Awake minimal invasive carinal resection-tightrope walking in thoracic surgery?

Surgery for small cell lung cancer: When and how

OBJECTIVE

Since data from large retrospective observational studies and cancer registries became available, suggesting a benefit for patients undergoing surgery, the role of surgery in the treatment of small cell lung cancer (SCLC) needs to be reconsidered. The aim of this study was to evaluate outcomes and results of patients with SCLC undergoing intent-to-treat surgery.

MATERIAL AND METHODS

We retrospectively analyzed 324 patients (1998-2018) with a diagnosis of SCLC referred to our Institution. 65 patients underwent surgical resection with curative intent. Kaplan-Meier and Cox regression analyses were used to compare overall survival (OS) for all patients.

RESULTS

Among the patients, 39 (60.0 %) patients had surgery upfront, whereas 24 (36.9 %) had surgery after chemotherapy (CT) alone, and 2 (3.1 %) after CT plus radiotherapy (RT). Twenty-nine (44.6 %) patients were stage I or had a complete response to induction treatment, 21 (32.3 %) had stage II, and 15 (23.1 %) stage III. Forty-four (67.7 %) patients underwent adjuvant treatment: 21 (32.3 %) had CT, 31 (47.7 %) RT, and 7 (10.8 %) both. Prophylactic cranial irradiation was administered in 15 patients (23.1 %). The median OS after initial diagnosis at 1, 5, 10 years was 1, 5, 10 years was 81.4 %, 41.4 % and 25.4 % respectively. Among patients who underwent surgical resection with curative intent, those with clinical stage I had a longer survival (5-year OS 62.9 %) p < 0.0001.

CONCLUSION

patients with stage I SCLC could be considered the best candidates for surgery, in a multidisciplinary setting. Instead, considering their worse survival, those with stage II and III should be carefully selected for the surgical approach, and alternative therapy should be considered.

Preliminary Results of Extracorporeal Membrane Oxygenation Assisted Tracheal Sleeve Pneumonectomy for Cancer

OBJECTIVE

Tracheal sleeve pneumonectomy is a challenge in lung cancer management and in achieving long-term oncological results. In November 2018, we started a prospective study on the role of extracorporeal membrane oxygenation (ECMO) in tracheal sleeve pneumonectomy. We aim to present our preliminary results.

METHODS

From November 2018 to November 2019, six patients (three men and three women; median age: 61 years) were eligible for tracheal sleeve pneumonectomy for lung cancer employing the veno-venous ECMO during tracheobronchial anastomosis.

RESULTS

Only in one patient, an intrapericardial pneumonectomy without ECMO support was performed, but cannulas were maintained during surgery. The median length of surgery was 201 minutes (range: 162-292 minutes), and the average duration of the apneic phase was 38 minutes (range: 31-45 minutes). No complications correlated to the positioning of the cannulas were recorded. There was only one major postoperative complication (hemothorax). At the time of follow-up, all patients were alive; one patient alive with bone metastasis was being treated with radiotherapy.

CONCLUSION

ECMO-assisted oncological surgery was rarely described, and its advantages include hemodynamic stability with low bleeding complications and a clean operating field. As suggested by our preliminary data, ECMO-assisted could be a useful alternative strategy in select lung cancer patients.

Laryngeal Mask as the Primary Airway Device During Laryngotracheal Surgery: Data From 108 Patients

BACKGROUND

Airway management during repair of laryngotracheal stenosis is demanding, and there is currently no accepted standard of care. Recently an increasing number of airway centers have started to use a laryngeal mask until the airway is surgically exposed and cross-table ventilation can be initiated. However detailed data on this approach are missing in the literature.

METHODS

Patients receiving laryngotracheal surgery from November 2011 until October 2018 were retrospectively included in this single-center study, except for patients who presented with a preexisting tracheostomy at time of surgery. Airway management uniformly consisted of laryngeal mask ventilation until cross-table ventilation was established. Clinical variables, perioperative complications, and airway complications were analyzed.

RESULTS

One hundred eight patients (65 women, 43 men) receiving tracheal resection (n = 50), cricotracheal resection (n = 49), or single-stage laryngotracheal reconstruction (n = 9) were included in the analysis. Of the included patients 23 (21.3%) had malignant disease and 85 (78.7%) a benign pathology. In the subgroup of patients with subglottic disease 85.1% had high-grade stenosis (Myer-Cotton III°). Airway management with a laryngeal mask was successful in all except 1 patient (99.1%). Mean pulse oximetry and mean end-tidal CO₂ during laryngeal mask ventilation was 98.7% ± 2.4% and 34.8 ± 7.6 mm Hg, respectively. At the end of surgery 95 patients (88%) were successfully weaned from the respirator using the laryngeal mask.

CONCLUSIONS

The laryngeal mask as the primary airway device is feasible and safe in patients undergoing laryngotracheal surgery even in cases with high-grade stenosis.