The purpose of this article, part of the Thoracic Surgery Worldwide series, is to provide a descriptive review of how thoracic surgery is organized in the Netherlands. General information is provided on the Dutch healthcare system, as well as on how Dutch thoracic surgeons are organized and trained. Additionally, this study provides information on our national quality surveillance system, an overview of the most common thoracic surgeries performed in our country, and details of academic research conducted by Dutch medical specialists. Furthermore, we discuss current challenges and future perspectives. In the Netherlands general thoracic surgical procedures are performed by approximately 110 general thoracic surgeons and 25 of the 135 cardiothoracic surgeons. Dutch thoracic surgeons provide minimally invasive lung surgery, chest wall surgery, thymic and mediastinal surgery, and surgical diagnosis and treatment of pleural disorders. Some recently published data on hospital mortality and postoperative adverse events of thoracic surgeries are reported. Furthermore, the structure of the thoracic surgical education and training program is discussed, highlighting the particular structure of two educational programs for thoracic surgery via a general thoracic and cardiothoracic surgery program. To assure high-quality surgical care, the Netherlands has a well-structured national quality surveillance system, involving frequent site visits and mandatory participation in the national lung cancer surgery registry for all hospitals. In terms of academic research, the Netherlands ranked 14th worldwide on number of clinical trials conducted across all medical disciplines in 2021. Furthermore, several thoracic-related (inter-)national multicenter randomized trials which are currently performed and initiated by Dutch hospital research groups are mentioned. Finally, future challenges and advances of Dutch thoracic surgery are addressed, including the implementation of lung cancer screening, imbalanced labor market, and centralization of care.

Background: Pectus excavatum often imposes significant burden on the patients’ quality of life. However, despite the known biopsychosocial effects, the deformity remains underappreciated. Patient reported outcome measures can be used to measure and appreciate results from a patient’s perspective. The pectus excavatum evaluation questionnaire (PEEQ) is the most employed disease specific instrument to measure patient-reported outcome measures (PROMs). A translation and linguistic validation of this questionnaire is presented for its use in the Dutch pediatric pectus excavatum population. By providing an insight in our translation process, we want to encourage other researchers to perform translations to other languages to make the questionnaire available to clinicians and researchers worldwide. Methods: The 22-item PEEQ was translated and adapted according to the leading guidelines for the translation of patient reported outcome measures. Conceptual equivalence and cultural adaptation were emphasized. Results: One forward translation was produced through reconciliation of two forward translations. Back translation resulted in 15 identical items, as well as 6 literal, and 1 conceptual discrepancy. The latter was expected as during the forward translation a more culturally appropriate translation was chosen. Ten patients were involved during the cognitive debriefing process, following which one item was revised and the final Dutch version was established. Conclusions: We provide a culturally appropriate and linguistically validated Dutch version of the PEEQ.

Background: Massive subcutaneous emphysema can cause considerable morbidity with respiratory distress. To resolve this emphysema in short-term, negative pressure wound therapy could be applied as added treatment modality. However, its use is sparsely reported, and a variety of techniques are being described. This study provides a systematic review of the available literature on the effectiveness of negative pressure wound therapy as treatment for massive subcutaneous emphysema. In addition, our institutional experience is reported through a case-series. Methods: The PubMed, Embase and Cochrane Library were systematically searched for publications on the use of negative pressure wound therapy for subcutaneous emphysema following thoracic surgery, trauma or spontaneous pneumothorax. Moreover, patients treated at our institution between 2019 and 2021 were retrospectively identified and analyzed. Results: The systematic review provided 10 articles presenting 23 cases. Studies demonstrated considerable heterogeneity regarding the location of incision, creation of prepectoral pocket, and surgical safety margin. Also closed incision negative pressure wound therapy and PICO© device were discussed. Despite the apparent heterogeneity, all techniques provided favorable outcomes. No complications, reinterventions or recurrences were documented. Furthermore, retrospective data of 11 patients treated at our clinic demonstrated an immediate response to negative pressure wound therapy and a full remission of the subcutaneous emphysema at the end of negative pressure wound therapy. No recurrence requiring intervention or complications were observed. Conclusions: The findings of this study suggest that negative pressure wound therapy, despite the varying techniques employed, is associated with an immediate regression of subcutaneous emphysema and full remission at the end of therapy. Given the relatively low sample size, no technique of choice could be identified. However, in general, negative pressure wound therapy appears to provide fast regression of subcutaneous emphysema and release of symptoms in all cases.

In their retrospective single-center study, Marchant et al. described their outcome after tracheal and cricotracheal resections and reconstructions in detail (1). They report on the outcome of a heterogenous population of 44 patients; 21 patients with a stenosis based on malignancy and 23 with a benign origin. The authors achieved an overall success in 75% of patients, which was defined as no need for reoperations or postoperative intervention. Complications occured in 20% of patients, with 13% being classified as Clavien Dindo grade IIIa or higher. Recurrent stenosis was rare (6.8% of patients). The overall outcome of the series by Marchant et al. is in line with previously reported data (2-4).

Background: A Nuss bar often placed to correct pectus excavatum is usually removed after a period of 2 to 3 years. Bar removal can result in potentially life-threatening complications. To minimize this risk, a recent systematic review recommends in-situ straightening of the bar before removal. Alternatively, the bar can be removed without straightening by extraction along the thoracic curvature. This study reports our single-center experience with this latter technique for bar removal, with focus on perioperative complications. Methods: A single-center retrospective observational cohort study was conducted. Consecutive patients undergoing Nuss bar removal between 2011 and 2020 were eligible for inclusion. The primary outcome was the incidence of perioperative complications. Secondary outcomes included duration of operation, blood loss, and length of postoperative hospital stay. Results: A total of 331 patients were included. Of these, 288 (87%) were male with a median age of 20 years [interquartile range (IQR), 19–26 years]. Perioperative complications occurred in a total of 4 patients (1%) following Nuss bar removal. Two patients (0.6%) experienced major complications (deep incisional surgical site infection and hemothorax respectively); there was no mortality. The median duration of surgery was 30 minutes (IQR, 20–40 minutes). Patients were discharged after a median postoperative stay of 1 day (IQR, 1–1 day). Conclusions: Nuss bar removal without prior in-situ bar straightening appears to be a safe and effective technique. It is associated with a low complication rate of 1%.