OBJECTIVES:Compared to lung resections, airway procedures are relatively rare in thoracic surgery. Despite this, a growing number of dedicated airway centres have formed throughout Europe. These centres are characterized by a close interdisciplinary collaboration and they often act as supra-regional referring centres. To date, most evidence of airway surgery comes from retrospective, single-centre analysis as there is a lack of large-scale, multi-institutional databases. METHODS:In 2018, an initiative was formed, which aimed to create an airway database within the framework of the ESTS database (ESTS-AIR). Five dedicated airway centres were asked to test the database in a pilot phase. A 1st descriptive analysis of ESTS-AIR was performed. RESULTS:A total of 415 cases were included in the analysis. For adults, the most common indication for airway surgery was post-tracheostomy stenosis and idiopathic subglottic stenosis; in children, most resections/reconstructions had to be performed for post-intubation stenosis. Malignant indications required significantly longer resections [36.0 (21.4-50.6) mm] when compared to benign indications [26.6 (9.4-43.8) mm]. Length of hospital stay was 11.0 (4.1-17.3) days (adults) and 13.4 (7.6-19.6) days (children). Overall, the rates of complications were low with wound infections being reported as the most common morbidity. CONCLUSIONS:This evaluation of the 1st cases in the ESTS-AIR database allowed a large-scale analysis of the practice of airway surgery in dedicated European airway centres. It provides proof for the functionality of ESTS-AIR and sets the basis for rolling out the AIR subsection to all centres participating in the ESTS database.

Background Vocal cord palsy after cervical mediastinoscopy is usually reported at less than 1%. However, its incidence might be underestimated and no follow-up studies are available. Our study aimed to evaluate the incidence of voice changes after cervical mediastinoscopy and report on long-term outcomes, including quality of life, after at least one-year follow-up. Methods A retrospective cohort study was performed, considering all patients who underwent cervical mediastinoscopy in our center between January 2011 and April 2016. Patients with pre-existing voice changes, voice changes only after pulmonary resection and patients who underwent neoadjuvant chemo(radio)therapy were excluded. Voice changes with full recovery within 14 days were attributed to intubation-related causes. Follow-up questionnaires, including the standardized Voice Handicap Index, were sent to patients with documented voice changes. Results Of 270 patients who were included for final analysis, 17 (6.3%) experienced voice changes after cervical mediastinoscopy, which persisted > 2 years in 4 patients (1.5%), causing mild to moderate disabilities in daily living. Twelve patients (out of 17, 71%) were referred for otolaryngology consultation, and paresis of the left vocal cord suggesting recurrent laryngeal nerve injury was confirmed in 10 (3.7% of our total study group). Additionally, 83% of the patients who were referred for otolaryngology consultation received voice treatment. Recovery rate after vocal exercises therapy and injection laryngoplasty was respectively 71% and 33%. Conclusions Voice changes after cervical mediastinoscopy is an underreported complication, with an incidence of at least 6.3% in our retrospective study, with persisting complaints in at least 1.5% of patients, leading to mild to moderate disabilities in daily living. These findings highlight the need for appropriate patient education for this underestimated complication, as well as the exploration of possible preventive measures.

