Offer

Infectious diseases are not primarily treated surgically. However, complications may develop during the course of the disease, making surgical intervention unavoidable.

In principle, a distinction should be made between 4 main groups, which can be easily differentiated on the basis of their localization:

• Thoracic wall
• pleura
• lung
• mediastinum

Thoracic wall

The most common form of infection in the thoracic wall is an abscess, which usually originates from the skin (skin glands, surgical wounds, etc.) or is caused by a tumor that grows into the chest wall from the inside and becomes secondarily infected. In this case, removal of the destroyed parts of the chest wall is unavoidable. The resulting defect may have to be reconstructed using the patient's own tissue.

Pleura

The most common inflammatory disease to be treated surgically is pleural empyema. This is an accumulation of pus between the pleura and the pleura of the lung, which occurs primarily in the context of protracted pneumonia.

The symptoms are often non-specific and are often attributed to pneumonia that has not yet healed. The patient feels weak, exhausted, has an elevated temperature, increased signs of inflammation in the blood, possibly shortness of breath and fluid visible on the X-ray that compresses the lungs. In this case, a distinction should be made at an early stage between a non-specific effusion and incipient empyema. This is often possible with a harmless puncture and laboratory analysis of the effusion. Empyema should be recognized and treated at an early stage. This includes carrying out a CT scan of the chest with contrast medium in order to be able to classify the stage of empyema. The treatment is based on this. In the case of a complicated effusion, drainage treatment may be sufficient. However, if the CT scan reveals air pockets or chambers within the fluid or if the pleura absorbs more contrast medium, then surgery is unavoidable. In the early stages, a video-assisted thoracoscopy is usually sufficient to clear the lungs of the inflammatory changes. In advanced stages, surgery to remove the pus and free the lung from the rind can only be performed safely in an open procedure. Here too, the earlier an empyema is operated on, the better the long-term results. In the late stage, the affected side of the chest shrinks and can no longer expand to its original size even after surgery, even if the lung can expand again throughout the chest. This affects the patient's lung capacity for the rest of their life.

Lungs

In rare cases, lung tissue is destroyed by inflammation ("destroyed lung") or abscesses form in the lungs. These can often be relieved by intervention. However, particularly in the case of retention of secretions in dilated central airways (so-called bronchiectasis), tuberculosis and other specific germs (e.g. aspergillosis, muccor, etc., especially in hematological diseases or after stem cell transplantation), the tissue is progressively consumed with the risk of bleeding. Surgical removal of the affected lung tissue is then necessary. This can be done locally and minimally invasively (VATS) in the case of easily localized infections such as bronchiectasis, but in the case of larger defects it may require the full skill of the thoracic surgeon and the use of the body's own replacement tissue (usually local muscle flaps) to fill the defect.

A special form of inflammation is the so-called pulmonary sequestrum. This is a piece of lung tissue secreted during embryonic development, which later comes to lie on or in the lung and has more or less contact with the surrounding lung tissue. As a result of this malformation, the secretion from the bronchial glands may not be able to be removed properly, causing the patient to cough constantly and cough up clear secretions, especially in the morning. This secretion can repeatedly become infected and lead to pneumonia. The affected part of the lung can be removed minimally invasively without functional impairment of the lung function, thereby alleviating the patient's symptoms.

Mediastinum

Inflammation of the mediastinum (mediastinitis) is a rare but dreaded disease that can develop from descending infections of the upper respiratory tract (e.g. tonsillitis or dental abscess) or the intervertebral discs (so-called spondylodiscitis) as well as after medical interventions in the soft tissues of the neck or in the mediastinum. Treatment essentially consists of urgent surgical relief with debridement and drainage of the inflammation, treatment of the focus of inflammation (tooth, intervertebral disc or similar) and administration of antibiotics. Treatment in the intensive care unit is often necessary.

The most common inflammatory disease to be treated surgically is pleural empyema. This is an accumulation of pus between the pleura and the pleura of the lungs, which occurs primarily in the context of protracted pneumonia.

The symptoms are often non-specific and are often attributed to pneumonia that has not yet healed. The patient feels weak, exhausted, has an elevated temperature, increased signs of inflammation in the blood, possibly shortness of breath and fluid visible on the X-ray that compresses the lungs. In this case, a distinction should be made at an early stage between a non-specific effusion and incipient empyema. This is often possible with a harmless puncture and laboratory analysis of the effusion. Empyema should be recognized and treated at an early stage. This includes carrying out a CT scan of the chest with contrast medium in order to be able to classify the stage of empyema. The treatment is then based on this. In the case of a complicated effusion, drainage treatment may be sufficient. However, if the CT scan reveals air pockets or chambers within the fluid or if the pleura absorbs more contrast medium, then surgery is unavoidable. In the early stages, a video-assisted thoracoscopy is usually sufficient to clear the lungs of the inflammatory changes. In advanced stages, surgery to remove the pus and free the lung from the rind can only be performed safely in an open procedure. Here too, the earlier an empyema is operated on, the better the long-term results. In the late stage, the affected side of the chest shrinks and can no longer expand to its original size even after surgery, even if the lung can expand again throughout the chest. This affects the patient's lung capacity for the rest of their life.

