[Specialised Intensive Care Treatment Concepts for Severe Chest Trauma]. / Spezielle intensivmedizinische Behandlungskonzepte des schweren Thoraxtraumas.

This review covers key elements of the critical care management of patients with thoracic trauma. Contrast-enhanced chest computertomography remains the diagnostic modality of choice, as it is more sensitive than conventional chest imaging. Regarding risk stratification, special caution is required in older patients with thoracic trauma given their high risk for posttraumatic complications. In the case of respiratory insufficiency, an attempt of non-invasive ventilation techniques is justified in most patients due to potential treatment benefits. Achieving sufficient pain control is a fundamental goal of critical care management. In this regard, erector-spinae-block and paravertebral block present potentially advantageous alternatives to thoracic epidural anaesthesia. In stable patients, the placement of small-calibre chest tubes may be a beneficial approach compared with large-bore tubes. If surgical stabilization of rib fractures is indicated, it should be done as early as possible.

[Application of artificial intelligence systems in the emergency room : Do the communication patterns give indications for possible starting points? An observational study]. / Anwendung von Systemen der künstlichen Intelligenz im Schockraum : Geben die Kommunikationsmuster Hinweise auf mögliche Ansatzpunkte? Eine Beobachtungsstudie.

BACKGROUND: High expectations are currently attached to the application of artificial intelligence (AI) in the resuscitation room treatment of trauma patients with respect to the development of decision support systems. No data are available regarding possible starting points for AI-controlled interventions in resuscitation room treatment. OBJECTIVE: Do information request behavior and quality of communication indicate possible starting points for AI applications in the emergency room? MATERIAL AND METHODS: A 2­stage qualitative observational study: 1. Development of an observation sheet based on expert interviews that depicts the following six relevant topics: situational factors (course of accident, environment), vital parameters, treatment-specific Information (treatment carried out). trauma-specific factors (injury patterns), medication, special features of the patient (anamnesis, etc.) 2. Observational study Which topics were inquired about during emergency room treatment? Was the exchange of information complete? RESULTS: There were 40 consecutive observations in the emergency room. A total of 130 questions: 57/130 inquiries about medication/treatment-specific Information and vital parameters, 19/28 of which were inquiries about medication. Questions about injury-related parameters 31/130 with 18/31 regarding injury patterns, course of accident (8/31) and type of accident (5/31). Questions about medical or demographic background 42/130. Within this group, pre-existing illnesses (14/42) and demographic background (10/42) were the most frequently asked questions. Incomplete exchange of information was found in all six subject areas. CONCLUSION: Questioning behavior and incomplete communication indicate a cognitive overload. Assistance systems that prevent cognitive overload can maintain decision-making abilities and communication skills. Which AI methods can be used requires further research.

Patients' satisfaction with local and general anaesthesia for video-assisted thoracoscopic surgery-results of the first randomized controlled trial PASSAT.

OBJECTIVES: The objective of this single-centre, open, randomized control trial was to compare the patients' satisfaction with local anaesthesia (LA) or general anaesthesia (GA) for video-assisted thoracoscopy. METHODS: Patients with indication for video-assisted thoracoscopy pleural management, mediastinal biopsies or lung wedge resections were randomized for LA or GA. LA was administered along with no or mild sedation and no airway devices maintaining spontaneous breathing, and GA was administered along with double-lumen tube and one-lung ventilation. The primary end point was anaesthesia-related satisfaction according to psychometrically validated questionnaires. Patients not willing to be randomized could attend based on their desired anaesthesia, forming the preference arm. RESULTS: Fifty patients were allocated to LA and 57 patients to GA. Age, smoking habits and lung function were similarly distributed in both groups. There was no significant difference between the 2 groups with regard to patient satisfaction with anaesthesiology care (median 2.75 vs 2.75, P = 0.74), general perioperative care (2.50 vs 2.50, P = 0.57), recovery after surgery (2.00 vs 2.00, P = 0.16, 3-point Likert scales). Surgeons and anaesthesiologists alike were less satisfied with feasibility (P < 0.01 each) with patients in the LA group. Operation time, postoperative pain scales, delirium and complication rate were similar in both groups. LA patients had a significantly shorter stay in hospital (mean 3.9 vs 6.0 days, P < 0.01). Of 18 patients in the preference arm, 17 chose LA, resulting in similar satisfaction. CONCLUSIONS: Patients were equally satisfied with both types of anaesthesia, regardless of whether the type of anaesthesia was randomized or deliberately chosen. LA is as safe as GA but correlated with shorter length of stay. Almost all patients of the preference arm chose LA. Considering the benefits of LA, it should be offered to patients as an equivalent alternative to GA whenever medically appropriate and feasible.

