Krystian Pawlak

Early post-pneumonectomy complications in the elderly

OBJECTIVE The surgical treatment of non-small cell lung cancer (NSCLC) in elderly patients presents a serious challenge to thoracic surgeons. As there is considerable divergence of opinion about both the mortality and morbidity rates, it is important to set guidelines for proper patient selection. METHODS Early post-operative complications in 42 patients aged over 70 years who had undergone pneumonectomy because of NSCLC (Group I) were analyzed. The control group (Group II) consisted of 48 patients, also aged over 70 years, but who had undergone lobectomy or wedge resections. In both groups, the pre-operative conditions and 30-day morbidity and mortality were evaluated. RESULTS Postoperative complications occurred significantly more frequently in pneumonectomy patients (78.5%) than in Group II (58%). Transient or long-standing arrhythmias were noted in 20 patients (47.6%) from Group I and in 17 (35.4%) from Group II. Pulmonary complications occurred in 17 patients (40.4%) from Group I and 16 (33.3%) from Group II. The most important factors contributing to post-operative complications in pneumonectomy patients were performance status (WHO), chronic obstructive pulmonary disease (COPD) and elevated level of blood urea nitrogen (BUN). The highest impact on early mortality in pneumonectomy patients was exerted by COPD, arterial hypertension, formation of broncho-pleural fistula (BPF), the need for re-thoracotomy and high level of BUN. CONCLUSIONS (1) Pneumonectomy in patients over the age of 70 carries a considerable risk of severe post-operative complications and death, when compared to patients with less extensive pulmonary resections. (2) Elderly patients with impaired Performance Status (WHO 2 or more) and co-existing arterial hypertension, COPD and elevated level of BUN should be considered for pneumonectomy very carefully and cautiously.

Life-Threatening Aortic Hemorrhage During Pectus Bar Removal

This report presents an unusual case of late, aortic hemorrhage that occurred during the removal of the stabilizing bar 3 years after a Nuss operation. The primary reason for this complication was a rotation of the sternum bar, which caused chronic damage to the aorta and development of an aortomediastinal fistula. Cardiopulmonary bypass and implantation of an aortic prosthesis were required for successful treatment of this complication.

Evaluation of serum amino acid profiles’ utility in non-small cell lung cancer detection in Polish population

OBJECTIVES Data from studies performed in Japanese and Korean populations suggest that free amino acid profiles have the potential to aid in non-small cell lung cancer (NSCLC) detection. However, there is still no data regarding abnormalities of free amino acids and their usefulness in NSCLC detection in European populations. The aim of the study was an evaluation of utility of amino acid profiles in NSCLC detection in Polish patients. MATERIALS AND METHODS Levels of 31 free amino acids were determined in 153 serum samples applying a liquid chromatography-tandem mass spectrometry-based methodology. Patients with I stage lung cancer represented a significant part of the studied group (46.7%). The obtained metabolite profiles along with clinical data were subjected to multivariate statistical tests. RESULTS The presented study indicated that the increased serum level of phenylalanine and decreased level of citrulline are among the most robust cancer signatures in blood of NSCLC group. In addition, increased levels of aspartic acid and β-alanine were also recognized as important features of NSCLC. Amino acid selected based on studies of Asian patients were found to have insufficient specificity in NSCLC detection in the studied population. Therefore, we proposed a new set of 6 amino acids (aspartic acid, β-alanine, histidine, asparagine, phenylalanine and serine), which ensured higher accuracy in sample classification (from 90.3% to 77.1% depending of histological type). CONCLUSION We indicated that some of the free amino acid alterations occur in serum of NSCLC patients in early stage of disease and thus they can be valuable components of a blood multi-marker panel for NSCLC detection.

Identification of Serum Peptidome Signatures of Non-Small Cell Lung Cancer.

Due to high mortality rates of lung cancer, there is a need for identification of new, clinically useful markers, which improve detection of this tumor in early stage of disease. In the current study, serum peptide profiling was evaluated as a diagnostic tool for non-small cell lung cancer patients. The combination of the ZipTip technology with matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF-MS) for the analysis of peptide pattern of cancer patients (n = 153) and control subjects (n = 63) was presented for the first time. Based on the observed significant differences between cancer patients and control subjects, the classification model was created, which allowed for accurate group discrimination. The model turned out to be robust enough to discriminate a new validation set of samples with satisfactory sensitivity and specificity. Two peptides from the diagnostic pattern for non-small cell lung cancer (NSCLC) were identified as fragments of C3 and fibrinogen α chain. Since ELISA test did not confirm significant differences in the expression of complement component C3, further study will involve a quantitative approach to prove clinical utility of the other proteins from the proposed multi-peptide cancer signature.