There are congenital or acquired deformities of the rib cage that can lead to considerable limitations for the patient, particularly in social terms. The best known are the funnel chest (lat. pectus excavatum) and the keel chest (lat. pectus carinatum). The lower part of the breastbone is either pulled inwards towards the spine or bulges outwards. This only leads to functional disorders of the organs (especially the heart) in extreme cases. However, the outwardly visible change in the contours of the chest causes patients to withdraw socially, as they do not want to be seen in public with a bare upper body (swimming pool, sport, beach, etc.). The more common funnel chest should be addressed therapeutically at an early stage. Good results are achieved in childhood with the suction cup. At this time, the sternum still consists largely of cartilage and thus adapts to the growth of the person. This can be utilized and this treatment can be carried out daily over a period of several months in an attempt to avoid surgery (depending on the severity of the funnel chest). However, years of therapy are required for permanent stabilization. If the patient is already older, the procedure of choice is the Nuss procedure, in which a (or two) metal stirrups are inserted behind the sternum through two small incisions on both sides of the lateral chest and anchored to the ribs. The stirrup pushes the sternum forward for at least a year and thus compensates for the deviation. The sternum is then displaced and the stirrup can be removed again. The end of adolescence (15-18 years) is the ideal time for this procedure. If patients do not wish to have their deformity corrected until later, then a modified Ravitch lift is still possible for patients over 20 years of age whose sternum is already largely ossified. In this procedure, the sternum is incised at the bend angle and straightened again. This requires the connections to the ribs on both sides of the sternum to be adjusted and the sternum to be supported with metal rods.

The appropriate procedure is determined individually with the patient before the operation. The success of the respective methods is therefore good and we achieve a beautiful aesthetic result.

Deformities of the ribcage also frequently occur in connection with a curvature of the spine (scoliosis). The treatment of scoliosis is the decisive factor here. If a deformity of the thorax remains, this is corrected secondarily.

Pulmonary emphysema is defined as a widening of the terminal parts of the lungs beyond the terminal bronchioles with destruction of the walls of the alveoli without or at most with slight fibrosis. The clinical picture in its various stages is referred to as chronic obstructive pulmonary disease. The main risk factor for the development of emphysema is smoking. In addition to environmental factors, smokers sometimes develop a restriction of their lung function very quickly, which initially becomes recognizable as "smoker's asthma". This asthma component can still be influenced by medication, but the long-term and lung-destroying progression can only be halted by giving up nicotine. Chronic obstructive pulmonary disease is now the fourth leading cause of death in industrialized countries and continues to gain ground. During the course of the disease, which lasts for many years and progresses gradually, the patient becomes increasingly breathless as the over-inflation of the lungs pushes the diaphragm downwards. As a result, the diaphragm can no longer bulge upwards during exhalation and cannot tighten accordingly during inhalation, i.e. the main respiratory muscle fails functionally. The patient has to use other muscles for breathing (intercostal muscles, throat muscles, etc.) that are not intended for this purpose. Accordingly, he uses more energy for these muscles, which can only partially replace the diaphragm. As a result, the patient quickly becomes breathless, can no longer exercise and is increasingly restricted in everyday activities (showering, shopping, etc.). The quality of life is severely restricted in the final stage.

The treatment of emphysema is generally in the hands of pulmonologists, physiotherapists and rehabilitation specialists. In special cases of end-stage disease, there is the possibility of surgical treatment, known as lung volume reduction surgery (LVRS). A large study in North America (NET trial) has shown better results in terms of quality of life and survival for certain patient groups with surgery than conservative treatment with medication. In the case of severe obstruction with severe hyperinflation in certain forms of emphysema (heterogeneous or intermediate), the mainly affected parts of the lung that are no longer functional are removed. This reduces the volume of the lungs and enables the diaphragm, as the main respiratory muscle, to participate in breathing again. The operation is performed as a standard thoracoscopic procedure on both sides. It leads to a reduction in breathlessness, an improvement in lung function, performance and therefore the patient's quality of life. Six months after the operation, the lungs have reached their best condition and then slowly deteriorate again. In patients who are generally suitable for transplantation, the time of transplantation can be postponed by approx. 3 years. A prerequisite for the surgical route is that the patient stops smoking.

In advanced cases of pulmonary emphysema, a lung transplant is also possible. The thoracic surgery team at the University Hospital Basel is experienced in transplantation and is happy to advise patients in this regard, also in collaboration with the in-house pulmonologists.

Pathological sweating is a very stressful condition for patients and often leads to social withdrawal. It affects around 1% of the population and its causes are ultimately unknown. A dysregulation of the autonomic nervous system or a direct malfunction of the sweat glands is assumed.

The excessive sweating is particularly troublesome on the hands, feet and armpits in varying degrees and sometimes requires the patient to change their underwear several times a day.

Conservative treatment methods such as ointments (aluminum chlorohydroxide in alcohol solution), iontophoresis (direct current in a salt bath) or Botox treatment must be carried out for life or repeatedly. Attempts at drug therapy with beta-blockers, sedatives or anticholinergics can also be undertaken. Surgical procedures can be used as a primary alternative or if conservative treatment is unsuccessful. The resection or suctioning of sweat glands is often associated with either disturbing scars or not lasting success. On the other hand, interrupting the regulatory pathways of the sympathetic part of the autonomic nervous system located in the upper thoracic cavity near the spine can provide a permanent solution to the problem. This also applies to the frequent blushing.

