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Geraci TC, McCormack AJ, Cerfolio RJ. Discharging Patients Home With a Chest Tube and Digital System After Robotic Lung Resection. Ann Thorac Surg 2024:S0003-4975(24)00378-3. [PMID: 38789008 DOI: 10.1016/j.athoracsur.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 04/22/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Our objective is to assess the feasibility, safety, and outcomes for patients discharged home with a chest tube connected to a digital drainage system after robotic pulmonary resection. METHODS This was a retrospective analysis of a prospectively collected database as a quality improvement initiative. All patients had planned discharge on postoperative day one (POD1) after robotic pulmonary resection. Those with an air leak were discharge home with a chest tube connected to a digital drainage system with daily communication with the surgeon. RESULTS From January 2019 to February 2023 there were 580 consecutive robotic resections, of which 69 (12%) patients had an air leak on POD1; 38 of 276 (14%) after lobectomy, 24 of 226 (11%) after segmentectomy, and 7 of 78 (9%) after wedge resection. Of these 69 patients, 52 patients (75%) were discharged on POD1, 15 patients (22%) on POD2, and 2 patients (3%) on POD3. Chest tubes were removed a median outpatient chest tube duration was 4 days (interquartile range, 3-5 days). Of the 69 patients sent home with a digital drainage system, there was 1 complication requiring readmission for increasing subcutaneous emphysema. Five patients (7%) had system malfunctions that required return to our clinic for problem-solving. There were no 30- or 90-day mortalities. CONCLUSIONS Patients who undergo robotic pulmonary resection and have an air leak can be safely and effectively discharged on the first postoperative day and managed as an outpatient by using daily texts and or videos with pulse oximetry data on a digital drainage system with limited morbidity.
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Affiliation(s)
- Travis C Geraci
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York.
| | - Ashley J McCormack
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York
| | - Robert J Cerfolio
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York
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Aprile V, Bacchin D, Calabrò F, Korasidis S, Mastromarino MG, Ambrogi MC, Lucchi M. Intraoperative prevention and conservative management of postoperative prolonged air leak after lung resection: a systematic review. J Thorac Dis 2023; 15:878-892. [PMID: 36910073 PMCID: PMC9992588 DOI: 10.21037/jtd-22-736] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 02/06/2023] [Indexed: 02/28/2023]
Abstract
Background Prolonged air leak (PAL) due to an alveolar-pleural fistula (APF) is the most common complication after lung surgery. PAL is associated with an increased risk of morbidity and mortality, a longer chest tube duration, hence a prolonged hospitalization. Management of PAL may be challenging, and the thoracic surgeon should be aware of the possible therapeutic strategies. Methods A systematic literature review was performed in PubMed, Cochrane Library, EMBASE, Ovid and Google Scholar. Title, abstract and full-text screening was performed, followed by structured data extraction, methodological quality assessment and Cochrane risk of bias assessment. Inclusion criteria were: case-control studies/randomized controlled trials (RCTs) comparing the new tested method with the standard of care to manage PAL after lung surgery; PAL due to APF; at least 10 patients; English-written papers. Results A total of 942 initial papers from literature search, resulted in 43 papers after the selection. This systematic review found that the use of intraoperative measures as surgical sealants or pleural tenting, as well as a proper management of the chest drain and the use of blood patch or sclerosant agents seem to reduce postoperative air leaks incidence and/or duration and length of chest drain stay and hospitalization. Conclusions Different measures have been described in literature to manage or prevent postoperative PAL. Most of them seem to be safe and efficient if compared to the "wait and see" strategy, even if large comparative studies that standardize the intra- and post-operative management of APF after lung resection are lacking and, actually, hard to conceptualize. However, there is a large consensus on the value of a preoperative PAL-risk stratification and on the necessity of tailoring PAL management or prevention's strategy and its timing on each patient's features.
