J. Pieróg

Accelerated treatment of postpneumonectomy empyema : a binational long-term study

OBJECTIVEnPostpneumonectomy empyema remains a clinical challenge. We proposed an accelerated therapy without an open chest window 5 years ago. This concept was evaluated on a larger scale in 2 centers in 2 different countries.nnnMETHODSnBetween July 1995 and October 2005, 75 consecutive patients with postpneumonectomy empyema were treated in Szczecin, Poland (n = 35), and Zurich, Switzerland (n = 40). The therapy consisted of repeated open surgical debridement of the pleural cavity after achievement of general anesthesia, a negative pressure wound therapy of the temporarily closed chest cavity filled with povidone-iodine-soaked towels, and continuous suction and systemic antimicrobial therapy. If present, bronchopleural fistulae were closed and reinforced either with a muscle flap or the omentum. Finally, the pleural space was filled with an antibiotic solution and definitively closed.nnnRESULTSnOf 75 patients (63 men; median age, 59 years; age range, 19-82 years), postpneumonectomy empyema was present on the right in 46 patients (32 with bronchopleural fistula) and in 29 patients (12 with bronchopleural fistula) on the left. Median time between pneumonectomy and postpneumonectomy empyema was 131 days (range, 7-7200 days). Bronchopleural fistulae have been closed and additionally reinforced by means of different methods (omentum, 18; muscle, 11; pericardial fat, 5; azygos vein, 1). The chest was definitively closed within 8 days in 94.6% of patients. The median hospitalization time was 18 days (range, 9-134 days). Postpneumonectomy empyema was successfully treated in 97.3% of patients, including 10 (13%) patients who needed a second treatment cycle. Three (4%) patients died within 90 days. The median follow-up time was 29.5 moths (range, 3-107 months).nnnCONCLUSIONSnTreatment of postpneumonectomy empyema with the accelerated treatment is effective and safe. Our results are superior compared with those in reported series using a (temporary) chest fenestration. Patients appreciate the physical integrity of the chest.

Additional pulmonary resections after pneumonectomy: actual long-term survival and functional results

OBJECTIVEnPulmonary resections after pneumonectomy due to metastases or metachronous non-small cell lung cancer (NSCLC) are rare because of the high potential risk of the second procedure and uncertain long-term results. On the basis of our series (largest in Europe) we tried to assess the long-term survival of patients treated in stage IV NSCLC.nnnMETHODSnRetrospective analysis was carried out on 18 patients treated at our department by pneumonectomy followed by additional resection in the years 1981-2002 (15 males and 3 females, 44-69 years, mean 57). Eleven pneumonectomies were performed on the right side and seven on the left. Twelve squamous cell carcinomas and six adenocarcinomas were diagnosed. All patients were staged postoperatively as IIB-IIIA (four were N2). Their WHO status ranged between 0 and 1. The second surgical procedure (16 wedge resections, 2 chest wall resections) was performed 4-106 months later (mean 26). The patients staged N2 were radiated postoperatively.nnnRESULTSnThere were no early postoperative deaths. The morbidity rate after second surgery was comparable to that observed after ordinary wedge resection. Histology of the lesions removed during the second operation was the same as after pneumonectomy in all patients. The pulmonary function tests (PFT) results worsened significantly but still reached 56-63% of the predicted values. Sixteen resected tumors of the remaining lung were staged T1 (<3cm), 2 - T3 (<3cm but infiltration of the parietal pleura on an area of 2-4cm(2)). Three patients revealed N2 disease (they were all N0 after pneumonectomy). All patients were considered M1 after second surgery. WHO status after the second procedure remained the same in 8 patients (44%) and worsened in 10 patients (56%). The survival rates were as follows: 11 patients survived 2 years (61%) while 8 patients survived 5 years (44%). The majority of patients died due to lung cancer (70%) but all the rest (30%) due to circulatory or respiratory insufficiency. There was a significant difference (p<0.05) in 5-year survival for N0-N1 vs N2 status (63% vs 14% - 1 patient) and also regarding the time interval between surgeries: less than 12 months vs more than 12 months (0% vs 63%).nnnCONCLUSIONSnPulmonary resections performed after pneumonectomy due to NSCLC are rare procedures but with an acceptable perioperative risk. The second procedure should be limited to wedge resection. The prognosis is poor for patients with N2 status and for those treated by second surgery earlier than 12 months after the first procedure.