The article published by Stanifer and colleagues [1Stanifer B.P. Andrei A.-C. Liu M. et al.Short-term outcomes of tracheal resection in The Society of Thoracic Surgeons database.Ann Thorac Surg. 2018; 106: 1612-1618Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar] is interesting and clinically relevant. Considering the rarity of the disease, inclusion of 1,617 patients is an impressive feat. The results from this study are consistent with outcomes previously published in comprehensive reviews, pointing out the safety and low mortality of tracheal resection [2Lewis S. Earley M. Rosenfeld R. Silverman J. Systematic review for surgical treatment of adult and adolescent laryngotracheal stenosis.Laryngoscope. 2017; 127: 191-198Crossref PubMed Scopus (47) Google Scholar]. Nevertheless, because the results are from a large database, no distinction is made as far as the underlying pathology of the disease. Consolidation of the malignant and benign group may lead to a biased view on the actual outcomes. In addition, subdivision of the benign group might provide more insight in the course of different pathologies. One of the major aspects of tracheal surgery in our experience (n = 25/year) is the variety in surgical risk, surgical approach, and restenosis rate based on the underlying pathology. For example, malignant tracheal tumors generally involve larger airway segments; the surgical risks are slightly higher and often require a sternotomy. The benign population on its own can be subdivided in various groups such as idiopathic, auto-inflammatory diseases, and post-intubation stenosis and may require a “straightforward” surgical approach. Recently, our group published the 20-year results on surgical resection of benign tracheal pathologies. Apart from a low mortality, we observed a range of voice alterations post surgery, in particular in the laryngotracheal resection group, without any surgical lesion to the laryngeal nerve [3Timman S.T. Schoemaker C. Li W.W. et al.Functional outcome after (laryngo)tracheal resection and reconstruction for acquired benign (laryngo)tracheal stenosis.Ann Cardiothorac Surg. 2018; 7: 227-236Crossref PubMed Scopus (17) Google Scholar]. Especially in women, a lower voice due to changes in the local anatomy (mainly the cricothyroid muscle), appeared to have a negative impact on their quality of life. The paper by Stanifer and associates suggests a mathematical optimum of a minimum of 4 cases a year to be safely operated. The calculation number is, unfortunately, not elucidated. From a clinical perspective, this number seems optimistic. It would be interesting to elaborate on the calculation. Considering the low incidence of these pathologies, achieving “the optimum number” for safe surgery remains a hurdle. On the other hand, this might provide an opportunity for collaboration and pooling of certain pathologies at specific centers with high levels of expertise. This expertise may further be combined with neighboring specialties, such as otolaryngology surgeons and (intervention) pulmonologists, for better perioperative care and more accurate patient selection—keeping in mind that alternative procedures (endobrochoscopy) and treatment options (radiotherapy for malignancy) also have to be considered. Short-Term Outcomes of Tracheal Resection in The Society of Thoracic Surgeons DatabaseThe Annals of Thoracic SurgeryVol. 106Issue 6PreviewTracheal surgery is uncommon, and most of the published literature consists of single-center series over large periods. Our goal was to perform a national, contemporary analysis to identify predictors of major morbidity and mortality based on indication and surgical approach. Full-Text PDF ReplyThe Annals of Thoracic SurgeryVol. 108Issue 5PreviewWe thank Timman and colleagues [1] for their letter regarding our article reporting outcomes of tracheal surgery derived from The Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTSD) [2]. Full-Text PDF

BackgroundIn this study we focus on functional outcomes after (laryngo)tracheal resection and reconstruction for acquired benign (laryngo)tracheal stenosis, with a specific interest in the impact of laryngeal involvement on postoperative outcome.MethodsAll patients who underwent (laryngo)tracheal surgery for benign pathology between 1996 and 2017 in our centre were included in this retrospective study. Surgical outcomes were procedural success rate, and airway- and voice-related complications. Functional results were assessed using (standardized) questionnaires for quality of life, sensation of dyspnea, swallowing function, and voice perception.ResultsOf 119 consecutive patients, 47 underwent laryngotracheal resection and reconstruction and 72 underwent segmental tracheal surgery (78% with an end-to-end tracheal anastomosis and 22% with a cricotracheal anastomosis). Overall success rate was 92% and was similar for all groups, with an overall significant improvement in quality of life when compared to the preoperative situation. However, after laryngotracheal surgery, airway-related complications were more common when compared to segmental resections with an end-to-end tracheal anastomosis (30% versus 7%, P=0.003). Additionally, early voice alterations without recurrent nerve palsy were reported twice as often (34% versus 16%, P=0.034) and voice quality experienced during follow-up was significantly worse when compared to segmental resections. Overall response rate to the questionnaires on functional outcome was 63%.Conclusions(Laryngo)tracheal surgery is safe and beneficial, with significant functional improvement during mid- and long-term follow-up. However, laryngeal involvement is a predictor for increased surgical airway-related complications. Additionally, voice alterations without recurrent nerve palsy are far more common after laryngotracheal resection and are a serious handicap. This aspect is underexposed in current literature and deserves further attention during preoperative counseling and patient follow-up. However, the results on functional outcome of this current study should be interpreted with caution due to the somewhat low response rate of the questionnaires.

