Łukasz Gąsiorowski

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.

Indocyanine green fluorescence in the assessment of the quality of the pedicled intercostal muscle flap: a pilot study

OBJECTIVES The pedicled intercostal muscle flap (IMF) is a high quality vascularized tissue commonly used to buttress the bronchial stump after pneumonectomy or bronchial anastomosis after sleeve lobectomy in order to prevent bronchopleural fistula formation. The evaluation of the viability of the muscle flap is difficult. The aim of this study was the assessment of the application of indicyanine green fluorescence for the evaluation of IMF perfusion. METHODS The study included 27 patients (10 males and 17 females), mean age 62.6 years (47-77 years). Indocyanine green fluorescence (ICG) was used for objective assessment of the IMF quality by a near-infrared camera system (Photodynamic Eye(®), Hamamatsu Photonics, Japan). The following factors that may have an impact on the quality of the IMF were assessed: age, gender, body mass index, comorbidities, IMF length and thickness and timing of the harvesting during the procedure. RESULTS The following surgical pulmonary resections with IMF harvesting were performed: 12 pneumonectomies, 2 sleeve lobectomies and 13 lobectomies. Intercostal muscle flap (IMF) was harvested before rib spreader insertion in 23 patients (85%) and at the end of the surgery in 4 patients (15%). The mean length and thickness of the harvested intercostal muscle were 19.9 ± 2.9 cm (range 13-24 cm) and 2.4 cm ± 0.7 cm (range 1.0-3.5 cm), respectively. Indocyanine green angiography showed ischaemia in the distal part of the muscle in all cases, despite the lack of obvious macroscopic signs. Median length of the ischaemic part was 4 cm (range 0.5-20 cm). The IMF length and thickness had a significant impact on the length of the ischaemic segment. In 24 patients, the ischaemic part of the muscle flap was severed. In 3 patients with the longest ischaemic segment (11, 13 and 20 cm), an alternative tissue was used to cover the bronchial stump. No major complications occurred. CONCLUSIONS Our preliminary results confirmed the simplicity and high efficacy of ICG in the assessment of intercostal muscle blood perfusion. ICG was superior to macroscopic evaluation and influenced surgical proceeding.

The role of simulation to support donation after circulatory death with extracorporeal membrane oxygenation (DCD-ECMO)

Maintaining the viability of organs from donors after circulatory death (DCD) for transplantation is a complicated procedure, from a time perspective in the absence of appropriate organizational capabilities, that makes such transplantation cases difficult and not yet widespread in Poland. We present the procedural preparation for Poland’s first case of organ (kidney) transplantation from a DCD donor in which perfusion was supported by extracorporeal membrane oxygenation (ECMO). Because this organizational model is complex and expensive, we used advanced high-fidelity medical simulation to prepare for the real-life implementation. The real time scenario included all crucial steps: prehospital identification, cardiopulmonary resuscitation (CPR), advanced life support (ALS); perfusion therapy (CPR-ECMO or DCD-ECMO); inclusion and exclusion criteria matching, suitability for automated chest compression; DCD confirmation and donor authorization, ECMO organs recovery; kidney harvesting. The success of our first simulated DCD-ECMO procedure in Poland is reassuring. Soon after this simulation, Maastricht category II DCD procedures were performed, involving real patients and resulting in two successful double kidney transplantations. During debriefing, it was found that the previous simulation-based training provided the experience to build a successful procedural chain, to eliminate errors at the stage of identification, notification, transportation, donor qualifications and ECMO organ perfusion to create DCD-ECMO algorithm architecture.

Customization of a patient simulator for ECMO training

Background: Poland is setting up its first regional ECMO program and relies heavily on the use of simulation in testing processes and training clinicians.1 As ECMO is a complex and expensive procedure, we developed an advanced ECMO simulator for high-fidelity medical simulation training.2–6 It can be used to modify any type of full-body patient simulator and allows for the creation of an unlimited number of scenarios. Methods: The system is equipped with an electronic core control unit (CCU) (Figure 1), a set of synthetic valves, pressure sensors, and hydraulic pumps. The major functions of the CCU are to stabilize the hydraulic system (flow of simulated blood, differential pressures in the arterial and venous lines), providing instant information about the system to the user via a display. Electric valves and sensors provide ‘on-the-fly’ information to the CCU about the actual systems status and it can be made to respond to specific instructions imitating the physiological circulatory system and simulating several scenarios (i.e. bleeding, low pressure, occlusion, reaction to proper and incorrect pharmacological treatment). It can be connected to an ECMO machine to act like the human body during ECMO run. Silicone tubes (modified polyethylene) that can be realistically cannulated using ultrasound imaging represent the artificial vessels. The CCU is made of electronic components that can be integrated to customize any mannequin as shown in Figure 1. The hardware includes both digital and analogue components that are controlled by a software run on a computer connected to the CCU via a serial port (RS232) (Figure 2). The software allows for the visualization of measurements obtained from the sensors and the control of the pumps and valves via electronic controllers. The controllers affect the ECMO circuit simulated blood flow, and hence the readings from the ECMO machine sensors, to recreate various clinical scenarios.Figure 1. The modified patient simulator with circulatory loop prepared for VA ECMO cannulation and CCU (core control unit) for high-fidelity simulations. Figure 2. The ECMO simulator architecture. Results: Every component used can be easily replaced. The total cost of the simulator modification, excluding the cost of the computer or future mobile device, is approximately 200 USD, and the consumable parts cost about 20 USD. It has been used to help simulate successfully a range of scenarios.1 Although the system is currently tethered, the next prototype will include a wireless controller so that the system can be controlled from a mobile application. Conclusions: This advanced simulator allows for unlimited possibilities with regard to creating clinical scenarios. Our ambition is to become a reference ECMO training center in Poland so that our high-fidelity ECMO simulator can be used to its full potential and for the benefit of more clinicians and their patients around Poland.

