PET/CT is the standard imaging-technique for radiation treatment (RT) planning in locally advanced non-small cell lung cancer (NSCLC). The purpose of this study was to examine the additional value of endobronchial-ultrasound transbronchial needle aspiration (EBUS-TBNA) to standard PET/CT for mediastinal lymph-node (LN) staging and its impact on clinical target volume (CTV). Materials and methods All consecutive patients with primary stage III NSCLC who underwent [18F]FDG-PET/CT and EBUS-TBNA prior to RT were analyzed from 12/2011 to 06/2018. LN-stations were assessed by an expert-radiologist and a nuclear medicine-physician. CTV was evaluated by two independent radiation oncologists. LNs were grouped with increasing distance along the lymphatic chains from primary tumor into echelon-1 (ipsilateral hilum), echelon-2 (LN-station 7 and ipsilateral 4), and echelon-3 (remaining mediastinum and contralateral hilum). Results A total of 675 LN-stations of which 291 were positive for tumor-cells, were sampled by EBUS-TBNA in 180 patients. The rate of EBUS-positive LNs was 43% among all sampled LNs. EBUS-positivity in EBUS-probed LNs decreased from 85.8% in echelon-1 LNs to 42.4%/ 9.6% in echelon-2/ -3 LNs, respectively (p < 0.0001, Fisher’s exact test). The false discovery rate of PET in comparison with EBUS results rose from 5.3% in echelon-1 to 32.9%/ 69.1% in echelon-2/ -3 LNs, respectively (p < 0.0001, Fisher’s exact test). Sensitivity and specificity of FDG-PET/CT ranged from 85 to 99% and 67 to 80% for the different echelons. In 22.2% patients, EBUS-TBNA finding triggered changes of the treated CTV, compared with contouring algorithms based on FDG-avidity as the sole criterion for inclusion. CTV was enlarged in 6.7% patients due to EBUS-positivity in PET-negative LN-station and reduced in 15.5% by exclusion of an EBUS-negative but PET-positive LN-station. Conclusion The false discovery rate of [18F]FDG-PET/CT increased markedly with distance from the primary tumor. Inclusion of systematic mediastinal LN mapping by EBUS-TBNA in addition to PET/CT has the potential to increase accuracy of target volume definition, particularly in echelon-3 LNs. EBUS-TBNA is recommended as integral part of staging for radiochemotherapy in stage III NSCLC.

Background: Robotic-assisted surgery is gaining more adaption in different surgical specialties. The number of patients undergoing robotic-assisted thymectomy is continuously increasing. Such procedures are accompanied by new challenges for anesthesiologists. We are presenting our primary anesthesiologic experience in such patients. Methods: This is a retrospective single center study, evaluating 28 patients who presented with thymoma or myasthenia gravis (MG) and undergone minimal invasive robotic-assisted thoracic thymectomy between 01/2020–01/2022. We present our fast-track anesthesia management as a component of the enhanced recovery program and its primary results. Results: Mean patient’s age was 46.8 ± 18.1 years, and the mean height was 173.1 ± 9.3 cm. Two-thirds of patients were female (n = 18, 64.3%). The preoperative mean forced expiratory volume in the first second (FEV1) was 3.8 ± 0.7 L, forced vital capacity (FVC) was 4.7 ± 1.1 L, and the FEV1/FVC ratio was 80.4 ± 5.3%. After the creation of capnomediastinum, central venous pressure and airway pressure have been significantly increased from the baseline values (16.5 ± 4.9 mmHg versus 13.4 ± 5.1 mmHg, p < 0.001 and 23.4 ± 4.4 cmH2O versus 19.3 ± 3.9 cmH2O, p < 0.001, respectively). Most patients (n = 21, 75%) developed transient arrhythmias episodes with hypotension. All patients were extubated at the end of surgery and discharged awake to the recovery room. The first 16 (57.1%) patients were admitted to the intensive care unit and the last 12 patients were only observed in intermediate care. Postoperatively, one patient developed atelectasis and was treated with non-invasive ventilation therapy. Pneumonia or reintubation was not observed. Finally, no significant difference was observed between MG and thymoma patients regarding analgesics consumption or incidence of complications. Conclusions: Robotic-assisted surgery is a rapidly growing technology with increased adoption in different specialties. Fast-track anesthesia is an important factor in an enhanced recovery program and the anesthetist should be familiar with challenges in this kind of operation to achieve optimal results. So far, our anesthetic management of patients undergoing robotic-assisted thymectomy reports safe and feasible procedures.

