Gabriel Marta

Efficacy and safety of TachoSil® versus standard treatment of air leakage after pulmonary lobectomy,

OBJECTIVESnAlveolar air leakage remains a serious problem in lung surgery, being associated with increased postoperative morbidity, prolonged hospital stay and greater health-care costs. The aim of this study was to evaluate the sealing efficacy and safety of the surgical patch, TachoSil®, in lung surgery.nnnMETHODSnPatients undergoing elective pulmonary lobectomy who had grade 1 or 2 air leakage (evaluated by the water submersion test) after primary stapling and limited suturing were randomised at 12 European centres to open-label treatment with TachoSil® or standard surgical treatment (resuturing, stapling or no further treatment at the surgeons discretion). Randomisation was performed during surgery using a centralised interactive voice response system. Duration of postoperative air leakage (primary end point), reduction of intra-operative air leakage intensity (secondary end point) and adverse events (AEs), including postoperative complications, were assessed.nnnRESULTSnA total of 486 patients were screened and 299 received trial treatment (intent-to-treat (ITT) population: TachoSil®, n=148; standard treatment, n=151). TachoSil® resulted in a reduction in the duration of postoperative air leakage (p=0.030). Patients in the TachoSil® group also experienced a greater reduction in intra-operative air leakage intensity (p=0.042). Median time until chest drain removal was 4 days with TachoSil® and 5 days in the standard group (p=0.054). There was no difference between groups in hospital length of stay. AEs were generally similar in both groups, including postoperative complications.nnnCONCLUSIONSnTachoSil® was superior to standard surgical treatment in reducing both postoperative air leakage duration and intra-operative air leakage intensity in patients undergoing elective pulmonary lobectomy.

Surgical specimens, haemodynamics and long-term outcomes after pulmonary endarterectomy

Background Chronic thromboembolic pulmonary hypertension is surgically curable by pulmonary endarterectomy (PEA). It is unclear whether PEA impacts primarily steady state right ventricular afterload (ie, pulmonary vascular resistance (PVR)) or pulsatile right ventricular afterload (ie, pulmonary arterial compliance (CPA)). Our objectives were to (1) quantify PEA specimens and measure the impact of PEA on PVR and CPA in a structure/function study and (2) analyse the effects of haemodynamic changes on long-term survival/freedom of lung transplantation in an outcome study. Methods Thrombi were laid out, weighed, photographed and measured. PVR, CPA and resistance times compliance (RC-time) were assessed at baseline, within 4u2005days after PEA (‘immediately postoperative’) and 1u2005year after PEA, in 110 consecutive patients who were followed for 34.5 (11.9; 78.3) months. Results Lengths and numbers of PEA specimen tails were inversely correlated with immediate postoperative PVR (p<0.0001, r=−0.566; p<0.0001, r=−0.580). PVR and CPA normalised immediately postoperatively while RC-time remained unchanged. Immediate postoperative PVR was the only predictor of long-term survival/freedom of lung transplantation (p<0.0001). Patients with immediate postoperative PVR<590u2005dynes.s.cm−5 had better long-term outcomes than patients with PVR≥590u2005dynes.s.cm−5 (p<0.0001, respectively). Conclusions PEA immediately decreased PVR and increased CPA under a constant RC-time. However, immediate postoperative PVR was the only predictor of long-term survival/freedom of lung transplantation. Our study confirms the importance of a complete, bilateral surgical endarterectomy. Low PVR measured immediately postoperative predicts excellent long-term outcome.

Successful lung volume reduction surgery brings patients into better condition for later lung transplantation.

OBJECTIVESnLung volume reduction surgery (LVRS) is accepted as a potential alternative therapy to lung transplantation (LTX) for selected patients. However, the possible impact of LVRS on a subsequent LTX has not been clearly elucidated so far. We therefore analyzed the course of 27 patients who underwent LVRS followed by LTX in our institution.nnnMETHODSnTwenty-seven patients (11 male, 16 female, mean age 51.9+/-2.2 years) out of 119 patients who underwent LVRS between 1994 and 1999 underwent LTX 29.7+/-3.2 months (range 2-57 months) after LVRS. Based on the postoperative course of FeV1 after LVRS (best value within the first 6 months postoperatively compared with the preoperative value) patients were divided into two groups: Group A (n=11) without any improvement (FeV1 <20% increase), and Group B (n=16) with FeV1 increase > or = 20% after successful LVRS which declined to preoperative values after 8-42 months. Subsequent LTX was performed 22.9+/-5.6 months after LVRS in Group A and 34.3+/-4.9 months after LVRS in Group B (P<0.05). Patients were analyzed according to the course of their functional improvement and of their body mass index (BMI) after LVRS and to survival after LTX, respectively. Values are given as the mean+/-SEM and significance was calculated by the chi(2)-test whereas continuous values were estimated by Students t-test.nnnRESULTSnPatients in Group A without improvement in FeV1 after LVRS had no increase in BMI as well and this resulted in a high perioperative mortality of 27.3% after LTX. On the contrary, patients in Group B, who had a clear increase of FeV1 after LVRS, experienced a significant increase of BMI of 23.2+/-4.5% as well (P<0.05). This improvement in BMI remained stable despite a later deterioration of FeV1 prior to LTX. After LTX, these patients had a significantly lower perioperative mortality of 6.3% as compared to Group A (P=0.03).nnnCONCLUSIONSnSuccessful LVRS delays the need for transplantation, improves nutritional status and brings patients into a better pretransplant condition, which results in decreased perioperative mortality at LTX. Patients after failed LVRS, however, should be considered as poor candidates for later transplantation.