In particular, increased sweating under the armpits and on the hands can be successfully treated in the long term in over 90% of cases by means of a minor thoracic surgical procedure (sympathectomy). The result is immediate and patients have warm and dry hands and armpits. In some cases, the regulatory disorder of the autonomic nervous system leads to increased sweating in the lower half of the body, although this is rarely perceived as a nuisance. Here too, a sympathectomy directly above the diaphragm (splanchnicectomy) can provide relief in individual cases.

With the help of minimally invasive surgery, the area of the sympathetic nerve bundle responsible for regulating sweating (and other vegetative functions such as blood circulation) is severed near the thoracic spine. This leads to an interruption of sympathetic overregulation and subsequently to the cessation of sweating and warmer skin on the upper extremities.

This operation is also successful for circulatory disorders in the hands caused by dysregulation of the autonomic nerves (Raynaud's disease).
The operation is performed under general anesthesia and both sides can be treated in one operation. The hospital stay usually lasts 2-3 days. The cosmetic result is excellent, as only very thin, needle-like instruments are used, the scars of which will hardly be visible later, especially as they are placed in areas of the upper body that are not openly visible.

Surgical treatment of the trachea is intended to eliminate a narrowing or obstruction of the trachea. This narrowing can have various causes. It is either congenital or caused by benign or malignant growths or other masses (e.g. bleeding) inside or outside the windpipe.

The consequences of long-term ventilation (scarring in the trachea) can often be remedied by partial removal of the trachea with direct suturing. Tumors of the trachea (e.g. carcinoid or mucosal polyp or similar) are also a good indication for tracheal surgery. In some cases, part of the trachea is also removed in the case of lung tumors located centrally at the root of the lung and the airways are sutured directly. Such procedures on the central airways require a great deal of experience and place high demands on the surgeon and the treating unit. They should only be performed at specialized centers that are suitably equipped for this purpose, such as the Thoracic Surgery Department at the University Hospital Basel.

In the treatment of narrowing of the trachea and main bronchi, so-called stents are used in many cases today, which are inserted into the trachea from the inside using bronchoscopy under general anesthesia. These wire tubes can be individually adapted to the patient's particular findings and can also be removed again if necessary.

The mediastinum is a spongy layer of connective tissue behind the breastbone up to the spine and separates the right and left halves of the body in the chest. Apart from the lungs, the mediastinum contains all the important organs and ducts of the chest, which are located in close proximity to each other and may also affect each other in the event of illness. The best known of these organs is the heart, whose large supply and drainage vessels are also suspended in the mediastinum (superior vena cava, aorta, pulmonary vessels). Also important are the trachea and esophagus, the thymus gland, lymph nodes with the large lymph duct (thoracic duct), which runs from the abdomen into the neck, and sometimes a part of the thyroid gland (retrosternal goiter). The numerous lymph nodes in particular are of central importance for a number of diseases. Other diseases of the mediastinum are generally rare. The lymph nodes can either become diseased themselves (lymphoma) or fulfill important filter functions as a drainage area for tissue water from the lungs, abdomen, esophagus and chest wall. Therefore, sampling of certain lymph nodes is often indicated in order to have sufficient tissue to analyze the extent of the disease or the type of underlying disease. This can result in far-reaching changes to the treatment strategy. The extraction of samples or entire lymph nodes (normal diameter a few mm to 1 cm, sometimes considerably larger in diseased patients) depends on the location of the target lymph node and must provide sufficient material for a reliable diagnosis and, if necessary, further examinations. In contrast to CT-guided or bronchoscopic puncture with a usually limited amount of tissue, which is sufficient for an assessment of benignity or malignancy, tissue is obtained for further examinations by means of endoscopy of the mediastinum (mediastinoscopy) or by an intervention past the sternum or thoracoscopically. The risk of these procedures is low at specialized centers. Samples are usually obtained as a short inpatient procedure (1 night in hospital).

There are 3 possible approaches for operating on tumors in the mediastinum. Either minimally invasive surgery can be performed with three to 5 mm accesses to the chest cavity from the side between the ribs or an incision can be made between the ribs below the nipple and surgery performed from the side (thoracotomy) or the sternum can be opened longitudinally (sternotomy) and the diseased tissue removed from the front. The choice of access route depends on the location of the tumor and is always selected in such a way that the operation is as gentle as possible and as safe as possible. Minimally invasive techniques are now very well developed, particularly in the case of benign but displacing tumors in the mediastinum (e.g. thymoma, neurinoma, cyst, etc.), which are not uncommon and allow even large findings to be removed without significantly affecting the patient. Above all, these techniques reduce the hospital stay to a few days.

