Martin Reichert

Immunomodulation by lipid emulsions in pulmonary inflammation: a randomized controlled trial

IntroductionAcute respiratory distress syndrome (ARDS) is a major cause of mortality in intensive care units. As there is rising evidence about immuno-modulatory effects of lipid emulsions required for parenteral nutrition of ARDS patients, we sought to investigate whether infusion of conventional soybean oil (SO)-based or fish oil (FO)-based lipid emulsions rich in either n-6 or n-3 fatty acids, respectively, may influence subsequent pulmonary inflammation.MethodsIn a randomized controlled, single-blinded pilot study, forty-two volunteers received SO, FO, or normal saline for two days. Thereafter, volunteers inhaled pre-defined doses of lipopolysaccharide (LPS) followed by bronchoalveolar lavage (BAL) 8 or 24 h later. In the murine model of LPS-induced lung injury a possible involvement of resolvin E1 (RvE1) receptor ChemR23 was investigated. Wild-type and ChemR23 knockout mice were infused with both lipid emulsions and challenged with LPS intratracheally.ResultsIn volunteers receiving lipid emulsions, the fatty acid profile in the plasma and in isolated neutrophils and monocytes was significantly changed. Adhesion of isolated monocytes to endothelial cells was enhanced after infusion of SO and reduced by FO, however, no difference of infusion on an array of surface adhesion molecules was detected. In neutrophils and monocytes, LPS-elicited generation of pro-inflammatory cytokines increased in the SO and decreased in the FO group. LPS inhalation in volunteers evoked an increase in neutrophils in BAL fluids, which decreased faster in the FO group. While TNF-α in the BAL was increased in the SO group, IL-8 decreased faster in the FO group. In the murine model of lung injury, effects of FO similar to the volunteer group observed in wild-type mice were abrogated in ChemR23 knockout mice.ConclusionsAfter infusion of conventional lipid emulsions, leukocytes exhibited increased adhesive and pro-inflammatory features. In contrast, FO-based lipid emulsions reduced monocyte adhesion, decreased pro-inflammatory cytokines, and neutrophil recruitment into the alveolar space possibly mediated by ChemR23-signaling. Lipid emulsions thus exert differential effects in human volunteers and mice in vivo.Trial registrationDRKS00006131 at the German Clinical Trial Registry, 2014/05/14

Stage-directed therapy of pleural empyema.

PurposeIntensivists and surgeons are often confronted with critically ill patients suffering from pleural empyema. Due to it’ s multifactorial pathogenesis and etiology, medicals should be sensitized to recognize the different stages of the disease. Besides a whole bundle of different established classification systems, the progress of pleural effusions can be subdivided into the early exudative, the intermediate fibropurulent and the late organized phase according to the classification of the American Thoracic Society.ResultsRapid diagnosis of pleura empyema is essential for patients’ survival. Due to the importance of stage-adapted therapeutic decisions, different classification systems were established. Depending on the stage of pleural empyema, both antimicrobial and interventional approaches are indicated. For organized empyema, minimally invasive and open thoracic surgery are gold standard. Surgery is based on the three therapeutic columns: removal of pleural fluid, debridement and decortication. In general, therapy must be intended stage-directed following multidisciplinary concepts including surgeons, intensivists, anesthesiologists, physiotherapists and antibiotic stewards. Despite an established therapeutic algorithm is presented in this review, there is still a lack of randomized, prospective studies to evaluate potential benefits of minimally invasive (versus open) surgery for end-stage empyema or of catheter-directed intrathoracic fibrinolysis (versus minimally invasive surgery) for intermediate-stage pleural empyema. Any delay in adequate therapy results in an increased morbidity and mortality.ConclusionThe aim of this article is to review current treatment standards for different phases of adult thoracic empyema from an interdisciplinary point of view.