AIMS:Preclinical results suggest therapeutic potential of mild hyperbilirubinemia in T2DM and cardiovascular disease. Translational data are limited, because an appropriate bilirubin formulation for parenteral human use is lacking. Considering its use in both clinical practice and medical research in the past, we explored the feasibility to reintroduce parenteral bilirubin for translational experiments.METHODS:We developed a preparation method in accordance with good manufacturing practice and evaluated the parenteral applicability in healthy volunteers (n = 8). Explorative pharmacokinetic and safety data were compared to the results from a literature study on the former parenteral use of bilirubin. Bilirubin was administered intra-arterially to raise the local plasma concentration in the forearm vascular bed (n = 4) and intravenously to raise the systemic plasma concentration (n = 4). Finally, pharmacokinetic characteristics were studied following a single bolus infusion (n = 3).RESULTS:During parenteral application, no side effects occurred. Adverse events mentioned during the two-week observation period were in general mild and self-limiting. Three more significant adverse events (appendicitis, asymptomatic cardiac arrhythmia and atopic eczema) were judged unrelated by independent physicians. A dose-concentration relationship appeared sufficiently predictable for both intra-arterial and intravenous administration. In line with existing knowledge, bilirubin pharmacokinetics could be described best according to a two-compartment model with a volume of distribution of 9.9 (±2.0) l and a total plasma clearance of 36 (±16) ml per minute.CONCLUSIONS:Supported by previous reports, our data suggest that it is both feasible and safe to perform translational experiments with parenteral albumin bound bilirubin.

Physical activity (PA) reduces the risk of cardiovascular disease and physically active survivors of a cardiac event are at lower risk of recurrent events. We hypothesized that patients with a decreased PA, undergoing cardiac surgery, are at higher risk for a postoperative complicated recovery (PCR).

We reported a 17-year-old boy with very deep asymmetric pectus excavatum and with a history of congenital diaphragmatic hernia repair and hypoplastic left lung. We performed a minimally invasive repair of pectus excavatum as described by Nuss et al., in 1998. We performed a left-sided thoracoscopy, instead of the right-sided according our normal routine, to provide a safe route. We created a substernal tunnel to have a clear definition of the deviant anatomy after congenital diaphragmatic hernia repair. However, we noticed an absence of the pericardium, which, by itself, can increase the risk of cardiac injury in both bar insertion and removal. Instead of the usual right-sided thoracoscopy, we recommend providing a safe view by left-sided thoracoscopy in comparable cases (e.g. congenital diaphragmatic hernia, other cardiac or vascular malformations) to reduce the risk of rupture or perforation of cardiac structures.

The endotracheal balloon catheter (A-view®) is a device developed to locate atherosclerotic plaques of the ascending aorta (AA) in cardiac surgery to prevent stroke. The saline-filled balloon is located in the trachea and combines the advantages of transoesophageal echocardiography (e.g. used before performing the sternotomy) and intraoperative epiaortic ultrasound scanning (e.g. complete view of the AA). We report the first severe complication after the use of A-view®. This is a case of a 66-year old woman who underwent elective myocardial revascularization complicated by an intraoperative iatrogenic tracheal rupture of 6 cm, after uncomplicated intubation and the use of an endotracheal balloon catheter (A-view®), which required direct surgical repair with a posterolateral thoracotomy after the myocardial revascularization was completed, weaning from bypass and closure of the median sternotomy.