Malignant tumors have a tendency to form metastases in other organs to varying degrees. The tumor cells prefer to settle in tissues that have the smallest blood vessels and allow the cells to migrate into the surrounding tissue. The lungs meet all the requirements here, which is why lung metastases often occur in malignant tumors. The fact that lung metastases are discovered indicates that the patient has an advanced tumor. On the other hand, with various types of tumor, surgery on the metastases can lead to a cure or at least a significant delay in the course of the disease. It should therefore not be decided prematurely that the metastases cannot be operated on. Patients should always be presented to a tumor board in the presence of a thoracic surgeon in order to develop an overall concept for the patient's treatment that takes all options into account. With a meaningful, up-to-date CT scan of the lungs with contrast medium, the thoracic surgeon can assess whether an operation can be carried out sensibly or whether other forms of therapy should be used. In quite a few cases (approx. 30%), round foci in the lungs and a history of a malignant tumor in the patient are mistakenly assumed to be metastases. The clarification of these findings and the assessment of technical feasibility should be carried out by the thoracic surgeon, as he is the specialist in this field.

If there is a history of the following tumors, there is a higher probability of metastases in lung foci:

• testicular tumor
• malignant melanoma
• soft tissue sarcomas
• colon cancer (colon carcinoma)

The removal of multiple lung metastases with sufficient thoroughness can only be achieved by open surgery on the chest. If the preoperative computer tomography is of sufficient quality, individual metastases can also be removed with sufficient reliability using minimally invasive surgery. The prerequisites for this are a limited number of foci, the longest possible time interval between the initial tumor and the discovery of the metastasis, the size and, above all, a favorable location in the periphery of the lung. To ensure that as little healthy lung tissue as possible is removed along with the metastases, laser surgery is often used at the University Hospital Basel, which allows the metastases to be removed very precisely with a margin of healthy tissue. As a result, respiratory impairment after the operation is minimal and no longer noticeable for the patient after one week. The hospital stay after such an operation also lasts this long.

The established indications for metastasis surgery are metastases from colon and kidney carcinomas and soft tissue sarcomas. Increasingly, the advantages of removing lung metastases from other tumors are also being published in the scientific literature. A significant development can be expected here in the coming years.

In many cases, repeated surgery can be performed if lung metastases recur. Study results also show significantly better results for this than for non-surgical treatment.

A pleural effusion is defined as an accumulation of fluid between the pleura and the pleura of the lungs. There are different causes of pleural effusion and different forms of treatment. A distinction is made between effusions that occur passively as a result of heart or liver disease due to fluid being squeezed out of the tissue and effusions that occur actively as a result of secretion from the altered pleura or lung lining as a result of inflammation, injury or growths.

In the first case, an attempt will be made to eliminate the effusion by treating the underlying disease, unless immediate measures (e.g. drainage) are required due to the extent of the effusion.

In the case of diseases of the pleura or lung, surgical treatment may be indicated, as these effusions are sometimes difficult for the body to reabsorb or can become secondarily infected (pleural empyema) or become very recurrent.

If the clinical picture is acute and subsides within a reasonable period of time, but the effusion is so pronounced that it restricts breathing and leads to shortness of breath in the patient, puncture and/or drainage of the effusion is sufficient.

If the effusion does not disappear or the clinical picture persists (e.g. in the case of metastases in the pleura), minimally invasive thoracic surgery can be used to surgically attach the pleura to the pleura. This procedure is carried out under general anesthesia and is performed using three 5 mm openings in the thorax, through which the camera and the necessary instruments can be inserted. The lung sticks to the ribs due to the talcum powder introduced and can no longer be displaced by fluid.

A special type of pleural effusion is the so-called hemothorax. This involves blood in the chest cavity. It can bleed into the chest cavity after injuries (e.g. rib fractures) or in the case of trivial injuries with simultaneous blood thinning. Liquid blood can be drained off using a drain, clotted blood must be removed by surgery (usually minimally invasive), as it takes too long for the lungs to shrink before the blood is broken down by the body and the lungs shrink during this time and can no longer expand later.

A special form of pleural effusion is the so-called chylothorax. In this case, lymph fluid leaks from the large lymph duct (thoracic duct) into the chest cavity. This occurs spontaneously (very rarely), after an accident or as a complication after surgery in the area of the lungs or esophagus. The first step in conservative therapy is a fat-free diet for 10 days, during which it is hoped that the leak will heal spontaneously. If the chylothorax persists after a provocation meal, surgical ligation of the lymphatic duct close to the diaphragm is indicated. This can be performed minimally invasively.

Pleural mesothelioma is a malignant proliferation of the pleura, which can usually occur with a delay of more than 15 years after exposure to asbestos fibers. The inhalation of asbestos fibers, which arise during the processing of asbestos (sawing, drilling, etc.), is a clear risk factor for the development of the disease. As the disease begins very gradually and is often only discovered when therapeutic measures can no longer lead to a cure, anyone who has had contact with asbestos as described above is encouraged to have regular X-rays of the lungs. The disease is one of the longest recognized occupational diseases and the costs of treatment are covered by Swiss accident insurance or the employers' liability insurance association. The assessment of the X-ray images taken as part of this screening is not trivial and should be carried out by a specialist. Any pleural effusion in people with asbestos exposure requires urgent clarification. Until a clear diagnosis can be made, it is considered to be due to mesothelioma.