A New Approach in Airway Management for Tracheal Resection and Anastomosis: A Single-Center Prospective Study.

OBJECTIVES: The evaluation of the use of laryngeal mask airways (LMA) as an alternative form of airway management for surgical tracheal reconstruction. DESIGN: A prospective case series. SETTING: At a single German university hospital. PARTICIPANTS: Ten patients. INTERVENTIONS: The use of LMA for airway management in surgical reconstruction of the trachea. MEASUREMENTS AND MAIN RESULTS: Ten patients with tracheal stenosis of 50% to 90% were enrolled prospectively during the study period. The airway management consisted of the insertion of an LMA. During resection and reconstruction, high-frequency jet ventilation was used. Several arterial blood gas analyses (ABG) were performed before, during, and after the tracheal resection and reconstruction. All values were presented as median and interquartile ranges or as absolute and relative values, and no emergency change to cross-field intubation was necessary. The lowest PaO2 was 93 mmHg in 1 patient after 20 minutes of jet ventilation, whereas PaO2 increased after the induction phase and remained stable in 9 patients. There were no intraoperative complications related to anesthetic management apart from transient hypercarbia during and after jet ventilation. Preoperative and postoperative ABG were comparable. One patient required immediate postoperative ventilatory support. Two patients developed postoperative pneumonia, leading to their admission to the intensive care unit. One patient was operated with a palliative approach due to massive dyspnea and died in the next postoperative course. CONCLUSIONS: The use of LMA is an alternative option in airway management for tracheal reconstruction, even in patients with significant tracheal stenosis. Potential advantages compared to tracheal intubation are unimpaired access to the operative field and the lack of stress on the fresh anastomosis.

[Anaesthetic Management of Non-intubated Video-assisted Thoracic Surgery]. / Anästhesie bei nicht intubierter videoassistierter Thoraxchirurgie (NiVATS).

Non-intubated thoracic surgery is currently gaining popularity. In select patients and in experienced centres, non-intubated approaches may enable patients to safely undergo thoracic surgical procedures, who would otherwise be considered at high risk from general anaesthesia. While non-intubated techniques have been widely adopted for minor surgical procedures, its role in major thoracic surgery is a topic of controversial debate.This article discusses disadvantages of intubated anaesthetic approaches and advantages of non-intubated thoracic surgery as well as the anaesthetic management. This includes surgical and anaesthetic criteria for patient selection, suitable regional anaesthetic techniques, concepts for sedation and maintenance of airway patency as well as the management of perioperative complications.Non-intubated thoracic surgery has the potential to reduce postoperative morbidity and hospital length of stay. Successful non-intubated management depends on a standardised and well-trained interdisciplinary approach, especially regarding patient selection and perioperative complications.

Dental Strain on Maxillary Incisors During Tracheal Intubation With Double-Lumen Tubes and Different Laryngoscopy Techniques - A Blinded Mannequin Study.

