Aris Koryllos

Benign stenosis of the trachea.

Benign stenosis of trachea results mainly from tracheotomy, ventilation, or trauma. The combination of a defect of the mucosa or the tracheal wall and infection produce secondary scar tissue healing with shrinkage of the tracheal lumen or instability of the tracheal wall. Standard of treatment consists of resection of the pathologic segment of the trachea with end-to-end anastomosis. In case of involvement of the larynx, partial resections of the anterior cricoid cartilage or division of the larynx with tracheolaryngeal silicone stents are used. Short-term and long-term results are satisfying considering some technical recommendations.

Unilateral Lobe Resection by Video-Assisted Thoracoscopy Leads to the Most Optimal Functional Improvement in Severe Emphysema

Background Lung volume reduction surgery (LVRS) is a well-established treatment option for pulmonary emphysema, but the most advantageous technical approach remains debatable. Methods Short- and long-term outcomes were comparably assessed in pulmonary emphysema patients who underwent unilateral LVRS with either lobe or sublobe (segment or wedge) resection. Patients were consecutively enrolled in the study after careful conventional and computer-based definition of the target region. Results A total of 36 patients with a mean age of 62.1 ± 8.9 years (range, 41-79 years) were recruited. Video-assisted thoracoscopy (VATS) was performed in 33 patients, while 3 patients with additional early-stage lung cancer received anterolateral thoracotomy. Surgery duration was longer for lobectomy (median 93 minutes, range 44-168 minutes) as compared with sublobe resection (median 52 minutes, range 25-131 minutes; p = 0.0007), but complication rates were similar. After 90 days postsurgery, mortality was zero and lung function improved to a similar degree in both the groups. After 1 year, total lung capacity (TLC) was still reduced by 17.2 ± 20.6% predicted as compared with the baseline values for lobe resection, while TLC was increased by 12.1 ± 14.5% predicted for sublobe resection. In addition, the 6-minute walking distance improved following LVRS, with slightly better results in lobe resection patients. Conclusions By careful definition of the target region, unilateral VATS-LVRS with lobe resection in severely affected pulmonary emphysema patients is a safe procedure that is superior to unilateral sublobe VATS resection in terms of improving long-term 1-year lung hyperinflation. Therefore, unilateral VATS lobe resection is a promising treatment approach that should be further evaluated by randomized controlled trials.

Management of chest trauma.

Trauma is the leading cause of death worldwide. Approximately 2/3 of the patients have a chest trauma with varying severity from a simple rib fracture to penetrating injury of the heart or tracheobronchial disruption. Blunt chest trauma is most common with 90% incidence, of which less than 10% require surgical intervention of any kind. Mortality is second highest after head injury, which underlines the importance of initial management. Many of these deaths can be prevented by prompt diagnosis and treatment. What is the role of the thoracic surgeon in the management of chest trauma in severely injured patients? When should the thoracic surgeon be involved? Is there a place for minimal invasive surgery in the management of severely injured patients? With two case reports we would like to demonstrate how the very specific knowledge of thoracic surgeons could help in the care of trauma patients.

New Approaches to Airway Management in Tracheal Resections—A Systematic Review and Meta-analysis

OBJECTIVES Although endotracheal intubation, surgical crossfield intubation, and jet ventilation are standard techniques for airway management in tracheal resections, there are also reports of new approaches, ranging from regional anesthesia to extracorporeal support. The objective was to outline the entire spectrum of new airway techniques. DESIGN The literature databases PubMed/Medline and the Cochrane Library were searched systematically for prospective and retrospective trials as well as case reports on tracheal resections. SETTING No restrictions applied to hospital types or settings. PARTICIPANTS Adult patients undergoing surgical resections of noncongenital tracheal stenoses with end-to-end anastomoses. INTERVENTIONS Airway management techniques were divided into conventional and new approaches and analyzed regarding their potential risks and benefits. MEASUREMENTS AND MAIN RESULTS A total of 59 publications (n = 797 patients) were included. The majority of publications (71.2%) describe conventional airway techniques. Endotracheal tube placement after induction of general anesthesia and surgical crossfield intubation after incision of the trachea were used most frequently without major complications. A total of 7 new approaches were identified, including 4 different regional anesthetic techniques (25 cases), supraglottic airways (4 cases), and new forms of extracorporeal support (25 cases). Overall failure rates of new techniques were low (1.8%). Details on patient selection and procedural specifics are provided. CONCLUSIONS New approaches have several theoretical benefits, yet further research is required to establish criteria for patient selection and evaluate procedural safety. Given the low level of evidence, it currently is impossible to compare methods of airway management regarding outcome-related risks and benefits.

