Uyen-Thao Le

Background/Objectives: Patients with single metastases from colorectal cancer constitute a subgroup with an excellent 5-year OS of 55–70% and with a real chance for cure. In this situation, local margin recurrence in the lung may impair the prognosis and thus is the main outcome target of surgery. Methods: A retrospective multicenter analysis of patients with single metastases from colorectal cancers was performed. Four German Thoracic Surgery units contributed data from their prospective metastasectomy databases. Statistical analysis was focused on tumor recurrence and risk factors for local margin recurrence. Results: 166 patients from four centers could be further analyzed. For later comparison, 93 (56%) anatomic resections and 73 (44%) non-anatomic resections were pooled. Tumor recurrence was detected: at any site 87/161 (54%), within the lung 62/161 (38.5%) at intrapulmonary margins 25/145 (17.2%) and in intrathoracic lymph nodes 14/138 (10.1%). Intrapulmonary local margin recurrence was more often found in non-anatomic (25.4%) versus anatomic (11.6%) resections (p = 0.052). After propensity score matching (PSM), local margin recurrence was significantly more frequent after non-anatomic resection of intermediate and peripherally located metastases (p = 0.042). Furthermore, local margin recurrence was associated with small safety margins (p < 0.001), small number of lymph nodes removed (p < 0.001) and with intrathoracic lymph node recurrence (p = 0.001). The 5- and 10-year OS of the whole group was 70% and 47% with a median survival of 9.0 years. The 5- and 10-year RFS of the whole group was 59% and 43% with a median of 7.3 years. Conclusions: This study demonstrates that anatomical resection of single CRC lung metastases is superior to non-anatomic resection with respect to local radicality and local intrapulmonary margin recurrence, but there was no difference in OS and RFS.

Background: Following anatomic lung resection, chest tubes are required for fluid and air evacuation. Delayed removal can considerably prolong pain and immobilization during the postoperative course. We aimed to analyse the impact of an adaptation of the chest tube management on aspects regarding enhanced recovery after surgery (ERAS). Methods: Patients at our institution were treated according to two different protocols with the new protocol allowing chest tube removal up to a fluid output of 500 mL/24 h, and the standard protocol insisting on an output ≤200 mL/24 h. We retrospectively collected data in these two groups between January 2021 and December 2022 with a focus on aspects of ERAS. Results: A total of 150 patients were included in this retrospective observational study, of whom 62 (41.3%) were treated according to the new protocol and 88 (58.7%) with the standard protocol. There were no differences in the patient characteristics between the two groups. With the new protocol, chest tubes were removed at a mean output of 230±30.3 mL during the last 24 hours, whilst with the standard protocol mean output was 161±7.9 mL (Pvs. 3.5 (IQR, 2–5) days, P=1.317e−05}. There was no difference in postoperative complications (Clavien-Dindo ≥3) between both cohorts [10 patients (16.1%) vs. 13 patients (14.8%), P=0.82] nor in the rate of re-interventions on the chest [8 patients (12.9%) vs. 15 patients (17%), P=0.65]. Furthermore, there was no difference in postoperative pain between both cohorts, with patients stating a mean pain score of 4.08±2.14 (4.18±2.21 vs. 4.01±2.09, P=0.56) on coughing on the first, 2.33±2.02 (2.16±1.96 vs. 2.44 ±2.07, P=0.46) on the third and 2.01±2.13 (1.88±2 vs. 2.11±2.21, P=0.58) on the fifth day after surgery on the visual analog scale (VAS). Opioid requirement for pain management were similar in both cohorts during the first 5 postoperative days (PODs). Patients from the new protocol cohort could be transferred from the intermediate-care unit one day sooner [median 1 (IQR, 1–3) vs. 2 (IQR, 1–3) days, P=0.89]. Conclusions: Chest tube removal up to a volume threshold of 500 mL/24 h after anatomic lung resection does not lead to increased complications, particularly thoracic interventions. All ERAS protocols should be designed accordingly.

Background/Objectives: Colorectal cancer (CRC) with hepatic (CRLM) and pulmonary metastases (CRLU) presents a significant clinical challenge, leading to poor prognosis. Surgical resection of these metastases remains controversial because of limited evidence supporting its long-term benefits. To evaluate the impact of surgical resection of both hepatic and pulmonary metastases on long-term survival in patients with multivisceral metastatic colorectal cancer, this retrospective cohort study included 192 patients with UICC stage IV CRC treated at a high-volume academic center. Methods: Patients were divided into two groups: those who underwent surgical resection of both hepatic and pulmonary metastases (n = 100) and those who received non-surgical treatment (n = 92). Propensity score matching was used to adjust for baseline differences. The primary outcome was overall survival (OS). Results: Unadjusted analysis showed a significant OS benefit in the surgical group (median OS: 6.97 years) compared with the conservative group (median OS: 2.17 years). After propensity score matching, this survival advantage persisted (median OS: 5.58 years vs. 2.35 years; HR: 0.3, 95% CI: 0.18–0.47, p < 0.0001). Conclusions: Surgical resection of hepatic and pulmonary metastases in multivisceral metastatic CRC significantly improves long-term survival, supporting an aggressive surgical approach in selected patients.