OBJECTIVES: To quantify dental forces during double-lumen tube intubations with different laryngoscopy techniques. DESIGN: Experimental biomechanical mannequin study. SETTING: Two German university hospitals. PARTICIPANTS: One hundred four anesthesiologists with varying levels of experience. INTERVENTIONS: Participants performed a sequence of intubations on a mannequin equipped with hidden forces sensors in the maxillary incisors. Different laryngoscopy techniques were evaluated under normal and difficult airway conditions. Direct laryngoscopy was compared with different videolaryngoscopy techniques: the C-MAC with a Macintosh blade, the GlideScope, and the KingVision with hyperangulated blades. MEASUREMENTS AND MAIN RESULTS: A total of 624 intubations were evaluated. In normal airway conditions, the median (interquartile range [range]) peak forces were significantly lower when the GlideScope (15.7 (11.3-22.0 [2.1-110.5]) N) was used compared with direct laryngoscopy (21.0 (14.1-28.5[4.7-168.6]) N) (p = 0.007). In difficult airways, resulting forces were reduced using hyperangulated videolaryngoscopes (GlideScope: -13.7 N [p < 0.001]; KingVision: -11.9 N [p < 0.001]) compared with direct laryngoscopy, respectively. The time to intubation was prolonged with the use of the KingVision (25.5 (17.1-41.9[9.2-275.0])s [p < 0.001]) in comparison to direct laryngoscopy (20.8 (15.9-27.4[8.7-198.6]) s). The C-MAC demonstrated the shortest time to intubation. CONCLUSIONS: Although hyperangulated videolaryngoscopes improve dental strain, clinicians also should consider the time to intubation, which is shortest with nonhyperangulated videoblades, when choosing a laryngoscopy technique on an individual patient basis.

Anesthesia for tracheal and carinal resection and reconstruction.

PURPOSE OF REVIEW: The aim of this review is to provide an overview of current anesthetic management of tracheal and carinal resection and reconstruction. RECENT FINDINGS: In addition to the traditional anesthetic approach using conventional tracheal intubation after induction of general anesthesia and cross-field intubation or jet-ventilation once the airway has been surgically opened, there is a trend toward less invasive anesthetic procedures. Regional anesthetic techniques and approaches focusing on the maintenance of spontaneous respiration have emerged. Especially for cervical tracheal stenosis, laryngeal mask airways appear to be an advantageous alternative to tracheal intubation.Extracorporeal support can ensure adequate gas exchange and/or perfusion during complex resections and reconstructions without interference of airway devices with the operative field. It also serves as an effective rescue technique in case other approaches fail. SUMMARY: The spectrum of available anesthetic techniques for major airway surgery is immense. To find the safest approach for the individual patient, comprehensive interdisciplinary planning is essential. The location and anatomic consistency of the stenosis, comorbidities, the functional status of respiratory system, as well as the planned reconstructive technique need to be considered. Until more data is available, however, a reliable evidence-based comparison of different approaches is not possible.

Current practice of thoracic anaesthesia in Europe - a survey by the European Society of Anaesthesiology Part I - airway management and regional anaesthesia techniques.

BACKGROUND: The scientific working group for "Anaesthesia in thoracic surgery" of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) has performed an online survey to assess the current standards of care and structural properties of anaesthesia workstations in thoracic surgery. METHODS: All members of the European Society of Anaesthesiology (ESA) were invited to participate in the study. RESULTS: Thoracic anaesthesia was most commonly performed by specialists/board-certified anaesthetists and/or senior/attending physicians. Across Europe, the double lumen tube (DLT) was most commonly chosen as the primary device for lung separation (461/ 97.3%). Bronchial blockers were chosen less frequently (9/ 1.9%). Throughout Europe, bronchoscopy was not consistently used to confirm correct double lumen tube positioning. Respondents from Eastern Europe (32/ 57.1%) frequently stated that there were not enough bronchoscopes available for every intrathoracic operation. A specific algorithm for difficult airway management in thoracic anaesthesia was available to only 18.6% (n = 88) of the respondents. Thoracic epidural analgesia (TEA) is the most commonly used form of regional analgesia for thoracic surgery in Europe. Ultrasonography was widely available 93,8% (n = 412) throughout Europe and was predominantly used for central line placement and lung diagnostics. CONCLUSIONS: While certain "gold standards "are widely met, there are also aspects of care requiring substantial improvement in thoracic anaesthesia throughout Europe. Our data suggest that algorithms and standard operating procedures for difficult airway management in thoracic anaesthesia need to be established. A European recommendation for the basic requirements of an anaesthesia workstation for thoracic anaesthesia is expedient and desirable, to improve structural quality and patient safety.