Uniportal video-assisted thoracoscopic surgery (VATS) sleeve resections for non-small cell lung cancer patients: an observational prospective study and technique analysis

Bronchus sleeve resection for operative treatment of non-small cell lung cancer (NSCLC) is a gold standard in modern thoracic surgery in cases of centrally located tumors or hilär lymph node metastases. Advanced instruments and growing surgical experience allowed surgeons to reduce the required incisions (from 3-port to uniportal) and to resect larger and more centrally located malignancies minimal invasively. It is a logical and expected advance in thoracic surgery that video-assisted thoracoscopic surgery (VATS) would be ultimately used also for complex bronchial resections. We therefore present in this study our early clinical results and technique of uniportal sleeve resections for patients with centrally located NSCLC or carcinoids. In the period 2015-2017, n:40 patients with NSCLC were found eligible for uniportal VATS sleeve resection in our institution. In two cases a thoracotomy conversion because of severe hilar scar tissue was necessary. In 38 cases a uniportal VATS sleeve resection could be completed. We believe that uniportal sleeve resections are the logical evolution of VATS allowing patients with locally advanced malignancies to have quicker recovery and reduced perioperative pain.

Perioperative outcome after open and thoracoscopic segmentectomy for the treatment of malignant and benign pulmonary lesions: a propensity-matched analysis

Background The aim of this study was to compare the perioperative outcome of patients receiving anatomic segmentectomy either by open surgery or video-assisted thoracoscopic surgery (VATS). To assess the short-term morbidity of the procedure itself, lung cancer patients in all stages as well as patients with pulmonary metastases and benign lesions scheduled for segmental resection were enrolled in this study. Methods A retrospective analysis of prospectively collected data on 445 consecutive patients that underwent segmentectomy either by VATS (n=233) or thoracotomy (n=212) was performed. A propensity-matched analysis was conducted based on age, gender, smoking history, histology, tumor size, forced expiratory volume in 1 second (FEV1) and history of previous pulmonary resections. The matched sample included two groups of 140 patients each. Results Both study groups were comparable with respect to age, gender, smoking history, diagnosis, tumor size, pulmonary function and history of previous pulmonary resections. VATS segmentectomy was associated with decreased length of stay (7.4 vs. 9.5 days, P<0.001), drainage treatment time (4.7 vs. 5.9 days, P=0.012) and severe postoperative complications (1.4% vs. 7.1%, P=0.018). Conclusions VATS segmentectomy is safe and effective for the treatment of benign and malignant pulmonary lesions. Compared with open thoracotomy, it is associated with shorter hospitalization time and decreased number of severe complications. The preservation of functional lung tissue, combined with a minimally invasive approach, make VATS segmentectomy highly suitable for patients with reduced pulmonary function or severe comorbidities.

Video assisted thoracic surgery vs. thoracotomy regarding postoperative chronic pain

Postoperative pain after major thoracic surgery still continues to be a main clinical issue for surgeons and patients. Advances in operative techniques and medical care show an obvious shift towards minimal invasive thoracic surgery (1). Faster recovery and reduction of operative trauma are the key factors pushing surgeons towards minimal invasive procedures (2). Nevertheless, the scientific proof regarding the benefits of video assisted thoracic surgery (VATS) for anatomical lung resections is still limited undoubtedly.

Spontaneous Pneumothorax: Epidemiology and Treatment in Germany Between 2011 and 2015