Video-assisted-thoracoscopic surgery in left-to-right Nuss procedure for pectus excavatum for prevention of serious complications – technical aspects based on 1006 patients

Introduction Additional use of the video-assisted thoracoscopic surgery (VATS) technique in the Nuss procedure has been globally accepted for the improvement of safety of surgical treatment as well as for decreased frequency of serious intraoperative and postoperative complications. Aim To evaluate VATS in surgical treatment of patients with pectus excavatum by the left-to-right Nuss procedure for prevention of serious intra- and postoperative complications. Material and methods From 2002 to 2016, 1006 patients with pectus excavatum aged 7 to 62 years (mean: 18.6) underwent the Nuss procedure. There were 796 males and 210 females. The clinical records of all patients were analyzed retrospectively. The follow-up varied from 1 to 172 months (mean: 80.7 ±43). Results The early 30-day postoperative mortality was zero. Early thoracoscopy-dependent postoperative complications, the majority transient and non-life-threatening, occurred in 35.6% of patients. The most frequent complication was pneumothorax, diagnosed in 24.5% of patients. Two patients required repeat surgery. One patient required VATS pleurectomy due to persistent postoperative air leakage. In another patient left thoracotomy following bleeding from the pleural cavity was performed. Conclusions The use of VATS in the left-to-right Nuss procedure for pectus excavatum ensures the safety of surgical treatment and minimizes the occurrence of serious intra- and postoperative complications concerning injury of the mediastinum, lung, diaphragm or abdominal cavity.

Long-term results of surgical treatment of non-small cell lung cancer in patients over 75 years of age

Introduction Patients over 75 years of age, who, in addition, often have already exceeded the average life expectancy, in the Polish population on average 77.4 years, are the subject of discussion concerning the most appropriate choice of treatment. Aim To analyse the long-term results in elderly patients over 75 years of age with lung cancer who underwent curative pulmonary resection. Material and methods 166 patients aged from 75 to 85 (mean: 77.4 ±2.3) operated on for non-small cell lung cancer (NSCLC) were included in this study. There were 128 (77%) men and 38 (23%) women. Results Lobectomy, including bilobectomy, was performed in 122 (74%) patients, pneumonectomy in 8 (5%) patients, and wedge resections or segmentectomy in the remaining 36 patients. Squamous or adenocarcinoma was diagnosed in 46% and 42% of cases respectively. Clinical stage I A was diagnosed in 36 (22%) patients, I B in 51 (31%), IIA in 30 (18%), IIB in 19 (11%) and IIIA in 30 (18%) of our cases. The early 30-day postoperative mortality was 5% whilst postoperative morbidity occurred in 47% of cases. The five-year survival rate was 30%. In statistical analysis, the TNM classification (p = 0.0490), the number of postoperative complications (p = 0.0001) and obstructive atelectasis requiring repeat bronchofibroscopic aspirations (p = 0.0137) in the early postoperative period most negatively influenced the long-term survival in the whole study group. Conclusions Surgical resections for lung cancer in patients over 75 years of age are characterised by a relatively good long-term prognosis. Careful and strictly detailed preoperative selection, particularly of patients with pulmonary comorbidities and the earliest possible diagnosis of a lung tumour, can reduce the occurrence of these postoperative complications in elderly patients, which negatively influence long-term results.

Complex corrective procedure in surgical treatment of asymmetrical pectus excavatum

Aim In this study we analysed the early and late results of surgical treatment of asymmetrical pectus excavatum using complex surgery combining the Ravitch procedure and the Nuss procedure in the same general anaesthesia. Material and methods Eighty out of 938 patients with pectus excavatum operated on between 2002 and 2013, 67 males and 13 females aged 11 to 49 years (mean: 19.2), underwent a complex surgical procedure. During surgery the Nuss procedure was usually performed first (one corrective bar was implanted in 35 patients and two bars were inserted in 45 patients). Because of the unsatisfactory cosmetic effect, additionally the Ravitch procedure was started. The bars were electively removed 3 years after the primary operation. Results No mortality was observed in the early postoperative period. Non-life-threatening and transient postoperative complications occurred in 44 (55%) patients. The most common was pleural effusion (21%), which in 50% of patients required pleural drainage. A satisfactory and stable correction effect was achieved in 88% of cases. Six of those patients required repeat surgery due to recurrence of deformity. Conclusions A complex corrective procedure is a successful method of surgical treatment in patients with asymmetrical pectus excavatum and is characterized by satisfactory postoperative results. The use of corrective bars enhances the cosmetic effect. The frequency of early, mostly non-life-threatening postoperative complications after a complex procedure is insignificantly higher than that after the Nuss procedure.