Most patient conditions do not a priori debilitate the sensitivity of thoracic ultrasound in thoracic surgery-a prospective comparative study.

BACKGROUND: The few existing studies on the accuracy of lung ultrasound in the detection of a postoperative pneumothorax after thoracic surgery differ in the sonographic technique and the inclusion criteria. Several conditions are considered unfavourable in the sonographic examination of the lung. We aim to test these conditions for their impact on the diagnostic accuracy of lung ultrasound. METHODS: We compared lung ultrasound and chest roentgenograms for the detection of a pneumothorax after lung-resecting surgery in two prospective trials (register ID DRKS00014557 and DRKS00020216). The ultrasound examiners and radiologists were blinded towards the corresponding findings. We performed posthoc subgroup analyses to determine the influence of various patient or surgery related conditions on the sensitivity and specificity of ultrasound in the detection of pneumothorax. RESULTS: We performed 340 examinations in 208 patients. The covariates were age, gender, body mass index, smoking status, severity of chronic obstructive pulmonary disease, previous ipsilateral operation or irradiation, thoracotomy, postoperative skin emphysema, indwelling chest tube and X-ray in supine position. In univariate analysis, an indwelling chest-tube was associated with a higher sensitivity (58%, p = 0.04), and a postoperative subcutaneous emphysema with a lower specificity (73% vs. 88%, p = 0.02). None of the other subgroups differed in sensitivity or specificity from the total population . CONCLUSIONS: Most of the patient- or surgery related conditions usually considered unfavourable for lung ultrasound did not impair the sensitivity or specificity of lung ultrasound. Further studies should not excluce patients with these conditions, but test the accuracy under routine conditions. TRIAL REGISTRATION: DRKS, DRKS00014557, registered 06/09/2018, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00014557 and DRKS00020216, registered 03/12/2019, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00020216.

To tube or not to tube: a skeptic's guide to nonintubated thoracic surgery.

PURPOSE OF REVIEW: The aim of this review is to provide an overview of the rationale and evidence for nonintubated thoracic surgery and guide clinicians, considering the implementation of nonintubated thoracic surgery, to find an anesthetic approach suitable for their department. RECENT FINDINGS: Based on physiologic considerations alone, nonintubated thoracic surgery would be expected to be an advantageous concept in thoracic anesthesia, especially in patients at high risk for pulmonary complications. Currently existing evidence, however, does not support these claims. Although the feasibility and safety have been repeatedly demonstrated, high-quality evidence showing a significant benefit regarding clinically relevant patient-centered outcomes is not available.Anesthetic approaches to nonintubated thoracic surgery differ significantly; however, they usually concentrate on six main aspects: maintenance of airway patency, respiratory support, analgesia, patient comfort, cough suppression, and conversion techniques. Given the lack of high-quality studies comparing different techniques, evidence-based guidance of clinical decision-making is currently not possible. Until further evidence is available, anesthetic management will depend mostly on local availability and expertise. SUMMARY: In select patients and with experienced teams, nonintubated thoracic surgery can be a suitable alternative to intubated thoracic surgery. Until more evidence is available, however, a general change in anesthetic management in thoracic surgery is not justified.

Use of Extracorporeal Membrane Oxygenation for Major Cardiopulmonary Resections.