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Affiliation(s)
- Vittorio Aprile
- Division of Thoracic Surgery, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Diana Bacchin
- Division of Thoracic Surgery, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Fabrizia Calabrò
- Division of Thoracic Surgery, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Stylianos Korasidis
- Thoracic Surgery Unit, Cardiac-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | | | - Marcello Carlo Ambrogi
- Division of Thoracic Surgery, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Marco Lucchi
- Division of Thoracic Surgery, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy.,Thoracic Surgery Unit, Cardiac-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
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Dias IR, Ghefter MC, Andrade Filho PHDE, Morais LLS, Marchetti Filho MA, Himuro HS, Feichas RLP. The impact of the COVID-19 pandemic on the decrease in the use of intensive care units in the postoperative period of anatomic lung resections. A retrospective analysis. Rev Col Bras Cir 2022; 49:e20223140. [PMID: 35792804 PMCID: PMC10578854 DOI: 10.1590/0100-6991e-20223140-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 04/09/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE COVID-19 pandemic required optimization of hospital institutional flow, especially regarding the use of intensive care unit (ICU) beds. The aim of this study was to assess whether the individualization of the indication for postoperative recovery from pulmonary surgery in ICU beds was associated with more perioperative complications. METHOD retrospective analysis of medical records of patients undergoing anatomic lung resections for cancer in a tertiary hospital. The sample was divided into: Group-I, composed of surgeries performed between March/2019 and February/2020, pre-pandemic, and Group-II, composed of surgeries performed between March/2020 and February/2021, pandemic period in Brazil. We analyzed demographic data, surgical risks, surgeries performed, postoperative complications, length of stay in the ICU and hospital stay. Preventive measures of COVID-19 were adopted in group-II. RESULTS 43 patients were included, 20 in group-I and 23 in group-II. The groups did not show statistical differences regarding baseline demographic variables. In group-I, 80% of the patients underwent a postoperative period in the ICU, compared to 21% in group-II. There was a significant difference when comparing the average length of stay in an ICU bed (46 hours in group-I versus 14 hours in group-II - p<0.001). There was no statistical difference regarding postoperative complications (p=0.44). CONCLUSIONS the individualization of the need for ICU use in the immediate postoperative period resulted in an improvement in the institutional care flow during the COVID-19 pandemic, in a safe way, without an increase in surgical morbidity and mortality, favoring the maintenance of essential cancer treatment.
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Affiliation(s)
- Ismael Rodrigo Dias
- - Hospital do Servidor Público Estadual de São Paulo- HSPE/IAMSPE, Departamento de Cirurgia Torácica - São Paulo - SP - Brasil
| | - Mario Claudio Ghefter
- - Hospital do Servidor Público Estadual de São Paulo- HSPE/IAMSPE, Departamento de Cirurgia Torácica - São Paulo - SP - Brasil
| | - Pedro Hilton DE Andrade Filho
- - Hospital do Servidor Público Estadual de São Paulo- HSPE/IAMSPE, Departamento de Anestesiologia - São Paulo - SP - Brasil
| | - Lilianne Louise Silva Morais
- - Hospital do Servidor Público Estadual de São Paulo- HSPE/IAMSPE, Departamento de Cirurgia Torácica - São Paulo - SP - Brasil
| | - Marco Aurelio Marchetti Filho
- - Hospital do Servidor Público Estadual de São Paulo- HSPE/IAMSPE, Departamento de Cirurgia Torácica - São Paulo - SP - Brasil
| | - Hebert Santos Himuro
- - Hospital do Servidor Público Estadual de São Paulo- HSPE/IAMSPE, Departamento de Cirurgia Torácica - São Paulo - SP - Brasil
| | - Rafael Lacerda Pereira Feichas
- - Hospital do Servidor Público Estadual de São Paulo- HSPE/IAMSPE, Departamento de Cirurgia Torácica - São Paulo - SP - Brasil