However, due to the virtual absence of symptoms, we see very few patients in the early stages. However, as we also want to help patients at an advanced stage, various treatment concepts have been developed. If the tumor is no longer operable and the effusion, i.e. the resulting shortness of breath, is the main symptom, a minimally invasive pleurodesis can be performed. If the tumor is at a locally operable stage, the patient should be treated as part of a trial, as the optimal treatment regime has not yet been developed. A tumor that is in principle operable is considered curable. The diagnosis must first be confirmed and the patient prepared for a multimodal procedure. A thoracoscopic sample is taken from several areas of the pleura and a so-called pleurodesis is performed, i.e. the pleura is adhered to the lung so that the tumor cannot secrete fluid during the subsequent treatment, which can lead to respiratory distress and possibly to the discontinuation of treatment. A combination of chemotherapy followed by surgery and possibly radiotherapy is then carried out. This aggressive approach can lead to a significant prolongation of life. Statistically speaking, the average survival can be extended from around 1 year after diagnosis to over three years after diagnosis. In other words, the probability of still being alive 5 years after diagnosis increases from approx. 10% to 30 - 40%. This applies to patients who have responded well to chemotherapy, have had the tumor completely removed and no lymph node involvement can be detected.

As part of this concept, surgery is usually performed 6 weeks after the end of chemotherapy. The lung in the pleural sac is dissected out of the chest and removed along with a portion of the attached pericardium and diaphragm. The pericardium and diaphragm are replaced with plastic mesh. The external appearance of the chest hardly changes noticeably after the operation. The recovery phase after this procedure lasts about 2 weeks. This is followed by rehabilitation before further treatment is carried out. The patient's quality of life is satisfactory after the treatment and is restored to such an extent that the interventional therapy is entirely justified from this point of view.

Tumor metastases to distant organs are rare. However, the tumor has a strong tendency to recur at the same site and grow into the adjacent internal organs, thereby initiating their functional failure.

The results in the treatment of pleural mesothelioma have improved significantly in recent years. In addition to modern concepts, this is mainly due to the fact that patients are treated at specialized centers that have standardized the complex treatment process.

Thoracic surgery at the University Hospital Basel is part of such a center and contributes to the improvement of treatment results by treating every patient with pleural mesothelioma in an interdisciplinary study.

A pneumothorax is air inside the chest cavity but outside the lungs. The air can get there either from the outside (e.g. through open injury), from inside the lungs (so-called spontaneous pneumothorax, without (primary) or with (secondary) underlying lung disease) or as a complication (e.g. when a venous catheter is inserted in the neck). Depending on the amount of air that has entered and the possibility of pressure equalization with the environment, the patient feels anything from nothing to shortness of breath with a feeling of tension to circulatory collapse, which can quickly lead to death as a so-called tension pneumothorax without immediate treatment.

In addition to a typical medical history, an X-ray of the lungs will confirm the findings. A chest tube is inserted into the affected side under sterile conditions. A suction system is connected and the lungs can be expanded again. The drain is then removed after a few days.

In some special cases, surgery is still recommended as a second step. In patients with a so-called primary spontaneous pneumothorax, the pneumothorax arises without warning from a state of complete well-being. In up to 90% of these patients, changes are found in the lungs that significantly increase the risk of a spontaneous pneumothorax recurring. These changes (vesicles, bullae) are usually located in the tip of the lung and are attributable to the formation of the lung during embryonic development. They occur preferentially in tall, lean men in young adulthood. If patients in whom these changes are detected by CT are operated on, the risk of developing a new pneumothorax is only one tenth (4%) of that expected with drainage treatment alone. Therefore, (mostly young) patients with a spontaneous pneumothorax are advised that they should undergo surgery, which is minimally invasive and is performed under general anesthesia through three approximately 10 mm incisions in the chest wall. The changes identified by CT are removed and the pleura is glued to the tip of the lung. Mechanical processing of the pleura is sufficient. Administration of talcum powder is not necessary in these cases. As the changes often occur on both sides, they also pose a certain risk of pneumothorax for the patient on the opposite side. For this reason, patients are recommended to have the opposite side operated on as well.

The advantage of surgery over drainage treatment is the significantly lower recurrence rate (by a factor of around 8-10), as the part of the lung causing the problem is removed and the impairment of the lung is minimized by targeted mechanical adhesion of the pleura in the affected section only. This is not the case with an untargeted administration of talc via a chest tube. In addition, the operation can shorten the overall hospital stay and the cosmetic result is also good due to the use of small incisions.

Patients are unsuitable for some professional activities due to the risk of pneumothorax and should also take this into account in their leisure activities. In particular, activities with strong pressure fluctuations in the environment or in the body such as diving or sport flying or similar should be avoided.

The pleura is a fine membrane that covers the inside of the chest wall and the diaphragm and stretches over the lungs (it is then called the pleura). It contains very little fluid as a lubricant and enables the lungs to follow the breathing movements in the chest and glide along the ribs.

The pleura itself is rarely diseased, but is often a mediator of disease. It is important for the patient as it is the only layer in the rib cage that can transmit pain. This means that pain in the chest can only be felt by the patient if the pleura is involved. On the other hand, not all diseases of the pleura are associated with pain.