BACKGROUND: In thoracic surgery, utilization of extracorporeal membrane oxygenation (ECMO) is mainly established for patients undergoing lung transplantation. The aim of our study was to summarize our single-center experience with intraoperative use of veno-venous- or veno-arterial-ECMO in patients undergoing complex lung surgery involving the main carina, or the left atrium or the descending aorta. METHODS: A total of 24 patients underwent combined complex lung, carinal, aortal, or left atrial resections. In cases of carinal resection, percutaneous veno-venous, jugular-femoral cannulation was considered suitable. For combined resection of lung and descending aorta, a percutaneous femoral veno-arterial cannulation was used. In cases of extended left atrial resection, a percutaneous jugular-femoral veno-venous-arterial cannulation was favored. RESULTS: Procedures were divided into three groups: carinal resections and reconstruction (n = 8), resections of the descending aorta and left lung (n = 7), resections of lung and left atrium (n = 9). No intraoperative complications occurred. Overall 30-day mortality was 25%. A complete resection was achieved in 18 patients. Median survival was 12 months. One- and 5-year survival were 48.1 and 22.7%, respectively. CONCLUSION: The present study shows that intraoperative use of ECMO for extended carinal, aortic, or atrial resections is feasible with minimal intraoperative complications allowing surgeons increased operating-field safety. Perioperative mortality is high, but this is rather an attribute of local extended disease and patient comorbidities.

Impact of blunt chest trauma on outcome after traumatic brain injury- a matched-pair analysis of the TraumaRegister DGU®.

BACKGROUND: Traumatic brain injury (TBI) is associated with high rates of long-term disability and mortality. Our aim was to investigate the effects of thoracic trauma on the in-hospital course and outcome of patients with TBI. METHODS: We performed a matched pair analysis of the multicenter trauma database TraumaRegisterDGU® (TR-DGU) in the 5-year period from 2012 to 2016. We included adult patients (≥18 years of age) with moderate to severe TBI (abbreviated injury scale (AIS)= 3-5). Patients with isolated TBI (group 1) were compared to patients with TBI and varying degrees of additional blunt thoracic trauma (AISThorax= 2-5) (group 2). Matching criteria were gender, age, severity of TBI, initial GCS and presence/absence of shock. The χ2-test was used for comparing categorical variables and the Mann-Whitney-U-test was chosen for continuous parameters. Statistical significance was defined by a p-value < 0.05. RESULTS: A total of 5414 matched pairs (10,828 patients) were included. The presence of additional thoracic injuries in patients with TBI was associated with a longer duration of mechanical ventilation and a prolonged ICU and hospital length of stay. Additional thoracic trauma was also associated with higher mortality rates. These effects were most pronounced in thoracic AIS subgroups 4 and 5. Additional thoracic trauma, regardless of its severity (AISThorax ≥2) was associated with significantly decreased rates of good neurologic recovery (GOS = 5) after TBI. CONCLUSIONS: Chest trauma in general, regardless of its initial severity (AISThorax= 2-5), is associated with decreased chance of good neurologic recovery after TBI. Affected patients should be considered "at risk" and vigilance for the maintenance of optimal neuro-protective measures should be high.

Anterior Chest Wall Reconstruction Using Polypropylene Mesh: A Retrospective Study.

BACKGROUND: Anterior chest wall resection for oncological purposes is usually combined with a form of reconstruction. Most surgeons are convinced that ventrally located defects more than 4 to 5 cm require adequate reconstruction to minimize the risk of lung herniation and respiratory distress through paradox motion. We describe our in-house results of ventral chest wall reconstruction using polypropylene mesh without the use of metallic or biological implants regardless of the extent of chest wall resection. METHODS: Patient selection involved ventral chest wall resection and reconstruction by polypropylene mesh for all indications such as primary tumors, metastasis, or infiltration by lung cancer from January 2008 to December 2016. Primary end point was the difference between both sides. Secondary end points were postoperative complications such as infection, surgical revision, and pulmonary complications. RESULTS: Forty-five cases of isolated anterior reconstruction could be identified. In 34 cases, postoperative computed tomography scan of the thorax was available. Fifteen males and 19 females with a median age of 70.5 years were operated. The evaluation of maximum hemithorax diameter between operated and nonoperated sides was documented in centimeters, and the difference was documented in percentage. The mean percentage difference was 11.1% (minimum: 0.3, maximum: 44.4). In one case, wound infection with positive culture could not be treated conservatively and required operative revision and removal of the polypropylene mesh. CONCLUSION: Polypropylene mesh, though not rigid, can safely be used for anterior chest wall reconstruction.

