David Sanchez-Lorente

Single double-lumen venous-venous pump-driven extracorporeal lung membrane support.

OBJECTIVE We sought to investigate the safety and feasibility of obtaining total respiratory support during 72 hours using a pump-driven (Levitronix CentriMag; Levitronix LLC, Waltham, Mass) venous-venous extracorporeal lung membrane (Novalung; Novalung GmbH, Hechingen, Germany) attached through a single double-lumen cannula (Novalung) into the femoral or jugular vein in pigs. METHODS Twelve pigs were initially mechanically ventilated for 2 hours (respiratory rate, 20-25 breaths/min; tidal volume, 10-12 mL/kg; fraction of inspired oxygen, 1.0; positive end-expiratory pressure, 5 cm H(2)O). Thereafter, the extracorporeal lung membrane was attached to the right femoral (n = 6, 26F) or jugular (n = 6, 22F) vein by using a single double-lumen cannula placed transcutaneously. Ventilatory settings were then reduced to near-apneic ventilation (respiratory rate, 4 breaths/min; tidal volume, 1-2 mL/kg; fraction of inspired oxygen, 0.21; positive end-expiratory pressure, 10 cm H(2)O), and pump flow was increased hourly until maximal efficacy. Blood gases and hemodynamics were measured hourly, and lung and plasma cytokine levels were measured every 4 hours. RESULTS The devices mean blood flow was 2.16 +/- 0.43 L/min, permitting an oxygen transfer and carbon dioxide removal of 203.6 +/- 54.6 and 590.3 +/- 23.3 mL/min, respectively. Despite static ventilation, all pigs showed optimal respiratory support, with a PaO(2), PaCO(2), and mixed venous oxygen saturation of 226.2 +/- 56.4, 59.7 +/- 8.8, and 85.6 +/- 5.3 mm Hg, respectively. There were no significant inflammatory, cellular, or coagulatory responses; lung cytokine levels remained in the normal range. Route (femoral vs jugular) or size (22F vs 26F) of the cannula did not change hemodynamic or respiratory parameters significantly. CONCLUSIONS This circuit provides total respiratory support over 72 hours without inducing significant hemodynamic, coagulatory, cellular, or inflammatory responses.

The pumpless extracorporeal lung membrane provides complete respiratory support during complex airway reconstructions without inducing cellular trauma or a coagulatory and inflammatory response

OBJECTIVE Our objective was to investigate the capacity of a pumpless extracorporeal lung membrane (iLA) (Novalung; Novalung GmbH, Hechingen, Germany) to provide adequate respiratory support and the impact on morbidity/mortality during complex airway reconstruction. METHODS Only patients unable to be ventilated via conventional intubation were eligible for the study. A larynx mask or orotracheal tubes were placed above the airway defect and the iLA was attached via femoral vessels (arteriovenous), providing extracorporeal gas exchange, apneic hyperoxygenation, and total tubeless airway reconstruction. Haptoglobulin, plasmin-antiplasmin complex, P-selectin activation, and interleukin 6 were measured before, during, and after iLA use and 72 hours postoperatively. RESULTS Fifteen consecutive patients (age, 42±17 years) underwent elective (n=7) or emergency (n=8) reconstruction of the airway owing to a variety of disorders or defects. The iLA was left in place for 185±61 minutes, diverted 1.70±0.48 L/min of the cardiac output, and provided an arteriovenous carbon dioxide removal and oxygen transfer of 173±94 and 144±83 mL/min, respectively. The arterial oxygen tension/inspired oxygen fraction (314±31 mm Hg), and arterial carbon dioxide tension (40±6 mm Hg) remained stable throughout the entire operations. The following procedures were performed: redo slide tracheoplasties (n=3), redo tracheoesophageal fistula repair (n=1), sleeve lobectomies (n=2), main carina reconstructions (n=7), and anastomotic stenting and myocutaneous coverages (n=2). Three patients required prolonged (9±2 days) postoperative iLA support. Two (13%) patients died during the hospital stay. The use of iLA was associated with significant (P<.05) but clinically nonrelevant and yet nonpathologic increases of haptoglobulin (hemolysis), plasmin-antiplasmin complex (coagulation activation), and P-selectin activation (platelet activation). Data normalized within 48 hours postoperatively. CONCLUSIONS Data suggest that iLA provides complete intraoperative respiratory support in patients who cannot receive conventional intubation/ventilation without relevant effects on cellular trauma, coagulatory response, and inflammatory response.