Using simulation to create a unique regional ECMO program for the Greater Poland region

Background: “ECMO for Greater Poland” is a program being developed to serve the 3.5 million inhabitants of the Greater Poland region (Wielkopolska) based on an approach already implemented in the USA1 or Qatar.2,3Method: The program is complex and takes full advantage of the ECMO perfusion therapy opportunities to save the life of patients in the Greater Poland region. The main implementation areas are: – treatment of patients with hypothermia;4 – treatment of reversible severe respiratory failure;5 – treatment of acute intoxication resulting in cardiorespiratory failure6 or other critical conditions resulting in heart failure; – in the absence of response to treatment and eventual death, and with donor authorization, there is possible organ transplantation from a non-heart beating donor (NHBD) to another patient.7 This led to the development of a program for donation after circulatory death (DCD). Study: The program will help to put in place a Medical Rescue System including ECMO (Figure 1). It requires training in specialized resuscitation, perfusion, and transplantation teams in the implementation of this “ECMO rescue chain”. The main strength of the program is the widespread use of extracorporeal perfusion. All program arms in the use of ECMO should be implemented in parallel to maximize its positive impact.Figure 1. Organizational model of “ECMO for Greater Poland” – “ECMO rescue chain” scheme divided into three stages: prehospital, hospital/perfusion, and transplantation. As this organizational model is complex and expensive, we used high-fidelity medical simulation to prepare for the real-life implementation of our ECMO program. During 4 months, we performed scenarios including: – “ECMO for DCD” which includes: prehospital identification, CPR ALS (cardiopulmonary resuscitation advanced life support), perfusion therapy (CPR-ECMO or DCD-ECMO), inclusion and exclusion criteria matching, mechanical chest compression, transport, DCD confirmation, and donor authorization, the veno-arterial (VA) cannulation of a mannequins artificial vessels, and starting on-scene organ perfusion.7 – “ECMO for INTOXICATION” which includes: hospital identification (Department of Toxicology), poisoning treatment, CPR ALS, mechanical chest compression, VA cannulation, for the implementation of ECMO therapy and transport to another hospital (Department of Cardiac Surgery).6 – “ECMO for RRF” (reversible respiratory failure) which includes: hospital identification (Regional Department of Intensive Care) – inclusion and exclusion criteria matching, ECMO team transport (80 km), therapy confirmation, veno-venous cannulation for the implementation of perfusion therapy, and return transport (80 km) with ECMO to another hospital in a provincial city (Clinical Department of Intensive Care), where the veno-venous (VV) ECMO therapy was continued for the next 48 hours.5 The training programs, in a short time, resulted in a team being appropriately trained to successfully undertake the complex procedures. Soon after these simulations, Maastricht category II DCD procedures were performed involving real patients and resulting in two double successful kidney transplantations, for the first time in Poland. One month later, we treated two hypothermia patients and, for the first time in the region, also treated on ECMO an adult patient with reversible respiratory failure. Conclusions: The “ECMO for Greater Poland” program will allow the use of perfusion therapy for the inhabitants of Wielkopolska in a comprehensive manner, covering all critical disease states, by what appears to be a unique regional program in Poland. The full-scale, high-fidelity simulation enabled standardized training and testing of new, commonly, and rarely used procedures, and facilitated clinicians’ skills development.

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.

The role of extracorporeal membrane oxygenation in patients after irreversible cardiac arrest as potential organ donors

The number of people waiting for a kidney or liver transplant is growing systematically. Due to the latest advances in transplantation, persons after irreversible cardiac arrest and confirmation of death have become potential organ donors. It is estimated that they may increase the number of donations by more than 40%. However, without good organization and communication between pre-hospital care providers, emergency departments, intensive care units and transplantation units, it is almost impossible to save the organs of potential donors in good condition. Various systems, including extracorporeal membrane oxygenation (ECMO), supporting perfusion of organs for transplantation play a key role. In 2016 the “ECMO for Greater Poland” program was established. Although its main goal is to improve the survival rate of patients suffering from life-threatening cardiopulmonary conditions, one of its branches aims to increase the donation rate in patients with irreversible cardiac arrest. In this review, the role of ECMO in the latter group as the potential organ donors is presented.