Differentiation of primary and metastatic tumours in synchronous multifocal colonic and bronchopulmonary adenocarcinoma by targeted next‐generation sequencing

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Bronchogenic Cyst in the Liver Mimicking Metastasis of Colorectal Carcinoma: A Case Report and Review

Introduction: Carcinomas of the colon and rectum are the third most common cancer entity in the world and bear a high risk of synchronous (25%) or metachronous (50%) hepatic tumor seeding. For therapeutic decisions the differential diagnosis between benign and malignant hepatic lesions in the computer tomography scan is of major importance. We herein discuss congenital hepatic cysts derived from the primitive foregut as potential differential diagnosis for hepatic metastases from a colorectal primary tumor. Case presentation: A caucasian, 56-year old female patient with the initial diagnosis of an adenocarcinoma of the rectum had initially been treated by an anterior rectum resection and hemihepatectomy due to synchronous hepatic metastases (pT3 pN1(2/13), G2, pM1(HEP), L1, V0, pR0) in a curative intention. The follow-up staging after 2 years showed recurrent liver metastases. A local resection of the hepatic foci was performed. One of three lesions was classified as a classical ventral foregut derived bronchogenic cyst located subcapsularly in the liver. A follow-up resection of pulmonary metastases was performed 13 months later. The patient is still alive and healthy 68 months after the primary operation. Conclusions: For the diagnosis and treatment of hepatic metastases of colorectal carcinomas it is very useful to know potential differential diagnoses in radiographic imaging. Foregut derived cysts can be histologically subclassified into Ciliated Hepatic Foregut Cysts and Bronchogenic Cysts. While Ciliated Hepatic Foregut Cysts are known to be located in the liver, we present the rare case of a Bronchogenic Cyst, which was located in the liver parenchyma.

Thoracotomy versus video-assisted thoracoscopic surgery (VATS) in stage III empyema—an analysis of 217 consecutive patients

BackgroundPleural empyema is an infectious disease of the chest cavity, with a high morbidity and mortality. According to the American Thoracic Society, pleural empyema gets graduated into three stages, with surgery being indicated in intermediate stage II and chronic stage III. Evidence for the feasibility of a minimally-invasive video-assisted thoracoscopic approach in stage III empyema for pulmonary decortication is still little.MethodsRetrospective single-center analysis of patients conducted to surgery for chronic stage III pleural empyema from 05/2002 to 04/2014 either by video-assisted thoracoscopic surgery (VATS, n = 110) or conventional open surgery by thoracotomy (n = 107). Multiple regression analysis and propensity score matching was used to evaluate the influence of operation technique (thoracotomy versus VATS) on the length of post-operative hospitalization.ResultsOperation time was longer in the thoracotomy-group (p = 0.0207). Conversion rate from VATS to open surgery by thoracotomy was 4.5%. Post-operative complication- (61 patients in thoracotomy- and 55 patients in VATS-group), recurrence- (3 patients in thoracotomy- and 5 in VATS-group) and mortality-rates (6.5% in thoracotomy- and 9.5% in VATS-group) did not differ between both groups; the length of (post-operative) stay at intensive care unit was longer in the VATS-group (p = 0.0023). Duration of chest tube drainage and prolonged air leak rate were similar among both groups, leading to a similar overall and post-operative length of hospital stay in both groups. Adjusted to clinically and statistically relevant confounders, multiple regression analysis showed an influence of the surgical technique on length of post-operative stay after pair matching of the patients (n = 84 in each group) by propensity score (B = − 0.179 for thoracotomy = 0 and VATS = 1, p = 0.032) leading to a reduction of 0.836 days after a VATS-approach compared to thoracotomy.ConclusionsVATS in late stage (III) pleural empyema is feasible and safe. The decrease in post-operative hospitalization demonstrated by adjusted multiple regression analysis may indicate the minimally-invasive approach being safe, more tolerable for patients, and more effective.

Lung decortication in phase III pleural empyema by video-assisted thoracoscopic surgery (VATS)—results of a learning curve study

Background Pleural empyema (PE) is a devastating disease with a high morbidity and mortality. According to the American Thoracic Society it is graduated into three phases and surgery is indicated in intermediate phase II and organized phase III. In the latter, open decortication of the lung via thoracotomy is the gold standard whereas the evidence for feasibility and safety of a minimally-invasive video-assisted thoracoscopic approach is still poor. Methods Retrospective single-center analysis of patients undergoing surgery for phase III PE from 02/2011 to 03/2015 [n=138, including n=130 VATS approach (n=3 of them with bilateral disease) and n=8 open approach]. The learning curve was assessed by grouping those 127 patients with unilateral disease who underwent a video-assisted thoracoscopic approach into two groups: VATS-1 (03/2011 to 06/2012, n=43) and VATS-2 (06/2012 to 03/2015, n=84). Results ASA-scores (P=0.0279) and rate of pre-operative drainage therapy (P=0.0534) were higher in VATS-2 patients. Operating times were longer in VATS-1 (P=0.0308), intra-operative complication as well as conversion to open surgery rates did both not differ. Rates of post-operative vasoconstrictive therapy (P=0.0191) and prolonged mechanical ventilation (P=0.0560) were both higher in VATS-2, however, post-operative length of stay (LOS) at intensive care unit, overall post-operative LOS and post-operative complication rate were similar in both groups. Conclusions Video-assisted thoracoscopic surgery is feasible for evacuation and decortication in late phase III PE. A learning curve of approximately 40 cases is sufficient to gain procedure-specific surgical skills and thus reduce the operating times sufficiently.