The pleura seals off the chest from the lungs, diaphragm and ribs, so that fluid (effusion, blood, pus) or air can collect in it. In most cases, the source of this can be found elsewhere than in the pleura.

Diseases of the pleura that can be considered for surgical treatment are pleural empyema (accumulation of pus), pleural carcinomatosis (seeding of a malignant tumor in the pleura) and pleural mesothelioma (asbestos-related malignant disease of the pleura).

For the detection and treatment of pleural empyema, please refer to the relevant section.

The seeding of a malignant tumor in the pleura is an unfavorable sign with regard to the progression of the disease. It is also often associated with increased fluid formation in the pleura. This fluid collects in the space between the pleura and the pleura of the lungs and can lead to a sometimes severe impairment of breathing with shortness of breath. This is described in the Pleural effusion section.

A round pulmonary focus is a radiological description of a round shadow in the chest X-ray that is no more than 3 cm in diameter. It can be single or multiple and the name does not allow any conclusions to be drawn about the type of disease. Therefore, each lung round spot must be further clarified until a form of cancer (lung carcinoma or metastasis) can be excluded with sufficient reliability. First of all, a CT scan should be performed with contrast medium and a maximum slice thickness of 4 mm. The findings should then be presented to an experienced pulmonologist and/or thoracic surgeon so that further action can be planned. As a general rule, a larger focus is also associated with a higher probability of malignancy. Patients with a risk constellation (smoking, family history, own tumor history, age, gender, etc.) are more likely to have malignant changes than patients without a risk constellation. In the latter case, observation of small, inconspicuous foci is more likely to be accepted in the short term than in patients with a risk constellation. In the latter case, at least cytological confirmation of the focus should be performed by puncture, and if necessary, minimally invasive removal of the findings with frozen section diagnostics during the operation. In the case of a small lung carcinoma, definitive tumor surgery can then be performed during the same operation.

Even today, it is not possible to assess round lung tumors with sufficient certainty based on imaging. Therefore, if in doubt, a tissue sample of the focus should always be obtained and examined.

The thymus gland is located behind the breastbone and plays an important role in the development of the immune system (defenses) during childhood. After that, the tissue shrinks and is often no longer recognizable. In some rare cases, however, the tissue of the thymus gland can become benign or (even more rarely) malignant in the course of life. Benign growths of the thymus gland are usually without pathological value, although sometimes a clear differentiation from other tumors of the mediastinum (e.g. lymphoma) is not possible by imaging alone and must therefore be clarified by biopsy.

There is a neurological disease known as myasthenia gravis or myasthenia, in which antibodies are formed against acetycholine receptors (receptor sites on the muscle cells for the neurotransmitters of the nerve cells). This results in progressive muscle weakness (e.g. drooping eyelids, facial muscle relaxation, speech disorders ("slurred speech")), which can only be treated with medication to a limited extent and sometimes with significant side effects. The drugs cannot combat the cause of the disease, but influence the immune system or the effects of the antibodies on the muscles in order to contain the effects of the disease. As the cause of the disease is not addressed, the medication must be taken for life, possibly with increasing doses. The antibodies that cause the disease are often produced in a remnant of the thymus gland. If a CT scan of the chest shows a growth there (thymoma), the probability that the disease will be cured after removal of the gland is around 80%. Even if the thymus gland is removed without a clear tissue proliferation, the treatment success rate is still 10 - 30%. However, almost all patients who have undergone surgery achieve symptomatic relief with a reduction in the dose of medication.

A thymoma can also develop without neurological symptoms and is usually discovered as an incidental finding during an X-ray examination of the lungs. The usually benign findings can be easily removed by videothoracoscopy or robotic surgery. The operation is minimally invasive with three max. 5 mm incisions and is associated with a hospital stay of 4-5 days after the operation. From a certain size (> 5 cm in diameter), thymomas can also degenerate and should then be removed via open surgery from the front (sternotomy). The final decision on the benignity or malignancy of the tumor can only be made by the pathologist, who can assess the tumor removed in its entirety, as different areas of the tumor can behave differently and a wide range of different tissue patterns are possible. Taking a sample as part of the clarification is therefore not sufficient to confirm the diagnosis.

In the western world, lung cancer is one of the leading causes of cancer death in both men and women and will remain so for decades to come. However, it is possible to cure 80% of patients in the early stages of the disease. Surgery makes a significant contribution to this.

Increasingly, multimodal therapy concepts are also being used in the early stages, but especially in the locally advanced stages of the disease, which plan the best individual approach for the patient through interdisciplinary interaction between different areas. This always includes a thoracic surgical assessment, as surgical treatment plays a central role in these therapy concepts. This means that a newly discovered lung cancer should always be assessed by a thoracic surgeon to determine whether it can be surgically removed. This is usually the case in the early stages, when the tumor can be removed together with the surrounding lung lobe and the associated lymph nodes. The size of the tumor alone says nothing about its resectability. Even large tumors can be surgically removed.