Background/introduction In contrast to patients who present with advanced stage lung cancer and associated poor prognosis, patients with early-stage lung cancer may be candidates for curative treatments. The results of the NELSON lung cancer screening trial are expected to stimulate the development and implementation of a lung cancer screening strategy in most countries. Widespread use of chest computed tomography scans will also result in the detection of solitary pulmonary nodules. Because reliable biomarkers to distinguish between malignant and benign lesions are lacking, tissue-based histopathological diagnostics remain the gold standard. In this study, we aimed to establish a test to assess the predictive ability of DNA hypermethylation of SHOX2 and PTGER4 in plasma to discriminate between patients with 1.) lung cancer, 2.) benign lesions, and 3.) patients with chronic obstructive pulmonary disease (COPD). Patients and methods We retrospectively analysed SHOX2 and PTGER4 methylation in 121 prospectively collected plasma samples of patients with lung cancer (group 1A), benign lesions (group 1B), and COPD without nodules (group 2). Results PTGER4 DNA hypermethylation was more frequently observed in patients with lung cancer than in controls (p = 0.0004). Results remained significant after correction for tumour volume, smoking status, age, and eligibility for the NELSON trial. Conclusions Detection of methylated PTGER4 in plasma DNA may serve as a biomarker to support clinical decision-making in patients with pulmonary lesions at lung cancer screening in high-risk populations. Further exploration in prospective studies is warranted.

Objective: Uterine carcinosarcoma (UCS) is a rare but highly aggressive malignancy with biphasic growth pattern. This morphology can be attributed to epithelial-mesenchymal transition (EMT) that often associates with tumor invasion and metastasis. Accordingly, we analyzed a novel patient-derived preclinical model to explore whether EMT is a potential target in UCS. Methods: A novel UCS cell line (PF338) was established from the malignant pleural effusion of a 59-year-old patient at time of disease progression. Immunohistochemistry was performed in primary and metastatic tumor lesions. Oncogenic mutations were identified by next-generation sequencing. Viability assays and cell cycle analyses were used to test in vitro sensitivity to different standard and novel treatments. E-cadherin, β-catenin and pSMAD2 expressions were measured by immunoblot. Results: Whereas immunohistochemistry of the metastatic tumor showed a predominantly sarcomatous vimentin positive tumor that has lost E-cadherin expression, PF338 cells demonstrated biphasic growth and carried mutations in KRAS, PIK3CA, PTEN and ARID1A. PF338 tumor cells were resistant to MEK- and TGF-β signaling-inhibition but sensitive to PIK3CA- and PARP-inhibition and first-line chemotherapeutics. Strikingly, histone deacetylase (HDAC) inhibition markedly reduced cell viability by inducing a dose-dependent G0/1 arrest and led to mesenchymal-epithelial transition as evidenced by morphological change and increased E-cadherin and β-catenin expression. Conclusions: Our data suggest that HDAC inhibition is effective in a novel UCS cell line by interfering with both viability and differentiation. These findings emphasize the dynamic manner of EMT/MET and epigenetics and the importance of molecular profiling to pave the way for novel therapies in UCS.

Non-small cell lung cancer (NSCLC)11 NSCLC: Non-small cell lung cancer; 18FDG: 18fluorine fluorodeoxyglucose; PET: positron emission tomography; CT: computed tomography; SUV: standardized uptake value; TAM: tumor-associated macrophage; CCL18: CC-chemokine ligand 18; SUVmax: maximum standardized uptake value; SQC: squamous carcinoma; AC: adenocarcinoma; FEV1: forced expiratory volume in 1 s; is one of the most common malignancies in the western world [1]. Despite multiple therapeutic and diagnostic advances, the overall survival is low and recurrence of NSCLC is a common problem with different treatment regimens. The inclusion of 18fluorine fluorodeoxyglucose (18FDG) positron emission tomography (PET) in combination with computed tomography (CT) in clinical practice was revolutionary for the staging of NSCLC [2]. 18FDG-PET/CT provides morphological, functional, and metabolic information about the tumor, which is usually highly, metabolically active. Due to the increased glucose uptake, 18FDG is actively accumulatedin the tumor tissues, resulting in an increased standardized uptake value (SUV). The tumor tissue itself consists of neoplastic cells, extracellular matrix, fibroblasts, and various immune cells. These immune cells include tumor-infiltrating lymphocytes, regulatory T cells, and macrophages. Macrophages have different activation patterns and play an essential role in inflammation and cancer. In particular, tumor-associated macrophages (TAMs) are a specialized group of alternatively activated or M2 macrophages. TAMs release several chemokines that are different from those released by classically activated macrophages found in an inflammatory environment. One of the most important chemokines released by TAMs is CC-chemokine ligand 18 (CCL18). Although CCL18 is present in healthy subjects, its levels are significantly elevated in the serum of patients with NSCLC. It correlates with overall survival and tumor stage in several malignant diseases [3,4]. A recurring problem is that increased glucose metabolism can be found in the inflammatory tissue, which can also lead to an increased SUV in 18FDG PET/CT, lowering its oncological specificity [5]. In a previous study, we demonstrated that serum CCL18 levels can be used to differentiate between patients with NSCLC and healthy subjects [3]. Hence, we investigated the correlation between serum CCL18 levels and the maximum standardized uptake value (SUVmax) of the primary tumor using 18FDG-PET/CT. We found a significant correlation between the SUVmax of the primary tumor and the serum CCL18 level. The data are important because they can be used to draw conclusions about immunometabolism. Furthermore, they can serve as basis for future prospective clinical studies.