Sensitivity of chest ultrasound for postoperative pneumothorax in comparison to chest X-ray after lung resecting surgery.

OBJECTIVES: Thoracic ultrasound is superior to chest X-ray for the detection of a pneumothorax in trauma and intensive care medicine. Data regarding its use in non-cardiac thoracic surgery are scarce and contradictory. Previous studies are heterogeneous regarding sonographic methodology and patient selection. This study aimed to evaluate the accuracy of thoracic ultrasound for pneumothorax assessment after lung resecting surgery in unselected patients. METHODS: SONOR (SONOgraphy vs x-Ray) is a prospective observational trial (registry-ID DRKS00014557). A total of 123 consecutive patients with lung resecting surgery received a standardized thoracic ultrasound the same day and in addition to routine chest X-rays in erect position after removal of the chest tube. The sonographer was blinded to radiological findings and vice versa. RESULTS: Sensitivity, specificity, positive and negative predictive values of ultrasound after removing the chest tube were 0.32, 0.85, 0.54, 0.69 for any pneumothorax and 1.0, 0.82, 0.19, 1.0 for pneumothorax ≥3 cm. No clinically relevant pneumothorax was missed. The agreement between sonography- and routine-based therapeutic decisions was 97%. Lung pulse was the most frequently detected sign to sonographically rule out a pneumothorax. CONCLUSIONS: Postoperative thoracic ultrasound in unselected patients has a low overall sensitivity to detect a residual pneumothorax; however, its sensitivity and negative predictive values regarding clinically relevant pneumothorax are high. Test quality depends on the distinct sonographic methodology and patient selection. Anatomic differences in postsurgical and medical patients may be responsible for the contradictory results of previous trials. Studies with a larger population size are required to validate the accuracy of relevant pneumothoraces and identify appropriate selection criteria. CLINICAL TRIAL REGISTRATION NUMBER: DRKS-German Clinical Trials Register, www.drks.de, registry-ID DRKS00014557.

Continuous lateral rotational therapy in thoracic trauma--A matched pair analysis.

INTRODUCTION: Given the lack of reliable evidence on the utility of continuous lateral rotational therapy (CLRT) in chest trauma, we performed a single-centre retrospective matched-pair analysis of patients treated either with CLRT or non-continuous manual turning after blunt thoracic trauma. METHODS: We included adult patients that were admitted to our level 1 trauma centre from 2010-2014 and presented with severe thoracic injuries (AISThorax ≥3) within 24 h after the injury and required at least 72 h of mechanical ventilation. Patients were either treated with manual turning every 2-4 h or CLRT. To ensure comparable injury severity and a similar risk for posttraumatic respiratory complications, we matched for thoracic injury severity, age, additional injuries (head, abdomen, extremities) and need for massive transfusion. RESULTS: A total of 22 pairs (n = 44 patients) were successfully matched and analysed. The use of CLRT did not have a statistically significant impact on respiratory function, gas exchange, duration of mechanical ventilation, ICU or hospital length of stay, or overall patient outcomes (e.g. pneumonia, sepsis, ARDS, mortality). During active rotation the level of sedation was lower compared to manual turning (Richmond Agitation Sedation Scale; manual turning: -3.6; CLRT: -4.0; p = 0.01). Patient agitation was noticed more frequently in the CLRT group (manual turning: n = 2 (9%); CLRT: n = 9 (41%); p = 0.02). DISCUSSION: In this well-matched sample, the use of CLRT did not seem to translate into relevant clinical benefits in patients with thoracic trauma in the setting of modern ICU care with the widespread implementation of lung protective ventilation. However, statistical power and generalisability were limited by the small sample size and single centre design. A large RCT is required to provide conclusive results.

Rationale and design of PASSAT - patients' satisfaction with local or general anaesthesia in video-assisted thoracoscopic surgery: study protocol for a randomised controlled trial with a non-randomised side arm.