Protective loop ileostomy increases the risk for prolonged postoperative paralytic ileus after open oncologic rectal resection

PurposePostoperative gut dysmotility is a physiologic and frequent temporary reaction after major abdominal surgery. If paralysis merges into a prolonged ileus state, it causes significant morbidity and subsequently worse outcome and discomfort for the patients. Pathophysiology of pathologic prolonged postoperative paralytic ileus remains multifactorial.MethodsWe present a retrospective single-center analysis of patients, who underwent a primary open oncologic anterior rectal resection with primary anastomosis with or without defunctioning loop ileostomy during a 43-month period of observation. Primary endpoint was the rate of prolonged postoperative paralytic ileus, defined by the intravenous administration of neostigmine. Confounders for regression analysis were assessed by univariate analysis and correlations between confounders were examined. Odds ratio for prolonged postoperative paralytic ileus in patients with defunctioning loop ileostomy was estimated by a logistic regression model.ResultsOf 101 patients (62 male), 62 (61.39%) received defunctioning loop ileostomy. In univariate analysis, male gender and patients with ileostomy showed more frequently prolonged paralysis by tendency (both p = 0.07). Logistic regression analysis proves the influence of a defunctioning ileostomy on the development of prolonged postoperative paralytic ileus after oncologic rectal resection (p = 0.047). Odds ratio for prolonged postoperative paralytic ileus in patients with ileostomy was 4.96 [95% CI 1.02–24.03].ConclusionsAlthough the construction of defunctioning loop ileostomies during rectal resection is a safe, uncomplicated surgical procedure, they can cause significant postoperative morbidity for the patients. High fluid and electrolyte loss are well-known complications, but herewith we raise the evidence for prolonged gut paralysis in patients with defunctioning loop ileostomy.

Use of very old donors for lung transplantation: a dual-centre retrospective analysis

OBJECTIVES To reduce the shortage of organs for transplantation by expanding organ selection criteria as a means to increase the pool of potential lung donors. In this study, we sought to investigate the impact of using lungs from very old donors aged >70 years on outcomes after lung transplantation. METHODS Between January 2010 and November 2016, 96 patients with end-stage lung disease underwent lung transplantation in our centres. Lung donors were divided into 3 groups according to age (donor aged <60 years, 60-69 years and ≥70 years). We examined the effect of donor age on various short- and long-term outcome parameters. RESULTS Lungs harvested from very old donors had a lower percentage of smoking history and shorter ventilation time. Survival rates of recipients did not show significant differences between older and younger donor groups. Most of the short- and long-term outcome parameters in recipients of lungs from very old donors did not differ significantly among the 3 age groups, except for post-transplant best forced expiratory volume in 1 s and treated acute rejections, which were lower and higher, respectively, in donors aged ≥70 years. CONCLUSIONS This dual-centre analysis showed that lung transplantation from donors aged ≥70 years was not associated with worse outcomes compared with the younger donors. This study supports the idea that it might be possible to use an extraordinarily cautious selection of lungs from very old donors to increase the pool of suitable donors, given the shortage of suitable organ donors available for lung transplantation.

Unklarer Lungenrundherd – Was tun bei einem Zufallsbefund?

(Solitare) Lungenrundherde werden haufig als Zufallsbefunde im Rahmen radiologischer Untersuchungen nachgewiesen. Ihnen konnen verschiedenste gutartige aber auch maligne Lungenveranderungen zugrunde liegen. Deshalb ist eine zeitnahe Abklarung hinsichtlich der Dignitat entscheidend, wobei dazu nicht immer invasive Masnahmen erforderlich sind. Im Rahmen dieses Artikels werden die Grundlagen zur Diagnostik und Therapie pulmonaler Rundherde anhand aktueller Empfehlungen zusammengefasst.