Lung cancer in situs inversus totalis (SIT) - literature review

We present 21 studies of cases of lung cancer in patients with situs inversus totalis (SIT) published worldwide. The first case was described in 1952. Thirteen patients were from Japan, 4 from Eastern Europe, including 2 Polish cases from the authors` center (Department of Thoracic Surgery, Pomeranian Medical University in Szczecin, Poland), 2 from Western Asia, 1 from the U.S. and 1 from Australia. Male patients (20/21) as well as left-sided lung cancer cases (14/21) and squamous cell carcinoma cases (8/21) dominated in the entire group. Thirteen patients underwent surgical treatment. There were 10 left-sided and 3 right-sided surgical interventions with uneventful intra- and postoperative course. Explorative thoracotomy was performed in one case only on the right side. Upper lobectomy was performed in 5 cases, pneumonectomy in 3 cases, lower bilobectomy and middle lobectomy in one case and lower lobectomy in two cases. Surgery was performed through thoracotomy in 10 cases, VATS-assisted approach in two cases and sternotomy in one case. Descriptions of the surgical anatomy confirmed mirror image of the anatomy in all cases and were consistent with the preoperative CT images. Preoperative diagnosis was discussed including the role of 3-D reconstruction of CT for improving perioperative safety in this group of patients. In conclusion, lung cancer/SIT cases despite inversed but regular anatomy can be operated on radically as cases with normal anatomy with preservation of intraoperative security level.

The impact of the sequence of pulmonary vessel ligation during anatomic resection for lung cancer on long-term survival - a prospective randomized trial

PURPOSEnThe aim of this prospective randomized trial was to assess the influence of the sequence of pulmonary vessel ligation, during anatomic resection, on long term survival in patients with NSCLC.nnnMATERIAL/METHODSnThis prospective randomized study included 385 patients treated surgically with lobectomy or pneumonectomy and standard lymphadenectomy between 1999 and 2003. Patients were randomly assigned to either primary ligation of the pulmonary artery or arteries (group A - 215 patients) or of the pulmonary vein or veins (group V - 170 patients). Patients were excluded if the sequence of vessel ligation was affected by technical difficulties or anatomic limitations. Univariate and multivariate analyses included: the sequence of vessel ligation, age, gender, tumor histology, stage (TNM), and cause of death (cancer related or non-cancer related).nnnRESULTSnMedian follow-up was 63 months. The groups were comparable regarding gender, histology, type of resection, and T, N, and overall stage. Overall, 5-year survival reached 50% in group A and 54% in group V (p = 0.82) and did not differ significantly in cancer related and non-cancer related deaths (p = 0.67 and p = 0.26, respectively). Univariate analysis identified higher T and N factors, advanced stage, pneumonectomy, male sex, and older age as negative prognostic factors. Multivariate analysis demonstrated that age, T3-4 disease, and nodal involvement were associated with inferior survival.nnnCONCLUSIONSnThe sequence of pulmonary vessel ligation during anatomic resection for non-small cell lung cancer does not significantly affect long-term survival.

Stricture caused by a plastic vascular clip used during an operation of minimally invasive esophagectomy

This article describes the case of a 62-year-old female who had had minimally invasive esophagectomy (Ivor-Lewis) for squamous cell carcinoma of the distal third of the esophagus. The anastomotic stenosis was accompanied by solid food dysphagia and the presence of a foreign body in the esophagus. The foreign body was fixed to the esophageal wall and could not be removed endoscopically. The patient was reoperated on through a 8xa0cm right thoracotomy. The anastomosis was reached via a gastrotomy, and the large-size plastic vascular clip was removed. The clip was primarily used to close the transsected azygos vein, it was then incorporated into the esophageal anastomotic region and subsequently partially protruded into the lumen of the gastrointestinal tract. After removal of the clip, backward dilatation of the anastomosis was performed by Savary-Gilliard dilators, with restoration of its proper diameter.

Vancomycin lung concentration in acute and hyperacute rejection models of lung transplantation in rats.

OBJECTIVESnThis study assesses vancomycin concentrations in allogenic transplanted rat lung tissue in acute and hyperacute rejection models of the lung.nnnMETHODSnLeft lung allotransplantation was performed from a male Brown Norway donor to a male Fisher F344 recipient in the case of an acute rejection model (the animals were sacrificed 5 days after transplantation) as well as a male Brown Norway donor to a male Wistar recipient in the case of hyperacute rejection (the animals were sacrificed 2 days after transplantation). Control rats were sham-operated and sacrificed on day 2 or 5, respectively, of the experimental model. Rejection was confirmed by blood gas assessment and lung histological examination. A single intraperitoneal dose of vancomycin 30 mg kg(-1) body weight was administered on the day of autopsy (day 2 or 5 from transplantation, respectively, of the experimental model), and then the blood and lung specimens were sampled at 0, 5, 1, 2, 4 and 6h from the time of drug injection.nnnRESULTSnArterial blood gas assessment (Wistar rats - pO(2): 44.33 ± 21.73 mmHg (mean ± standard deviation (SD)); Fisher rats - pO(2:) 50.67 ± 14.30 mmHg (mean ± SD)) as well as histopathologic examinations of lung grafts confirmed rejection. Vancomycin lung/plasma concentration ratio was significantly higher in transplanted rats than in sham-operated animals.nnnCONCLUSIONSnBoth acute and hyperacute lung rejection affect the lung/serum of vancomycin in the transplanted lung resulting in higher drug accumulation, especially in late post-dosage time.