Background: Pulmonary metastasectomy is an established treatment modality for patients with soft as well as bone tissue sarcomas. Aim of this study is to describe the Essen experience in the surgical management of patients with pulmonary sarcoma metastases. Methods: This is a retrospective single center analysis of perioperative outcome of patients undergoing pulmonary metastasectomy for sarcoma metastases from 1997-2017 and a summary of published papers on this topic. Results: During the observation period 327 patients (49.23% female) underwent pulmonary metastasectomy for metastases of extrathoracic sarcomas in curative intent. The number of resected metastases was 1–3 in 283 cases (86.54%), 4–9 in 31 cases (9.48%) and 10 or more lesions in 14 cases (4.28%). Wedge resections or precision excisions with laser or electrocautery were performed in 278 cases (85.02%), anatomical segmental resections in 16 patients (4.89%) and lobectomies in 33 patients (10.09%). Bilateral procedures were performed in 98 cases (29.96%). Lymphadenectomy was performed in 122 patients. Positive lymph nodes were found only in 6 cases. All of these cases were patients with soft tissue sarcoma as primary tumor. Preoperative neoadjuvant treatment was performed in 79 patients (24.15%) with chemotherapy, in 54 patients (16.51%) with radiochemotherapy and in 10 patients (3.05%) with radiotherapy. Major postoperative complications were observed in 2.75% of all patients. Thirty-day mortality was 0%. Conclusions: Pulmonary metastasectomy in sarcoma patients is a feasible and safe treatment strategy even in patients with bilateral metastases and multiple lesions. Thoracic lymph node metastases are rare and did not influence survival in our cohort.