Giant hemangioma of anterior mediastinum mimicking bilateral pleural effusion

Address for correspondence: Krystian Pawlak MD, Department of Toracosurgery, Poznan University of Medical Sciences, 62 Szamarzewskiego St, 60-569 Poznań, Poland, phone: +48 509 835 550, e-mail: krystianp@hotmail.com Received: 26.02.2017, accepted: 15.06.2017. Hemangioma is a rare mediastinal tumor corresponding to approximately 4–8% of all benign tumors in children and less than 0.5% in the overall population [1]. In more than half of cases it is situated in the anterior mediastinum and in 75% it affects young patients under 35 years of age in similar frequency in both sexes [1, 2]. The case of a huge hemangioma in the anterior mediastinum, radically removed during thoracotomy, diagnosed in a 22-year-old patient, is presented. A 22-year-old man, without history of disease, was admitted to the hospital in a severe general condition with respiratory failure. The patient reported dyspnea at rest, increasing for 2 months. On the day of admission, all laboratory tests, including β-human chorionic gonadotropin (β-HCG) and α-fetoprotein (AFP), did not reveal any abnormalities, except for an arterial blood gas test that demonstrated significant hypoxemia. The patient had not been subjected to a chest radiograph before. The chest radiograph demonstrated a total opacity of the left and 2/3 of the upper half of the chest (Fig. 1). In the chest computed tomography (CT) scan, an encysted extensive nodular lesion, filled with a heterogeneous fluid, was described (Fig. 2). The tumor filled almost the entire left pleural cavity, causing atelectasis of the left lung, and displaced the mediastinum with the heart and large vessels to the right side. The lesion also filled the upper and anterior part of the right pleural cavity, arranged along the anterior chest wall from the diaphragm to the level of the 4th intercostal space, with atelectasis of the middle lobe. Echocardiography did not reveal any impairment of the heart or pericardial cavity. The ultrasound examinations of the abdomen, neck and testicles were normal. Because of life-threatening symptoms the left pleural cavity was punctured, evacuating approximately 1500 ml of bloody fluid. A cytological examination of the pleural fluid was negative. After improvement in the patient’s general condition was achieved, diagnostic left-sided video-assisted thoracic surgery (VATS) was performed. During the procedure, after the introduction of trocars, significant bleeding from the pleural cavity was observed. Video-assisted thoracic surgery was immediately converted to left anterolateral thoracotomy, under the fifth rib, and a cystoid, smoothly encysted elastic tumor involving both pleural cavities and the anterior mediastinum was recognized. The tumor, filled with 6200 ml of bloody fluid, was attached to the chest wall, mediastinum and diaphragm by soft adhesions. The tumor’s vessels were derived from the internal thoracic artery and brachiocephalic vein. Finally, the tumor underwent radical resection (Fig. 3). In histological examination an arteriovenous hemangioma was identified. The tumor had the dimensions 25 × 14 × 5 cm and consisted of numerous cystic spaces containing dark cherry-colored fluid. The diagnosis was confirmed by immunohistochemistry based on positive results of reactions of CD31, CD34, SM A markers and desmin. Because of anemization, in the perioperative period the patient required a transfusion of four blood units. Otherwise, there were no complications in the early postoperative period. Chest tubes were removed on postoperative day 5. The control chest radiograph demonstrated a normal lung re-expansion (Fig. 3). The patient was discharged home in good general condition on postoperative day 13. Currently, the patient, without clinical symptoms, is undergoing routine outpatient follow-up. The chest radiograph performed six months ago did not demonstrate any abnormalities. Mediastinal hemangiomas are usually well defined and encysted, and tumor size can range from 2 to over 20 cm [3]. Histologically, hemangiomas are divided into cavernous, capillary hemangiomas, which correspond to approximately 90% of all mediastinal hemangiomas, and rare venous and arteriovenous hemangiomas. In half of cases, the disease is asymptomatic and is diagnosed accidentally during a performed chest radiograph; however, in some patients such nonspecific symptoms as cough, dyspnea or chest pain and shortness of breath may occur. In the case of compression or infiltration of the surrounding structures, dysphagia, superior vena cava syndrome (SVCS), Horner’s syndrome, or neurological symptoms may develop [1, 4]. Although in the literature mediastinal hemangiomas of a significant size, measuring up to 20 cm, are described, Giant hemangioma of anterior mediastinum mimicking bilateral pleural effusion

HISTORY OF CARDIAC AND THORACIC SURGERY A historical outline of surgical treatment for congenital chest wall deformities

This paper presents the most important events concerning the surgical treatment of congenital chest wall deformities from the early twentieth century to current times. This historical outline features the most deserved and most prominent surgeons in this field, such as F. Sauerbruch, M. Ravitch, D. Nuss, and others. We also recall the Polish pioneers of the surgical treatment of chest wall deformities, including M. Rzepecki, R. Drews, and J. Fibak, at the same time referring to contemporary experiences.