BACKGROUND Few reliable data are available on the epidemiology and treatment of spontaneous pneumothorax. We studied the sex and age distribution, frequency of hospitalization, mortality, and conservative versus surgical care of this condition in Germany in order to draw well-founded conclusions about its in-hospital diagnosis and treatment. METHODS Data from all patients aged 10 or older who were hospitalized in the period 2011-2015 with a main discharge diagnosis of pneumothorax of neither traumatic nor iatrogenic origin were retrieved from the German Federal Statistical Office. Because of their source, all data were based on case numbers rather than patient numbers. RESULTS During the period of the study, there were 52 738 admissions with the main diagnosis of spontaneous pneumothorax, corresponding to an annual frequency of hospitalization of 14.3 per 100 000 persons per year (95% confidence interval, 14.0 to 14.5). Men were more frequently affected than women. The lethality and in-hospital mortality of this condition (≤ 0.08% and ≤ 0.3%, respectively) were low among persons aged 15 to 45, but markedly higher in persons over age 90 (9.4% and 15.9%, respectively). The frequency of accompanying pulmonary diagnoses also rose with age. Computerized tomography (CT) was performed in 38.9-54.6% of hospitalizations, depending on age. Monitoring on an intensive care unit was carried out in 36% of cases. More than one-quarter of cases involved surgical treatment. CONCLUSION The danger to life and the likelihood of an accompanying pulmonary diagnosis are both low up to age 45. Treatment on an intensive care unit and computerized tomography of the chest should be performed only for strict indications in patients under age 45. The pathophysiological basis of the differing patterns of illness depending on age and sex requires further investigation.

Scientific prove of better quality of life and postoperative pain by minimal invasive thoracic surgery

We read with great interest the results of the trial of Bendixen et al . (1). The randomised controlled study of the University Hospital of Odense, Denmark demonstrated that video-assisted thoracoscopic lobectomy is superior to anterolateral thoracotomy and lobectomy for early stage lung cancer in terms of postoperative pain and quality of life. The authors point out that video-assisted thoracoscopic surgery (VATS)-lobectomy has a small but significant advantage in documented postoperative pain and a significantly better self-reported quality of life.

Einfluss der angioplastischen Erweiterungen auf die Bronchusheilung und das Überleben bei Bronchus-Sleeve-Resektionen

Einfuhrung: Der Einfluss der Bronchus-Sleeve-Resektion auf die postoperative Lungenfunktion, Lebensqualitat sowie auf das Gesamtuberleben ist in der Literatur sehr gut belegt. Regelmasig werden Sleeve-Resektionen mit angioplastischen Erweiterungen unterschiedlicher Art (Angioplastik, Double-Sleeve, Perikard-Patch, Pulmonalis-Prothesen) kombiniert. Ziel dieser retrospektiven Analyse war den Einfluss der angioplastischen Erweiterung auf die Bronchusheilung sowie auf das Uberleben zu untersuchen. Materialien und Methoden: Alle Bronchus-Sleeve-Resektionen im Zeitraum 2006 – 2014 wurden retrospektiv analysiert. Insgesamt handelte es sich um n:467 bronchoplastische Operationen mit oder ohne neoadjuvanter Therapie (Chemo-, Chemoradio-, Radiotherapie). Davon bei n:89 Patienten erfolgte eine angioplastische Erweiterung. Insgesamt wurden n:48 einfache Angioplastiken, n: 27 Double-Sleeve, n:11 Double-Sleeve-Bilobektomien und n:2 Perikard-Patches durchgefuhrt. Alle Bronchusanastomosen wurden nach 7 Tagen postoperativ bronchoskopisch kontrolliert um die Heilung zu beurteilen. Ergebnisse: Es zeigte sich kein signifikanter Unterschied bezuglich der Heilung der Anastomosen zwischen der beiden Gruppen (Grading der Anastomosen). Bezuglich der Art der angioplastischen Erweiterung war die Double-Sleeve-Bilobektomie die Operation mit den haufigsten Komplikationen (n:2 narbige Stenose, n:1 Anastomoseninsuffizienz, n:2 ARDS). Das 5-Jahres-Uberleben war 69,9% fur die angioplastische Gruppe (n:89) und 58% fur die Sleeve-Gruppe (n:378) p:0,03. Insgesamt zeigte sich kein negativer Einfluss der angioplastischen Erweiterung auf das Uberleben. Die 30-Tage-Mortalitat war 1,1% fur die angioplastische Gruppe und 2,2% fur die Sleeve-Lobektomie-Gruppe. Zusammenfassung/Schlussfolgerung: Die angioplastische Erweiterung der Sleeve-Lobektomie hat keinen negativen Einfluss auf das Gesamtuberleben oder die Heilung der Bronchusanastomose. Allerdings ist die Double-Sleeve-Bilobektomie die risikoreichste angioplastische Erweiterung.