Performing a routine postoperative chest X-ray (CXR) after general thoracic surgery is daily practice in many thoracic surgery departments. The quality, frequency of pathological findings and the clinical consequences have not been well evaluated. Furthermore, exposure to ionising radiation should be restricted to a minimum and therefore routine practice can be questioned.As a hospital standard, each patient was given a routine CXR after opening of the pleura and inserting a chest tube. From October 2015 to March 2016, each postoperative patient with a routine CXR was included in a prospective database, including film quality, pathological findings, clinical and laboratory results and cardiorespiratory monitoring, as well as clinical consequences.546 patients were included. Risk factors for postoperative complications were obesity in 50 patients (9.2%), emphysema in 127 patients (23.3%), coagulopathy in 34 patients (6.2%), longer operation time (more than two hours) in 242 patients (44.3%) and previous lung irradiation in 29 (5.3%) of patients. Major lung resections were performed in 191 patients (35.9%). 263 (48.2%) patients had procedures with minimally invasive access. The quality of the X-ray film was insufficient in 8.2% of patients. 90 (16.5%) of CXRs were found to show pathological findings, with a trend for more pathological findings after open surgery (55/283; 19.4%) compared to minimally invasive surgery (35/263; 13.3%) (p = 0.064). 11 (2.0%) patients needed a surgical or clinical intervention during postoperative observation; this corresponds to 12.2% of patients with a pathological finding on CXR. Nine of these 11 patients were clinically symptomatic and only two (0.37%) patients were asymptomatic with a relevant pneumothorax.Our study cannot support routine postoperative CXR after general thoracic procedures and we believe that restriction to clinically symptomatic cases should be a safe option.Die Anfertigung einer Röntgenaufnahme des Thorax nach thoraxchirurgischen Eingriffen ist in vielen Abteilungen tägliche Routine. Die Qualität der Aufnahme, Häufigkeit pathologischer Befunde und die klinischen Konsequenzen daraus wurden bisher nicht tiefergehend untersucht. Des Weiteren soll die Anwendung ionisierender Strahlung auf ein Minimum reduziert werden. Eine Routineanwendung ist daher zu hinterfragen.Von Oktober 2015 bis März 2016 wurde jeder Patient mit einer Routineaufnahme des Thorax in einer prospektiven Datenbank erfasst. Als Abteilungsstandard wurde von jeher jeder Patient postoperativ geröntgt, sobald die Pleura eröffnet und eine Drainage gelegt worden ist. Erfasst wurden die Bildqualität, die pathologischen Befunde, Ergebnisse der klinischen Untersuchung und Laboruntersuchung sowie das kardiorespiratorische Monitoring, weiterhin die klinischen Konsequenzen aus den Ergebnissen.546 Patienten wurden erfasst. Risikofaktoren für früh-postoperative Komplikationen waren Adipositas in 50 (9,2%), Lungenemphysem in 127 (23,3%), Gerinnungsstörung in 34 (6,2%), Operationsdauer 2 Stunden in 242 (44,3%) und vorausgegangene Strahlentherapie des Thorax in 29 (5,3%) der Patienten. Eine Major-Lungenresektion wurde bei 191 (35,9%) Patienten durchgeführt. 263 (48,2%) hatten einen minimalinvasiven Zugang. Das Röntgenbild war bei 45 (8,2%) von eingeschränkter Qualität. 90 (16,5%) Röntgenbilder waren auffällig mit einem Trend für mehr Auffälligkeiten nach offener Chirurgie (55/283; 19,4%) verglichen mit Patienten nach minimalinvasiven Operationen (35/263; 13,3%) (p = 0,064). Elf (2,0%) der Patienten benötigten eine Intervention als Konsequenz auf die postoperativen Beobachtungen. Das entspricht 12.2% derer mit auffälligem Röntgenbild. Neun dieser 11 Patienten waren klinisch auffällig und nur 2 (0,37%) hatten einen relevanten Pneumothorax ohne klinische Beschwerden.Mit dieser Studie kann der Nutzen der Routineaufnahme des Thorax nach thoraxchirurgischen Operationen nicht belegt werden. Wir empfehlen eine eingeschränkte Indikationsstellung zur postoperativen Röntgenkontrolle nur für klinisch auffällige Patienten.

Background Prolonged air leaks (PALs) after lung resection are one of the most common complications in thoracic surgery. Several options are available to treat PALs. The autologous blood patch pleurodesis is commonly used but has not been thoroughly investigated. Materials and methods We conducted a prospective randomized study including all consecutive patients with PALs after pulmonary resections. Patients were randomized to either having received pleurodesis by injecting 100 mL autologous blood at d 5 and 6 (Group A) or being placed under observation (Group B). Patients from either group undergoing revisions were further investigated by a post hoc analysis and formed Group C. Results A total of 24 patients were included: 10 patients were randomized to group A and 14 to group B. Six patients (3 from each group) underwent surgical revision and were included in Group C. Groups A and B did not differ in baseline characteristics. The median time to drainage removal was 9 d (range: 5-23 d) in Group A; 9 d (range: 2-20 d) in Group B; and 6 d in Group C (range: 3-10 d), (A/B versus C, P Conclusions There is no evidence indicating a benefit for blood patch pleurodeses in patients undergoing lung resections and presenting with postoperative PALs for more than 5 d. An early operative closure of postoperative air leakage seems to be more effective.

Staging in malignant pleural mesothelioma (MPM) still remains a huge challenge. Accurate staging is the basis of a more customized treatment approach for MPM patients. In this review all relevant steps towards the current staging system based on the International Association for the Study of Lung Cancer (IASLC) mesothelioma database are pointed out (1). The effects of international cooperation and the contribution towards global databases are particularly important in rare diseases where even national databases fail to provide sufficient evidence for diagnostic or therapeutic algorithms.