Apnoeic oxygenation on one-lung ventilation in functionally impaired patients during sleeve lobectomy

We describe a useful salvage method for hypoxaemia during one-lung ventilation (OLV) in functionally impaired patients during a sleeve bronchial reconstruction. When dependent-lung OLV strategies for hypoxaemia fail during bronchial anastomosis (increasing the oxygen administration to fraction of inspired oxygen (FiO(2)) 1 and positive end-expiratory pressure (PEEP), recruitment strategy and perfusion modulation), a very simple and efficient method for oxygen administration to the non-dependent lung can be easily employed. Oxygen flow of 5-10 l min(-1) administered by a paediatric intra-field catheter placed in the distal bronchi during bronchial anastomosis of the spared lobe(s), following the principles of apnoeic (hyper)oxygenated ventilation, successfully improves oxygenation without significant impairment of the operation field.

Síndrome de fuga aérea por enfermedad del injerto contra huésped

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Prehabilitation in thoracic surgery

Surgical resection remains the best treatment option for patients with early stage of non-small cell lung cancer (NSCLC). However, it may be responsible of postoperative complication and mortality, especially in patients with impaired pulmonary function. Enhanced recovery after surgery (ERAS) programs have been focused mainly in minimal invasive surgery approach during lung resection and respiratory rehabilitation after surgery. Preoperative exercise-based intervention (prehabilitation) has demonstrated reduction of morbi-mortality in other surgeries but in thoracic surgery continues to be under discussion. Cardio-pulmonary exercise test (CPET) is the gold standard technique to predict postoperative morbi-mortality. The implementation of a preoperative respiratory rehabilitation could optimize patients physical capacity before surgery and improve outcomes and enhance recovery. The aim of this systematic review of the literature is to identify the effectiveness and safety of prehabilitation programs in thoracic surgery, the type of exercise and its duration, and the group of patients with best benefit. Prehabilitation is a safe intervention without side effects in patients. High-intensity interval training (HIT) with duration of 2 to 6 weeks seems to be the best exercise programme in a prehabilitation intervention but it exists heterogeneity in terms of intensity and duration. Prehabilitation increase exercise capacity and significantly enhances pulmonary function. But the reduction of postoperative complication and mortality has not been clearly demonstrated. Different criteria selection, type of intervention and small sample size, in addition to no randomization, could justify disparate results. It seems that not all patients can benefit from prehabilitation and it could be indicated only in patients with impaired lung function. Further randomized clinical trials with enough patients, correct duration of HIT (2 to 6 weeks) and focused in COPD patients are needed to clarify the suitability of prehabilitation. Meanwhile, safety of prehabilitation and good results of some studies support this intervention in high-risk patients.

Is it appropriate to perform video-assisted thoracoscopic surgery for advanced lung cancer?

Video-assisted thoracoscopic surgery (VATS) has showed benefits in terms of pain, hospital stay and accomplishment of adjuvancy therapy versus open surgery in early stage of non-small-cell lung cancer. Over the last years, the indication of VATS technique has been expanded to advanced lung cancer. In this article, we discuss the definition of VATS and advanced lung cancer, and the safety and feasibility of VATS technique for the resection of advanced tumors.

N2 disease in non-small-cell lung cancer: straight to surgery?

The correct treatment for patients with non-small-cell lung cancer and ipsilateral mediastinal involvement (N2) remains a challenge. The heterogeneity of this group of patients has been shown, as well as many different prognostic factors, that will determine a specific management to each of them. Although the standard treatment is based on a multimodality therapy consisting of chemotherapy, radiotherapy and surgery, surgery is not always indicated. The selection of patients who are going to be operated, reminds being a key point of the treatment of this disease. Recent reports on operable N2 disease have been reviewed by our group in order to discuss surgery indications and when to bring it about, with the possibility to go straight to surgery.

Posterior thoracic approach for Pancoast tumour resection

Pancoast tumour is an uncommon presentation of lung cancer. Its specific location and surrounding structures invasion characterizes the Pancoast’s syndrome clinical presentation—shoulder pain, radicular arm affection and Horner’s syndrome. At the same time thoracic outlet location makes it difficult to detect by simple chest X-ray and delays the diagnosis. Pancoast tumour is considered a locally advanced lung cancer. In consequence aggressive staging and accurate surgical planning are mandatory. Induction therapy, although no entirely accepted is used to increase resectability in our centre’s protocol. Anterior and posterior approaches have been described to resect superior sulcus tumours. Selection is normally based on tumour location and peripheral structures involvement as well as surgeon’s personal experience and preferences. In the following text we describe the posterior approach technique for tumour resection and the tricks and tips we learned in our experience to minimize surgical risks. We prefer the posterior approach in those tumours with no major vessel involvement evidence. Anterior chest wall resection and posterior costo-vertebral junction disarticulation are carried out before the lobectomy to achieve a complete en bloc resection. Special care must be taken during the dissection and division of the first rib because of thoracic outlet structures proximity. After resection, we prefer not to reconstruct the wall systematically. It is reserved for selected patients who had a large chest wall resection and have higher risk of complications.