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Dinjens L, de Boer WS, Stigt JA. Ambulant treatment with a digital chest tube for prolonged air leak is safe and effective. J Thorac Dis 2022; 13:6810-6815. [PMID: 35070365 PMCID: PMC8743419 DOI: 10.21037/jtd-21-1196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/28/2021] [Indexed: 11/16/2022]
Abstract
Background Outpatient or ambulatory treatment for prolonged air leak (PAL) has been reported previously in various studies. Evidence regarding efficiency and safety is nevertheless poor. This report describes the experience of 10 years ambulatory care with a digital chest drain system monitored by specialized nurses in our centre. The aim of the study is to give further insights in the effectiveness and safety of this treatment. Methods Retrospective data of 10 years ambulatory care for PAL were examined. One hundred and forty patients with PAL after pneumothorax or pulmonary surgery were included. Results A total of 140 patients with PAL were included. Treatment was successful in 112 patients (80.0%). Hospital readmission was necessary in 33 patients (23.6%) and 28 (20.0%) of them received additional treatment. Additional treatment consisted of video-assisted thoracoscopic surgery (VATS) in 19 patients (13.6%), new chest tube placement in 8 patients (5.7%) and pleurodesis (with talc slurry) in 1 patient (0.7%). Minor complications occurred in 10 patients (7.1%), major complications requiring readmission occurred in 14 patients (10.0%). Conclusions Ambulatory treatment of PAL with a digital monitoring device resulted in a high success rate with a limited complication rate.
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Affiliation(s)
- Lars Dinjens
- Department of Pulmonology, Isala Klinieken, Zwolle, The Netherlands
| | - Wytze S de Boer
- Department of Pulmonology, Isala Klinieken, Zwolle, The Netherlands
| | - Jos A Stigt
- Department of Pulmonology, Isala Klinieken, Zwolle, The Netherlands
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DIAS ISMAELRODRIGO, GHEFTER MARIOCLAUDIO, ANDRADE FILHO PEDROHILTONDE, MORAIS LILIANNELOUISESILVA, MARCHETTI FILHO MARCOAURELIO, HIMURO HEBERTSANTOS, FEICHAS RAFAELLACERDAPEREIRA. O impacto da Pandemia de COVID-19 na diminuição do uso de Unidade de Terapia Intensiva em pós-operatório de ressecções pulmonares anatômicas. Uma análise retrospectiva. Rev Col Bras Cir 2022. [DOI: 10.1590/0100-6991e-20223140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO Introdução: a pandemia de COVID-19 exigiu otimização dos fluxos institucionais hospitalares, especialmente quanto ao uso de leitos de unidade de terapia intensiva (UTI). O objetivo deste estudo foi avaliar se a individualização da indicação de recuperação pós-operatória de cirurgias pulmonares em leitos de UTI associou-se a mais complicações perioperatórias. Método: análise retrospectiva de prontuários dos pacientes submetidos a ressecções pulmonares anatômicas por câncer em hospital terciário. A amostra foi dividida em dois grupos: Grupo-I, composto pelas cirurgias realizadas entre março/2019 e fevereiro/2020, pré-pandemia, e Grupo-II, composto pelas cirurgias realizadas entre março/2020 e fevereiro/2021, período de pandemia no Brasil. Analisamos dados demográficos, riscos cirúrgicos, cirurgias realizadas, complicações pós-operatórias, tempo de UTI e de internação hospitalar. Foram adotadas medidas preventivas de COVID-19 no grupo-II. Resultados: foram incluídos 43 pacientes, 20 no grupo-I e 23 no grupo-II. Os grupos não apresentaram diferenças estatísticas quanto às variáveis demográficas basais. No grupo-I 80% dos pacientes fizeram pós-operatório em UTI, comparados a 21% do grupo-II. Houve diferença significativa na comparação de tempo médio de permanência em leito de UTI (46 horas no grupo-I versus 14 horas no grupo-II - p<0,001). Não houve diferença estatística quanto a complicações pós-operatórias entre grupos (p=0,44). Conclusões: a individualização da necessidade do uso de UTI no pós-operatório imediato de cirurgias pulmonares resultou em melhora no fluxo assistencial institucional durante a pandemia de COVID-19, de maneira segura, sem aumento na morbimortalidade cirúrgica, favorecendo a manutenção do tratamento oncológico essencial.