Background Robotic surgery has been developed as a sophisticated tool to expand possibilities in minimal invasive surgery. The learning curve for this method is short in various surgical fields; however, limited data exist on the learning curve in robotic thoracic surgery. Methods This study analyzes a single center experience of robotic lobectomies using a prospectively kept database. Perioperative data and outcome of patients during the learning curve were compared with patients operated with increased institutional experience. The learning curve was defined as the initial 20 lobectomies. Results Sixty-four robotic lobectomies were performed between January 2014 and February 2017. Indications, preoperative lung functions, comorbidities, patient age, and tumor stage were comparable between patients operated during the learning curve and thereafter. The mean operative time could be significantly reduced after the learning curve (286 ± 86 vs. 211 ± 62 minutes; p = 0.0003). The conversion rate dropped from 4 of 20 (20%) during the learning curve to 2 of 44 (4.5%, p = 0.07) thereafter. Chest tube duration (4.3 ± 2.9 vs. 3.8 ± 2.1 days) and hospital stay (8.3 ± 3.4 vs. 7.9 ± 4.5 days) were not different in the two phases. The number of resected lymph nodes increased from 11.2 ± 6.8 to 13.9 ± 6.5 (p = 0.0797). Lymph node upstaging was achieved in 8 (12.9%) cases. Ninety-day mortality was 0%, and 2-year overall survival was 83%. Conclusions Robotic thoracic surgery can be safely performed and trained with low complication rates and contributes to the extension of minimal invasive thoracic surgery. The initial learning curve in our experience is overcome after 20 cases. However, to become proficient in more advanced procedures and to further reduce operative time, additional training is required. Prospective studies are required to clearly determine the role of robotic surgery in comparison to the video-assisted thoracoscopic surgery (VATS) procedures.

Hintergrund: Die Resektion von Lungenmetastasen ist ein wichtiger Baustein in der Therapie metastasierter solider Tumoren. Ziel der vorliegenden Untersuchung ist es, die Bedeutung der laserassistierten Metastasektomie zu evaluieren und mit anderen Resektionstechniken zu vergleichen. Patienten/Material und Methoden: Retrospektiv wurden die Daten aller zwischen Januar 2005 und Juni 2010 mit kurativer Intention in unserer Abteilung primar pulmonal metastasektomierten Patienten analysiert. Der Krankheitsverlauf wurde anhand von Ambulanzberichten oder Versand von Fragebogen an die nachsorgenden Arzte ermittelt. Ergebnisse: 301 Patienten gingen in die Auswertung ein. Ein Nd-YAG-Laser wurde bei 62 Patienten eingesetzt (20,6 %). Trotz einer signifikant hoheren Anzahl resezierter Lasionen bei Verwendung des Lasers als bei anderen Resektionsmethoden (Median: 7,0 vs. 2,0; p

Fernmetastasen solider maligner Tumore finden sich am haufigsten in der Lunge. Die meisten Patienten mit Lungenmetastasen weisen eine Vielzahl von Herden auf oder haben Metastasen in anderen Organen, sodass eine operative Therapie nicht in Frage kommt. Viele Untersuchungen belegen jedoch einen Uberlebensvorteil fur Patienten, bei denen eine vollstandige chirurgische Entfernung aller Lungenmetastasen moglich ist. Bei einigen Patienten ist die pulmonale Metastasektomie die sogar einzige kurative Behandlungsoption. Bei V. a. Lungenmetastasen ist die kontrastmittelverstarkte Computertomografie des Thoraxes das diagnostische Verfahren der ersten Wahl. Die bei kurativer Intention geltenden Regeln bei der Indikationsstellung zur Metastasektomie sind die Kontrolle des Primartumors, die technisch mogliche komplette Resektion aller Metastasen, der Ausschluss extrathorakaler Metastasen mit Ausnahme resektabler Lebermetastasen sowie die funktionelle Operabilitat. Die wichtigsten Prognosefaktoren sind die vollstandige Resektion, die Tumorentitat, das krankheitsfreie Intervall und in beschranktem Mas auch die Anzahl der Metastasen. Bei bilateralen Metastasen kommen die Sternotomie und die sequenzielle oder simultane Thorakotomie als Zugangswege in Betracht, wobei die Thorakotomie bei zentralen Herden oder Herden im linken Unterlappen von Vorteil ist. Bei einseitigem Befall kann unter bestimmten Voraussetzungen auch eine videoassistierte Resektion in Betracht gezogen werden. Primares Ziel muss immer eine R0-Resektion sein. Neben anatomischen Resektionen finden daher vor allem parenchymsparende lungendissezierende Techniken Anwendung. Insbesondere bei zentralen Metastasen oder multiplen Herden ist grose thoraxchirurgische Expertise notwendig, um moglichst viel funktionsfahiges Lungenparenchym zu erhalten. Der sekundare Befall von mediastinalen Lymphknoten ist mit einer ungunstigen Prognose assoziiert, sodass dieser praoperativ ausgeschlossen werden sollte.