BACKGROUND: Although general anaesthesia (GA) with one-lung ventilation is the current standard of care, minor thoracoscopic surgery, i.e. treatment of pleural effusions, biopsies and small peripheral pulmonary wedge resections, can also be performed using local anaesthesia (LA), analgosedation and spontaneous breathing. Whilst the feasibility and safety of LA have been demonstrated, its impact on patient satisfaction remains unclear. Most studies evaluating patient satisfaction lack control groups or do not meet psychometric criteria. We report the design of the PASSAT trial (PAtientS' SATisfaction in thoracic surgery - general vs. local anaesthesia), a randomised controlled trial with a non-randomised side arm. METHODS: Patients presenting for minor thoracoscopic surgery and physical eligibility for GA and LA are randomised to surgery under GA (control group) or LA (intervention group). Those who refuse to be randomised are asked to attend the study on the basis of their own choice of anaesthesia (preference arm) and will be analysed separately. The primary endpoint is patient satisfaction according to a psychometrically validated questionnaire; secondary endpoints are complication rates, capnometry, actual costs and cost effectiveness. The study ends after inclusion of 54 patients in each of the two randomised study groups. DISCUSSION: The PASSAT study is the first randomised controlled trial to systematically assess patients' satisfaction depending on LA or GA. The study follows an interdisciplinary approach, and its results may also be applicable to other surgical disciplines. It is also the first cost study based on randomised samples. Comparison of the randomised and the non-randomised groups may contribute to satisfaction research. TRIAL REGISTRATION: German Clinical Trials Register, DRKS00013661 . Registered on 23 March 2018.

Impact of body mass index on outcomes after thoracic trauma-A matched-triplet analysis of the TraumaRegister DGU®.

INTRODUCTION: Chest trauma and obesity are both associated with increased risks for respiratory complications (e.g. hypoxia, hypercarbia, pneumonia), which are frequent causes of posttraumatic morbidity and mortality. However, as there is only limited and inconsistent evidence, the aim of our study was to analyse the effect of body mass index (BMI) on patient outcomes after thoracic trauma. PATIENTS AND METHODS: We screened 50.519 patients entered in TraumaRegister DGU®, between 2004-2009, when the BMI was part of the standardized dataset. After matching for injury patterns and severity of trauma we performed a matched tripled analysis with regard to the BMI (group 1: <25.0 kg/m2; group 2: 25.0-29.9 kg/m2; group 3: >30.0 kg/m2). Data are shown as percentages and mean values with standard deviation. RESULTS: The matching process yielded a cohort of 828 patients with serious blunt thoracic trauma, evenly distributed over the 3 BMI groups (276 triplets). BMI did not have an impact on the need for prehospital or emergency department interventions. There was a trend towards more liberal use of whole-body-CT scanning with increasing BMI (group 1: 68.8%; group 2: 73.2%; group 3: 75.0%). Additional abdominal injuries were more common in normal weight patients (Group 1: 28.3%; Group 2: 14.9%; Group 3: 17.8%). Obesity (BMI > 30.0 kg/m2) had a significant impact on the duration of mechanical ventilation (in days; group 1: 6.5 (9.4); group 2: 6.4 (8.9); group 3: 9.1 (14.4); p = 0.002), ICU days (in days; group 1: 11.5 (11.5); group 2: 10.9 (9.6); group 3: 14.1 (16.7); p = 0.005) and hospital length of stay (in days; group 1: 27.8 (19.3); group 2: 27.4 (19.2); group 3: 32.2 (25.9); p = 0.009). There were no significant differences regarding overall mortality (group 1: 3.6%; group 2: 1.8%; group 3: 4.0%; p = 0.26). CONCLUSIONS: Obesity has a negative impact on outcomes after blunt chest trauma, as it is associated with prolonged duration of mechanical ventilation, ICU and hospital length of stay. Mortality did not seem to be affected, yet, further research is required to confirm these results in a larger cohort.

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.