Background: To date, several chest drainage systems are available, such as digital drainage systems (DDS) and traditional systems with continuous suction or water seal. However, none of these systems were yet shown to be favorable in the treatment of complex situations such as persistent air leaks or residual spaces. We present in-vitro as well as clinical data of a novel hybrid drainage system consisting of an optimized digital drainage system (ODDS) and an underwater seal drainage system (UWSD). Methods: For in-vitro analysis, a DDS and an ODDS were connected to a pleural cavity simulator. Different air leaks were produced and data on intrapleural pressure and air flow were analyzed. Furthermore, we tested the hybrid drainage system in 10 patients with potential air leaks after pulmonary surgery. Results: In in-vitro analysis, we could show, that with advanced pump technology, pressure fluctuations caused by the drainage system when trying to maintain a set pressure level in patients with airleaks were much smaller when using an ODDS and could even be eliminated when using a fluid collection canister with sufficient buffer capacity. This minimized air leak boosts caused by the drainage system. Optimizing the auto-pressure regulation algorithms also led to a reduced airflow through the fistula and promoted rest. Switching to a passive UWSD also reduced the amount of airflow. Clinical application of the hybrid drainage system yielded promising results. Conclusion: The novel hybrid drainage system shows promising results in the treatment of patients with complex clinical situations such as persistent air leaks.

We present the case of a 23-year-old man with a chondroid chordoma of the sternum. The patient underwent chest wall resection, followed by stabilization using a sandwich graft of Prolene mesh and methylmethacrylate, covered with bilateral pedicled M. pectoralis flaps. After adjuvant radiotherapy and two years of follow-up, the patient developed a graft-associated infection. We removed the allogeneic material and the encapsulated abscess, and the wound was conditioned through negative wound pressure therapy. This time, wound closure and chest wall stabilization were achieved with a Prolene mesh covered by a free anterolateral thigh flap. This case demonstrates the importance of carefully considering the material for chest wall stabilization and establishing multidisciplinary cooperation.

Background: Diaphragm plication remains the only effective treatment for diaphragm paralysis. Robot-assisted thoracoscopic (RATS) diaphragm plication combines advantages of open and thoracoscopic techniques. We present our experiences focussing on lung-function improvement and surgical outcome. Methods: In this single-center retrospective study with comparative analysis, perioperative data of all patients who underwent RATS or thoracoscopic (VATS) diaphragm plication between 2015 and 2022 at our institution were assessed. Functional outcome was analysed with pre- and postoperative pulmonary function tests in sitting and supine position. Results: We included 43 diaphragm plications, of which 31 were performed via RATS. Morbidity in the RATS- and VATS-cohort were 13 and 8%, respectively (p = 0.64), without any major complication (Clavien-Dindo ≥ III, 0%). Surgical time for RATS diaphragm plication was reduced drastically with a median operating time for the first 16 patients of 136 min (range 84–185) and 84 min (range 56–122) for the most recent 15 patients (p < 0.0001). Pulmonary function testing after RATS-plication showed a mean increase in vital capacity (VC) of 9% (SD 8, p < 0.0001) and of 7% (SD 9, p = 0.0009) in forced expiratory volume in 1 s (FEV1) when sitting and 9% (SD 8, p < 0.0001) for VC as well as 10% (SD 8, p = 0.0001) for FEV1 when in supine position. Conclusion: RATS diaphragm plication is a very safe and feasible approach, yielding good results in improving patients’ pulmonary function. Further studies are required to elucidate possible advantages over VATS or open approaches. Graphical

Zusammenfassung: Das Leitsymptom des erworbenen einseitigen Zwerchfellhochstands ist die Atemnot, die typischerweise im Liegen, beim Bücken und beim Schwimmen verstärkt auftritt. Die Ätiologie ist vielfältig, wobei die idiopathische Genese und die Zwerchfellparese nach Schädigung des N. phrenicus, bspw. bei (kardio-)thorakalen Eingriffen, die häufigsten Ursachen darstellen. Trotz vielfältiger Behandlungsansätze ist die operative Zwerchfellraffung die aktuell einzige effektive Therapie. Ziel der Operation ist die Wiederherstellung der Spannung des Zwerchfells, wodurch die Atemmechanik verbessert, das Ausdehnungsvolumen erhöht und eine mögliche Kompression von basal durch abdominelle Organe verringert wird. Hierfür stehen verschiedene Operationstechniken mit verschiedenen Zugangswegen zur Verfügung. Die roboterassistierte thorakoskopische Zwerchfellraffung verbindet die Vorteile eines minimalinvasiven Zugangs mit einer hervorragenden Darstellung des Situs und einem großen Handlungsspielraum für den Operateur. Diese Operationsmethode ist sehr sicher, vergleichsweise einfach zu erlernen und geht mit deutlichen funktionalen Verbesserungen einher.

Original Article Surgery for thoracic oligoprogression in metastatic renal cell cancer in the era of new systemic therapies Uyen-Thao Le, Bernward Passlick, Severin Schmid