The most common malignant tumor of the lung (approx. 85%) is non-small cell lung cancer (NSCLC), which includes various cell types (squamous cell carcinoma, large cell carcinoma, adenocarcinoma, bronchoalveolar carcinoma and other rare types). There is also small cell lung cancer (SCLC), which is a special form of neuroendocrine carcinoma and is classified and treated independently of these (approx. 15%). Surgery plays a subordinate role here, as only in the "very limited disease" stage (usually an incidental finding) does resection offer a survival advantage compared to the (radio)chemotherapy that is otherwise usual in more advanced stages. SCLC is only discovered at an operable early stage in exceptional cases and often grows at the root of the lung. It is both locally very aggressive and metastasizes early. In 70 - 80% of cases, the types of cancer mentioned are related to smoking, in the case of SCLC in almost 100% of cases.

Finally, there are the neuroendocrine carcinomas, which cover a wide spectrum of tumor aggressiveness, from the typical carcinoid that grows in almost exclusively locally to the aggressive, early metastasizing large-cell neuroendocrine carcinoma. Treatment is planned depending on these differentiation criteria, the extent of the tumor and the patient's condition. In order to be able to assess these three factors, a number of diagnostic and functional examinations are required.

The most common injury in the chest area is a rib contusion. It is very painful, can last for several weeks and heals without consequences.

The second most common injury, a rib fracture, is a step more serious. This is usually a single rib due to an impact (table edge, kerb, door handle, etc.). In the event of a larger impact (traffic accident, accident at work, etc.), several ribs located one below the other can also break, which is known as a serial rib fracture. This normally has no effect on the stability of the ribcage, as the ribs only break at one point and are supported by the surrounding tissue. However, if several ribs fracture at the same time ("flail chest"), the stability for adequate breathing may no longer be guaranteed, resulting in so-called paradoxical breathing. Conservative treatment is usually indicated here too. A stabilizing procedure is performed if there is a risk of shrinkage of the chest, there are no other life-threatening injuries, the injury is in the anterior and lateral part of the chest, which is protected by little muscle, or the patient cannot be weaned off the ventilator due to the injury. There are various procedures for this, ranging from metal pins to screw fixation with metal plates. At the Department of Thoracic Surgery at the University Hospital Basel, a titanium clamp is used, which is placed around the rib and pressed tight with forceps. If necessary, the staples can also be supplemented with struts to bridge larger defect zones.

Every rib fracture is quite painful regardless of the treatment and requires adequate pain therapy, which, in addition to conventional painkillers, is usually not possible without morphine derivatives. Patients are well treated for pain if they can breathe freely without pain. This is important, as pneumonia regularly complicates the healing process if breathing is restrained due to pain. This can be avoided through pain therapy and breathing training.

After every injury to the chest, at least one X-ray of the lungs is performed to detect injuries to the lungs. If the findings are inconclusive, a CT scan is often ordered to rule out further injuries. In the case of rib fractures, regardless of the number of ribs affected, each individual fragment can be pushed inwards during the injury and injure the lung. This is known as a traumatic pneumothorax, i.e. air escaping from the lungs into the chest as a result of an accident. In these cases, it is usually necessary to insert a drainage tube to relieve the pneumothorax and allow the lung to fully expand again. The lungs usually stick together spontaneously within a few days, so that drainage treatment is sufficient for a few days. If no air escapes via the drainage, it can be removed again.

The same applies to injuries to blood vessels. A bundle of blood vessels and nerves runs under each rib, which can rupture if the rib is broken. The blood then runs into the chest (haematothorax), where it can no longer drain away and compresses the lungs. It must therefore be drained via a drainage system. If blood continues to flow or has already clotted, a minimally invasive procedure (VATS) may be required to stop the source of the bleeding or remove the clots. As soon as there is no more blood to drain, the drainage can be removed.

Strong force is required to cause a fracture of the sternum. Surgery is only necessary if the fracture is severe. Pain treatment is usually sufficient here too.

Diaphragmatic injuries often occur in connection with multiple injuries caused by high force and appear as tissue tears. Due to the increased pressure in the abdomen compared to the chest, the abdominal organs are pushed into the chest through the resulting gap in the diaphragm, sometimes severely obstructing the patient's breathing. In this case, the diaphragm must be sutured surgically after the abdominal organs have been repositioned. This can be done from both sides of the diaphragm and can be performed minimally invasively, provided that no further injuries require major open surgery.

In addition to the blunt injuries described above, there are also injuries that open the chest (gunshot or stab wounds), which, like injuries in the context of multiple injuries (so-called polytrauma), can lead to serious bleeding or tissue destruction of the lungs and require immediate surgery.

However, these are rare cases that are individual in nature and for which no standardized procedure can be described. For a more detailed description of these clinical pictures and other rare injuries, please refer to the relevant textbooks on thoracic surgery.

Miniaturization in medicine continues to advance. More and more possibilities are being developed to treat various diseases using gentle surgical methods. Thoracic surgery has historically been a pioneer in this field. The first thoracoscopy (chest endoscopy) was performed by the Swedish doctor Jacobaeus around 100 years ago. Since then, techniques have undergone constant change, so that today the majority of all thoracic surgical procedures can be performed using video-endoscopic methods.