Outcome after extrapleural pneumonectomy for malignant pleural mesothelioma.

BACKGROUNDnMalignant pleural mesothelioma is a mainly asbestos-related neoplasm that occurs with increasing frequency and is associated with a poor prognosis. Extrapleural pneumonectomy which was initially performed as a stand-alone treatment in patients with resectable disease is now currently almost uniformly applied as part of a multi-modal approach. Its value and advantage over other therapeutic strategies remain points of discussion. We therefore analysed our experience with extrapleural pneumonectomy in the treatment of malignant pleural mesothelioma.nnnMETHODSnWe retrospectively reviewed our institutional experience with all consecutive patients undergoing extrapleural pneumonectomy for malignant pleural mesothelioma from 1994 to 2005. Patients were analysed with regard to hospital mortality and morbidity and long-term outcome.nnnRESULTSnForty-nine patients (10 female/39 male, mean age 58+12 years) underwent extrapleural pneumonectomy during the observation period. Median ICU stay was 1 day, median postoperative length of hospital stay was 13 days. After a mean follow-up of 2573 days, median survival was 376 days (mean 672+121 days, range 9-3384). One-year survival was 53%, 3-year survival 27% and 5-year survival 19%.nnnCONCLUSIONnExtrapleural pneumonectomy as part of a multi-modality treatment regimen is a good treatment option for selected patients with malignant pleural mesothelioma. The long-term results of this limited series compare favourably to non-surgical treatment regimens. Larger randomised prospective multi-centre trials are warranted to establish clear guidelines.

Cofilin, a hypoxia-regulated protein in murine lungs identified by 2DE: Role of the cytoskeletal protein cofilin in pulmonary hypertension

Chronic alveolar hypoxia induces vascular remodeling processes in the lung resulting in pulmonary hypertension (PH). However, the mechanisms underlying pulmonary remodeling processes are not fully resolved yet. To investigate functional changes occurring during hypoxia exposure we applied 2DE to compare protein expression in lungs from mice subjected to 3 h of alveolar hypoxia and those kept under normoxic conditions. Already after this short‐time period several proteins were significantly regulated. Subsequent analysis by MALDI‐MS identified cofilin as one of the most prominently upregulated proteins. The regulation was confirmed by western blotting and its cellular localization was determined by immunohisto‐ and immunocytochemistry. Interestingly, enhanced cofilin serine 3 phosphorylation was observed after short‐term and after chronic hypoxia‐induced PH in mice, in pulmonary arterial smooth muscle cells (PASMC) from monocrotaline‐induced PH in rats, in lungs of idiopathic pulmonary arterial hypertension patients and in hypoxic or platelet‐derived growth factor BB‐treated human PASMC. Furthermore, elevated cofilin phosphorylation was attenuated by curative treatment of monocrotaline‐induced PH in rats and hypoxia‐induced PH in mice with the PDGF‐BB receptor antagonist imatinib. In conclusion, short‐term hypoxic exposure induced prominent changes in lung protein regulation. These very early changes allowed us to identify potential triggers of PH. Thus, respective 2DE analysis can lead to the identification of new target proteins for the possible treatment of PH.

A rare indication for video‐assisted thoracoscopic surgery: headscarf needle aspiration

Headscarf needle aspiration is a rare event, especially in Middle and Western European countries. Here, we report the case of a 37‐year‐old Austrian woman of Turkish origin who accidentally aspirated a turban pin. Repeated bronchoscopy was not successful in removing the aspirated foreign body, which extended past the right middle lobe to the interlobar fissure. The needle was finally removed by video‐assisted thoracoscopic surgery.