Background: The effect of pleurectomy/decortication or extrapleural pleuropneumonectomy on pulmonary function has not yet been evaluated. The aim of this study was to determine the parameters of pulmonary function before and after pleurectomy/decortication or extrapleural pleuropneumonectomy. Methods: We conducted a review of 48 patients with unilateral malignant pleural mesothelioma who underwent pleurectomy/decortication or extrapleural pleuropneumonectomy. Data including medical history, histology, survival, and pre- and postoperative pulmonary function were extracted from the medical database of the University Medical Center Freiburg, or sought by telephone interview with the general practitioner or patients. Results: 25 patients underwent extrapleural pleuropneumonectomy and 23 had pleurectomy/decortication. Pulmonary function was not significantly reduced in the pleurectomy/decortication group postoperatively. In the extrapleural pleuropneumonectomy group, the median preoperative total lung capacity of 4.8 L (77.7%) differed significantly from the postoperative total lung capacity of 3.5 L (55.3%; p Conclusions: Pleurectomy/decortication preserved good pulmonary function, whereas extrapleural pleuropneumonectomy significantly reduced pulmonary function, which may lead to dyspnea and influence the quality of life of these patients.

Background: Chemotherapy with radiation has to be considered the standard therapy for limited-stage small cell lung cancer but surgical resection is possible in a small subgroup in which it may improve survival. Surgery is not recommended as the standard treatment, but a few small studies have demonstrated a benefit of surgery in highly selected cases of limited-stage small cell lung cancer. Methods: We conducted a retrospective study of 29 patients with limited-stage small cell lung cancer undergoing surgical resection in our department. There were 7 (24%) women and 22 (76%) men with a median age of 62 years (range, 46–82 years). Medical history, histology and survival status were extracted from the medical database of the University Medical Center Freiburg. Results: The median overall survival was 20.7 months. In 15 patients who received neoadjuvant treatment, the median survival was 89.4 months. Karnofsky performance status and neoadjuvant chemotherapy had a significant influence on median survival ( p Conclusions: We concluded that surgical resection can be beneficial in a highly selected group of patients as a part of a multidisciplinary approach. In addition, surgical resection is safe with acceptable mortality and morbidity.

Background Immunocompromised patients, particularly after lung transplantation, are at high risk to develop atypical forms of pulmonary infections including influenza A/H1N1. Acute Fibrinous and Organizing Pneumonia (AFOP) is a special histological pattern in acute respiratory failure with high mortality. Case presentation We describe a 66-year-old woman with double lung transplantation in August 2009 due to end stage pulmonary fibrosis. After prolonged weaning and subsequent promising course, she developed atypical pneumonia with diffuse pulmonary infiltrates in both lungs in January 2010. Infection with influenza A/H1N1 virus was verified. The patient rapidly suffered from respiratory insufficiency and died eight days after this diagnosis. The post-mortem revealed especially in the lower parts of the lungs the classical histological pattern of pure AFOP. Molecular analyses of lung tissue were positive for influenza A/H1N1. Conclusion To our knowledge we present the first case of AFOP triggered by viral infection, here proven to be influenza virus A/H1N1. Thus, also in the setting of viral infection the highly deadly differential diagnosis of AFOP must be considered.

The aim of this study was to evaluate the risk of an air embolization with the volume of the insufflation tube during induction of laparoscopy. A further objective was to determine the LD50 of air in young piglets. End-tidal carbon dioxide pressure ( $$ P_{{{\text{CO}}_{2} ,{\text{et}}}} $$ ), pulmonary arterial pressure (P pa), heart rate (f c), and mean arterial pressure (P a carot) were measured in 17 piglets divided into three groups: group 1 (n = 6), bolus application (CO2 embolization, followed by air embolization, 2 mL/kg each), group 2 (n = 7), continuous air embolization (30 min, 0.2 mL/kg/min), and group 3 (n = 4), continuous CO2 embolization (30 min, 0.4 mL/kg/min). All animals survived CO2 embolism. Air embolization as a bolus (2 mL/kg) or with an accumulated volume of 3.1 mL/kg led to death. Decreases in $$ P_{{{\text{CO}}_{2} ,{\text{et}}}} $$ indicated air or massive CO2 embolization only. There was a good correlation between $$ P_{{{\text{CO}}_{2} ,{\text{et}}}} $$ and P pa in case of air embolization (r = −0.80, p