Mediastinoscopy
Mediastinoscopy has been established for a long time. In this procedure, the mediastinum is examined directly in front of the trachea by making a small incision in the neck approx. 3 cm below the larynx under general anesthesia and inserting an endoscope approx. 10 mm thick into the space in front of the trachea. This allows samples of lymph nodes or tumors to be obtained or certain areas to be removed completely.

VATS
Video-assisted thoracoscopic surgery, abbreviated to VATS ("S" from surgery), has also become very widespread. In this procedure, the right or left thoracic cavity is mirrored with the aid of a mini-camera through three openings in the chest wall, usually around 5 mm in size, and the surgical procedures are performed. This can range from simple sampling of the pleura to smaller tissue removal from the lungs and even the complete removal of lung lobes or lobes. The incision may only need to be widened to remove the tissue. Nowadays, the patient is always offered the gentlest procedure available with the same level of treatment success. The thoracic surgery department at the University Hospital Basel is equipped with high-resolution cameras and HDTV technology and has all the modern options for minimally invasive thoracic surgery, including laser technology.

Not only can the access trauma be reduced by modern procedures, but the loss of healthy tissue is also minimized by technical developments. By using the laser, for example, metastases can be operated on gently while preserving as much healthy lung tissue as is currently possible.

The use of minimally invasive techniques is also very important in the surgical treatment of emphysema. In this case, the stability and functionality of the chest wall, which is crucial for respiratory mechanics, is not disturbed by an incision and therefore allows the patient to recover immediately after the operation.

Palliation refers to the improvement of quality of life in the case of an incurable and progressive disease. In order for the stress of a surgical procedure to be justified in this situation, either the level of suffering must be very high or the improvement in quality of life must be significant. The extent of the intervention required also plays a role in the decision to proceed with surgery. The options for palliative medicine are quite varied and are often decided on an interdisciplinary basis. Specialist knowledge of modern developments is required for surgical measures, as minimally invasive procedures are initially in the foreground. Good communication within the treatment team is important here so that the individual treatment steps can be well coordinated. As the patient's expectations are very individual, we discuss carefully with each patient which procedure is best suited to their case.

As there are always several treatment options with varying degrees of palliation, the most appropriate one is selected and implemented with the patient.
The most common complaints that may require palliative thoracic surgery are shortness of breath, pain and a general feeling of illness in chronic infections with a focus of inflammation in the thorax.

In the course of malignant diseases, metastases in the pleura (so-called pleural carcinomatosis) can lead to a sometimes massive pleural effusion, which compresses the lung on the affected side so that it is no longer available for breathing and causes shortness of breath. The effusion can be punctured as an acute treatment. However, these effusions often resolve quite quickly within a few days. A small, minimally invasive operation can then be performed to remove the tumor from the pleura via 2 openings in the chest wall, no larger than 5 mm, and to create a complete adhesion of the lung to the pleura under optimal visual control so that no more effusion can form. This eliminates the shortness of breath. If the lung is bound by a pronounced tumor and can no longer expand after removal of the effusion, the feeling of breathlessness may still be better without the effusion. In selected cases, an attempt can then be made to expand the lung by removing the (tumor) rind from the lung (so-called decortication). However, if the lung is still too far away from the pleura to allow successful adhesion, it is possible to insert a catheter tunneled into the skin into the chest cavity. This catheter enables the patient to drain enough effusion at home at regular intervals to prevent an increase in breathlessness.

In the case of tumor-related pain, either the tumor can be surgically removed or a special locally effective pain pump can be installed to block the nerve pathways that transmit tumor pain. Radiotherapy to relieve the pain is also an option.

Tumors often block the airways and lead to pneumonia in the downstream section of the lung, as the mucus and bacteria cannot be removed via the blocked bronchus. Pneumonia is a secondary problem that does not heal as long as the tumor blocks the bronchus. As it progresses, an abscess may form and the affected section of the lung may be destroyed. An abscess can also occur if a tumor grows very quickly and disintegrates in the middle and these tissue remnants become infected by the germs present in the lung. In both cases, the abscess leads to a general feeling of illness and even blood poisoning. The source of the infection can then only be eliminated by removing the affected section of the lung. Only then can chemotherapy be initiated. In this case, the tumor will not be cured.

Tumor treatment often requires a permanent catheter access into the venous system in order to administer chemotherapy. So-called port systems are often used for this purpose. These are small plastic pots that are placed approx. 5 - 10 cm below the collarbone under the skin and are connected to a tube that ends in the superior vena cava. A special needle is used to puncture the membrane on the front of the pot through the skin during use. These port systems are implanted at the University Hospital Basel under local anesthesia and usually remain in the body for several months or years. The procedure can also be performed on an outpatient basis. The most common complications are infection (in which case the port must be removed) and clot formation (thrombosis, port is no longer functional but can be left in place).

Interventional bronchoscopy can also lead to lasting improvements in airway obstructions caused by tumors in a very gentle manner. The tumor can be "cooked" with a laser or the constriction in the bronchial system can be bridged with a stent specially adapted to the patient. This is a special wire mesh that expands into its original shape when exposed to body heat and exerts pressure on the surrounding area ("memory metal"). This allows constrictions to be permanently widened again. Ideally, such stents are inserted under anesthesia. This allows the stent to be optimally placed.