Considerations on infectious complications using a drowned lung for transplantation

Recently, the applicability of lungs from drowned victims for transplantation has been anecdotically described in literature. However, no data exist about hazards or limitations. Herein, we describe a case of lung transplantation from a submersion victim and the subsequent development of an Aeromonas hydrophila infection in the implanted organ. Based on this case we propose standard procedures, which should be followed when considering drowned donor lungs, in order to minimize risks for infectious complications.

Right-sided approach for management of left-main-bronchial stump problems

OBJECTIVEnAlthough the incidence of bronchopleural fistula (BPF) has decreased in the past decades, it remains a serious complication following pulmonary resection. The management of left-sided bronchial stump fistulas is difficult and depends on the choice of the approach. In contrast to several surgical procedures published in the past, herein we report our experience managing five left-main-bronchial stump (LMBS) problems through a right thoracotomy route.nnnMETHODSnFive women, who underwent left pneumonectomy and later developed BPF, were managed with this novel procedure at our Institution. BPF appeared between 12 days and 24 years after pneumonectomy. Diagnosis of BPF or bronchoesophageal fistula (BEF) was made by computed tomography (CT) scan and fiberoptic bronchoscopy. Through a right posterolateral thoracotomy incision, the LMBS was re-stapled and covered with pedicled flaps in all cases. In patient #4, carinal resection was performed also, with temporary extracorporeal membrane oxygenation (ECMO) application.nnnRESULTSnThe main results are depicted in the table. In all cases, encircling of the LMBS and stapling at the level of the carina was performed without difficulties. In patients #1, #2 and #3, resection of the bronchial stump remnant was also done and, in patient #4, carinal resection was also performed. All patients are doing well, with no evidence of recurrence of fistula.nnnCONCLUSIONSnWe advocate the right posterolateral thoracotomy route for the management of left-sided BPFs as an alternative to transternal transpericardial and transthoracic closures. It is a safe, feasible and time-efficient approach that provides control of central structures and avoids previously manipulated or infected operative fields.

A modified technique of laryngotracheal reconstruction without the need for prolonged postoperative stenting

OBJECTIVESnRepair of laryngotracheal stenosis with pronounced side-to-side narrowing and involvement of the glottis is challenging and usually requires laryngotracheal reconstruction with rib cartilage interpositions. This technique, as first described by Couraud, needs prolonged postoperative stabilization with Montgomery T-tubes, imposing significant morbidity and discomfort on patients. We describe our initial experience with a modified laryngotracheal reconstruction technique that avoids the need for prolonged postoperative stenting.nnnMETHODSnFrom November 2012 through May 2015, a series of 5 adult patients with glottosubglottic stenosis were operated in our institution. All patients had pronounced scar formation in combination with advanced side-to-side narrowing extending up to the level of the vocal folds. Operative technique consisted of a complete anterior and posterior laryngeal split followed by rib cartilage interposition in the cricoid plate posteriorly to enlarge the glottosubglottic diameter. The lateral edges of the rib graft were trimmed in such a way that lateral flanges were created, which allowed stable positioning of the graft. The distal trachea was then slid into the larynx, and the posterior defect was completely covered with a liberal membranous flap. The anterior part of the larynx was enlarged with a V-shaped segment of the anterior tracheal wall.nnnRESULTSnThis technique provided immediate stability without the need for temporary endoluminal stenting. The perioperative course was uneventful in all patients, and functional outcome was excellent.nnnCONCLUSIONSnWe conclude that this modified technique of laryngotracheal reconstruction represents a valid treatment option for patients with complex glottosubglottic stenosis, avoiding the need for prolonged postoperative stenting.

Split lung transplantation with intraoperative extracorporeal membrane oxygenation (ECMO) support

Pulmonary bipartitioning or split lung transplantation, which was first described in 1997, presently represents the most efficient use of donor lungs. With this technique, a left donor lung can be separated into an upper and lower lobe and used for bilateral transplantation in a smaller recipient. The right donor lung remains for use as a single lung graft in another patient. In 2001, a similar technique for splitting a right lung was described. The technique of harvesting and procurement of the donor organ for split lung transplantation is identical to the standard lung transplantation technique. The final separation of the donor lung is performed at the level of the interlobar fissure immediately prior to implantation. The lower lobe is implanted in the left recipient hemithorax, whereas the upper lobe, after closing of the central end of the left main pulmonary artery, and a 180° rotation along the vertical axis, is grafted into the right hilus. The use of extracorporeal membrane oxygenation (ECMO) provides intraoperative hemodynamic stability and protects the first implanted lobe from overflow and resulting reperfusion injury. This report discusses the technique developed at the department of cardiothoracic surgery of the Medical University of Vienna.