S. Taghavi

Predictors of Outcome in Chronic Thromboembolic Pulmonary Hypertension

Background— Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by intraluminal thrombus organization and fibrous obliteration of pulmonary arteries. Recently, associated medical conditions such as splenectomy, ventriculoatrial shunt for the treatment of hydrocephalus, permanent central intravenous lines, inflammatory bowel disease, and osteomyelitis were found to be associated with the development of CTEPH. The study aim was to define the impact of these novel risk factors on survival. Methods and Results— Between January 1992 and December 2006, 181 patients diagnosed with CTEPH were tracked with the use of our centers customized computer database. A Cox regression model was used to examine relations between survival and associated medical conditions, age, sex, hemodynamic parameters, modified New York Heart Association functional class at diagnosis, CTEPH type, pulmonary endarterectomy, and anti-cardiolipin antibodies/lupus anticoagulant. During a median observation time of 22.1 (range, 0.03 to 152) months, the clinical end point of cardiovascular death or lung transplantation occurred in 48 cases (27%). Pulmonary endarterectomy (hazard ratio, 0.14; 95% CI, 0.05 to 0.41; P=0.0003), associated medical conditions (hazard ratio, 3.17; 95% CI, 1.70 to 5.92; P=0.0003), and pulmonary vascular resistance (hazard ratio, 1.02; 95% CI, 1.00 to 1.04; P=0.04) were predictors of survival. Thirty-day postoperative mortality (24% versus 9%) and the incidence of postoperative pulmonary hypertension (92% versus 20%) were substantially higher in patients with associated medical conditions. Conclusions— CTEPH-predisposing medical conditions, such as splenectomy, permanent central intravenous lines, and certain inflammatory disorders, predict poor survival in CTEPH.

Lobar lung transplantation--is it comparable with standard lung transplantation?

Lobar lung transplantation is used mainly for urgent small recipients who are less likely to obtain size matched lungs in due time. Only limited numbers have been published, and we herewith report the largest series of lobar‐LuTX. We analyzed our LuTX database from 1/2001 to 12/2012 and compared the outcome of lobar‐LuTX recipients with those receiving standard LuTX. Seven hundred and seventy‐eighty LuTX (group 1) were performed either in standard technique by implanting the whole lungs (n = 539) or with downsizing by wedge resection of the right middle lobe and/or the left lingula (n = 239). One hundred and thirty‐eight LuTX were performed in lobar technique (group 2) to overcome more pronounced size discrepancies. Patients in group 1 had a different spectrum of diagnoses and were less frequently bridged to LuTX (P < 0.001). Intubation time, ICU stay, and hospital stay were shorter in group 1 (P < 0.001). One‐year survival was 84.8% vs. 65.1%, and 5‐years survival 69.9% vs. 54.9% (P < 0.001). In multivariate analyzes, procedure, diagnosis, and pre‐operative bridging were shown to be significant prognostic factors in survival. Early postoperative outcome in Lobar LuTX was significantly inferior to standard LuTX recipients. However, survival rates of successfully dismissed patients were comparable with standard LuTX (P = 0.168); thereby, Lobar‐LuTX remains an important option in the management of urgent small recipients.

Transperitoneale Unterbindung des Ductus thoracicus zur Behandlung eines Chylothorax nach Lungentransplantation

ZusammenfassungGrundlagen: Chylothorax stellt eine seltene Komplikation nach thoraxchirurgischen Eingriffen dar. Falls die Beherrschung über diätetische Maßnahmen nicht gelingt, ist ein chirurgischer Eingriff nicht zu umgehen. Dabei kann das Risiko einer thorakalen Reintervention beträchtlich sein. Die transperitoneale Unterbindung des Ductus thoracicus im Bereich des Hiatus diaphragmaticus stellt eine alternative Eingriffsmöglichkeit dar.Methodik: Wir berichten über einen 41jährigen männlichen Patienten, bei dem unmittelbar nach unilateraler Lungentransplantation eine Chylusfistel auftrat. Nachdem die diätetische Fettrestriktion keinen Erfolg erbracht hatte, wurde eine offene parietale Pleurektomie durchgeführt. Da auch nach diesem Eingriff der Chylothorax persistierte und mittels Lymphographie eine hoch gelegene Chylusfistel dargestellt werden konnte, wurde die Indikation zur Reoperation gestellt. Um das Risiko eines dritten thorakalen Eingriffes zu vermeiden, wurden über eine mediane Laparotomie die Lymphbahnen im Bereich des Hiatus diaphragmaticus unterbunden.Ergebnisse: Es kam zu keinem weiteren Chylothorax und der Patient konnte in gutem Zustand entlassen werden.Schlußfolgerungen: Um das Risiko einer thorakalen Reinter-vention nach extensiven thoraxchirurgischen Eingriffen zu minimieren, ist die transperitoneale Unterbindung des Ductus thoracicus eine alternative Behandlungsmöglichkeit für Chylothorax.SummaryBackground: Chylothorax is an unfrequent complication after thoracic surgery. If conservative therapy fails, surgical treatment is indicated. The risk of a thoracic reintervention may be high in this setting. Transperitoneal ligation of the thoracic duct represents an alternative therapeutical strategy.Methods: We report about a 41 year old male patient who presented with a chylothorax immediately after right single lung transplantation. After dietary fat restriction had failed, an open pleurectomy was performed. Chylothorax still persisted, and a chylous fistula was detected by lymphography. In an attempt to minimize the risk of a third thoracic operation, a ligature of the lymph vessels at the level of the diaphragmatic hiatus was performed through a median laparotomy.Results: Chylothorax did not reoccur and the patient was finally discharged.Conclusions: Transperitoneal ligation of the thoracic duct is an alternative therapeutical strategy with little operative risk for chylothorax after extensive thoracic surgery.

Erweiterte Resektionen bei nichtkleinzelligem Bronchuskarzinom

SchlußfolgerungenDie Abschätzung der erzielten Langzeitergebnisse ist schwierig, da es sich zumeist um ausgewählte Operationen an sehr kleinen Patientenserien handelt.