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Jean RA, Chiu AS, Boffa DJ, Detterbeck FC, Kim AW, Blasberg JD. Delayed discharge does not decrease the cost of readmission after pulmonary lobectomy. Surgery 2018; 164:1294-1299. [DOI: 10.1016/j.surg.2018.05.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 05/15/2018] [Accepted: 05/31/2018] [Indexed: 01/07/2023]
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French DG, Gilbert S. Technology and evidence-based care enhance postoperative management of chest drains. J Thorac Dis 2018; 10:6399-6403. [PMID: 30746174 DOI: 10.21037/jtd.2018.11.99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Daniel G French
- Division of Thoracic Surgery, Dalhousie University, Queen Elizabeth II Hospital-Victoria Campus, Halifax, NS, Canada
| | - Sebastien Gilbert
- Division of Thoracic Surgery, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, ON, Canada
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Aguayo E, Cameron R, Dobaria V, Ou R, Iyengar A, Sanaiha Y, Benharash P. Assessment of Differential Pressures in Chest Drainage Systems: Is What You See What You Get? J Surg Res 2018; 232:464-469. [PMID: 30463758 DOI: 10.1016/j.jss.2018.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 04/30/2018] [Accepted: 06/01/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Dry-suction chest drainage systems are used to achieve proper drainage of the pleural space after cardiothoracic operations. Data on the actual intrapleural pressure during the use of these systems is lacking. The present study was performed to evaluate pressure differences across the circuit using an ex vivo model. METHODS An ex vivo apparatus coupled to a hospital-grade pleural drainage system was devised to provide calibrated levels of suction and air leak. Simultaneous pressure measurements were obtained at the system outlet and the simulated patient entry site. Trials were conducted with increasing levels of water between the patient and drainage modules at various levels of suction and leak pressures. Signals were recorded at 100 Hz and analyzed using two-way ANOVA. RESULTS With no obstruction, the drainage system provided precise levels of negative pressure at the patient level (10-40 cm H2O). Addition of fluid in the drainage tubing caused significant differences in transmitted suction (P < 0.001). With increasing air leakage and fluid volume, the pressure differential between the system and patient increased significantly (1.14 to 36.69 cm H2O, P < 0.001). In the off-suction setting, increasing levels of obstruction to 22 cm of water led to development of positive intrapleural pressures (2.6 to 11.1 cm H2O, P < 0.001). CONCLUSIONS While commercially available chest drainage systems are able to provide predictable levels of suction at the device, intrapleural pressures can be highly variable and depend on complete patency of connecting tubes. Systems capable of modulating the level of suction based on actual intrapleural pressures may enhance recovery after procedures requiring tube thoracotomy.
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Affiliation(s)
- Esteban Aguayo
- Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Robert Cameron
- Division of Thoracic Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Vishal Dobaria
- Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Ryan Ou
- Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Amit Iyengar
- Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Yas Sanaiha
- Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Peyman Benharash
- Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, California.
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French DG, Plourde M, Henteleff H, Mujoomdar A, Bethune D. Optimal management of postoperative parenchymal air leaks. J Thorac Dis 2018; 10:S3789-S3798. [PMID: 30505566 DOI: 10.21037/jtd.2018.10.05] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Air leaks are the most common complication after pulmonary resection. Enhanced recovery after surgery (ERAS) programs must be designed to manage parenchymal air leaks. ERAS programs should consider two components when creating protocols for air leaks: assessment and management. Accurate assessment of air leaks using traditional analogues devices, newer digital drainage systems, portable devices and chest X-rays (CXR) are reviewed. Published data suggests that digital drainage systems result in a more confident assessment of air leaks. The literature regarding the management of postoperative air leaks, including the number of chest tubes, the role of applied external suction, invasive maneuvers and discharge with a portable device is reviewed. The key findings are that a single chest drain is adequate in the majority of cases to manage an air leak, the use of applied external suction is unlikely to prevent or prolong an air leak, autologous blood patch pleurodesis may potentially shorten postoperative air leaks and there is sufficient data to support that patients can safely be discharged with a portable drainage system. There is also literature to support the design of protocols for management of postoperative air leaks. Standardization of postoperative care through ERAS programs will allow for the design of larger RCTs to better understand some of the controversies around the management of postoperative air leaks.
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Affiliation(s)
- Daniel G French
- Division of Thoracic Surgery, Department of Surgery, Queen Elizabeth II Hospital - Victoria Campus, Dalhousie University, Halifax, NS, Canada
| | - Madelaine Plourde
- Division of Thoracic Surgery, Department of Surgery, Queen Elizabeth II Hospital - Victoria Campus, Dalhousie University, Halifax, NS, Canada
| | - Harry Henteleff
- Division of Thoracic Surgery, Department of Surgery, Queen Elizabeth II Hospital - Victoria Campus, Dalhousie University, Halifax, NS, Canada
| | - Aneil Mujoomdar
- Division of Thoracic Surgery, Department of Surgery, Queen Elizabeth II Hospital - Victoria Campus, Dalhousie University, Halifax, NS, Canada
| | - Drew Bethune
- Division of Thoracic Surgery, Department of Surgery, Queen Elizabeth II Hospital - Victoria Campus, Dalhousie University, Halifax, NS, Canada
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Patella M, Saporito A, Mongelli F, Pini R, Inderbitzi R, Cafarotti S. Management of residual pleural space after lung resection: fully controllable paralysis of the diaphragm through continuous phrenic nerve block. J Thorac Dis 2018; 10:4883-4890. [PMID: 30233862 DOI: 10.21037/jtd.2018.07.27] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Residual pleural space after lung resection associated with air leak is a challenging issue, potentially causing serious complications. We report a new, postoperative technique to reduce the pleural space, inducing a controlled and reversible paralysis of the diaphragm. Methods Ten patients were enrolled (7 lobectomies, 2 bilobectomy, 1 wedge resection). Inclusion criteria were: digitally detected air flow >200 mL/min at post-op day 3, presence of empty pleural space at chest x-ray, absence of restrictive lung disease, absence of known arrhythmias. A 22G nerve-block catheter was place under ultrasound guidance in proximity to the phrenic nerve, between the sternocleidomastoid muscle and the anterior scalene muscle at the level of 6th cervical vertebra. Continuous infusion of ropivacaine 0.2% 3 mL/h was started. Fluoroscopy was used to confirm significant reduction in hemidiaphragm movements. Monitoring of vital signs and intense respiratory physiotherapy were enhanced. The infusion was stopped at air leak cessation and the catheter was removed along with the chest drain. Results No peri- and post-procedural complications occurred. In all patients, we observed an immediate reduction of the empty pleural space and resolution of the air leak within few days (3±1.16 days). After suspension of local anaesthetic, complete restoration of the hemidiaphragm function has been documented. Conclusions This is an effective and minimally invasive method to reduce the residual pleural space after lung resections. Narrowing of the pleural space facilitates the contact between the lung and the chest wall promoting the resolution of the air leak. Diaphragm paralysis is controlled and temporary with no residual disabilities.
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Affiliation(s)
- Miriam Patella
- Department of Thoracic Surgery, San Giovanni Hospital, Bellinzona, Switzerland
| | - Andrea Saporito
- Perioperative Medicine Research Group, San Giovanni Hospital, Bellinzona, Switzerland
| | - Francesco Mongelli
- Department of Thoracic Surgery, San Giovanni Hospital, Bellinzona, Switzerland
| | - Ramon Pini
- Department of Thoracic Surgery, San Giovanni Hospital, Bellinzona, Switzerland
| | - Rolf Inderbitzi
- Department of Thoracic Surgery, San Giovanni Hospital, Bellinzona, Switzerland
| | - Stefano Cafarotti
- Department of Thoracic Surgery, San Giovanni Hospital, Bellinzona, Switzerland
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