W Schreiner

Modified technique for thoracomyoplasty after posterolateral thoracotomy.

OBJECTIVE Thoracomyoplasty after prior posterolateral thoracotomy (PLT) remains a challenge for the thoracic surgeon. Thoracodorsal artery division after PLT impairs the vascularization supply of the latissimus dorsi muscle (LDM) resulting in muscle mass reduction due to distal atrophy. This makes adequate filling of residual empyema space and/or surgical closure of bronchial stump insufficiency more difficult, and they require alternative surgical procedures. We present an alternative approach using a four-muscle flap technique to include the infraspinatus, the subscapularis and the teres major muscle group, all pedicled from the subscapular artery as a part of a modified thoracomyoplasty technique for closing residual empyema space and bronchial stump insufficiency. METHODS Between 2002 and 2008 we performed the technique in 7 patients with residual empyema space. Three patients had post-tuberculosis syndrome, 2 had postpneumectomy empyema, and 2 had chronic parapneumonic empyema. Three cases were combined with a bronchopleural fistula. All patients underwent a two-stage procedure. First, open window thoracostomy was performed followed by definitive surgical treatment after 3-6 months. In all cases with bronchial insufficiency the stump was covered with a subscapularis muscle flap. The infraspinatus and the teres muscle group were used in combination with a local thoracoplasty. RESULTS Mean age was 68 +/- 7.9 years. Time from open window thoracostomy to thoracomyoplasty averaged 4 +/- 1.3 months. The number of resected ribs ranged between 4 and 8. Mean postoperative stay in the ICU was 3 +/- 2.9 days. The thoracic drains were removed after 5 +/- 2.3 days. Total hospital stay was 15 +/- 7.6 days. No hospital mortality was noted. Minor postoperative complications occurred in 2 cases. Shoulder function without pain allowed abduction up to 90 degrees. Function was decreased by 16 +/- 9 degrees compared to preoperative evaluation. No severe progressive scoliosis was noted. CONCLUSIONS Division of the LDM and its vascular supply after posterolateral thoracotomy results in a reduction of muscle mass. The shoulder girdle muscles offer an adequate alternative to fill residual empyema space with acceptable long-term results and restriction in shoulder motion. In all cases with bronchial fistula, bronchial stump closure with a pedicled subscapular muscle was an effective alternative operative technique.

V. A. C.-INSTILL®-Therapie – neue Wege in der septischen Thoraxchirurgie

BACKGROUND The V. A. C. INSTILL® therapy is an innovative process for treating chronic wounds that are not optimally accessible to a systemic antibiotic therapy or infected with multi-resistant pathogens. We report on our first experience and applications of V. A. C. INSTILL® therapy in the field of septic thoracic surgery. MATERIALS AND METHODS V. A. C. INSTILL therapy was used in 11 cases between 11/2009 and 01/2012. Three patients had sternum osteomyelitis (2 MRSA, 1 Finegoldia magna). In 3 patients chronic pleural empyema after lobectomy (1 Streptococcus viridans, 1 mixed infection with MRSA among others) and after pneumectomy (1 MRSA) were detected. In 2 cases there was an acute pleural empyema with extensive phlegmona in the region of the thoracic soft tissues (2 streptococci). In 1 patient a chronic pleural empyema with MRSA infection was treated. Septic arthritis of the sternoclavicular joint with joint destruction and extensive phlegmona in the region of the cervical soft tissues (1 Streptococcus pneumoniae, 1 Staphylococcus aureus) was treated in 2 patients. In all cases instillation of the wound was performed with Lavasept 0.2 %. Swabs of the wound were taken before starting and after ending V. A. C. INSTILL® therapy as well as before wound closure. RESULTS Mean patient age was 48.8 ± 18.9 years. V. A. C. INSTILL® therapy was performed for 6.5 ± 1.7 days. Instillation time amounted to 21.7 ± 5.7 s. The duration of action was standardised at 18 min in all cases. In 2 cases (1 MESA, 1 finegoldia) the V. A. C. INSTILL® therapy was repeated. In 10 patients a sterile wound status was achieved before secondary wound closure. All wounds underwent secondary closure without recurrence. CONCLUSIONS Chronic osteomyelitis with MRSA infections as well as chronically infected residual cavities after empyema surgery and extensive phlegmona are possible indications for V. A. C. INSTILL® therapy in order to help eradicating the infection as quickly and as completely as possible.

Oligometastasiertes nicht kleinzelliges Lungenkarzinom – chirurgische Optionen und Behandlungsstrategien

OBJECTIVE The therapeutic strategies for oligometastatic non-small cell lung cancer have changed over the last decade from palliative to curative intent. The role of surgery in this multimodal treatment in selected patients remains a subject for open discussion. METHODS Data of 34 patients with one or two metastases treated from January 1998 to January 2013 were retrospectively analysed. RESULTS The mean age was 59.7 (± 10.1) years. The male vs. female ratio was 20 vs. 14. Adenocarcinoma was the most common histological type (58.8 %). The synchronous metastases were present in 15 patients, the metachronous in 19 patients. Single metastases were present in 27 patients, two metastases in 7 patients. The most frequently involved organs were brain (58.8 %) and the lungs (23.6 %). The primary tumour resection was achievable in 20 patients as R0 and in 2 patients as R1. The median overall survival, the local and the systemic disease-free survivals in the entire group were 40, 38 and 25 months, respectively. The 5 year overall survival, the 5 year local and systemic disease-free survivals were 29.2, 26.9 and 16.5 %, respectively. The treatment strategies including surgery for primary tumour as well as for pulmonary metastases site, combined with the lymph node dissection and the resection of the extracerebral and cerebral metastases, were identified as independent prognostic factors for long-term survival. CONCLUSION Surgery in oligometastatic non-small cell lung carcinoma is feasible for primary tumour and for metastases. It is an effective option in the multimodal treatment in highly selected patients. The lymph node dissection should remain an important integral part of the surgical treatment.

Forty-Two Years' Experience with Pulmonary Resections of Metastases from Colorectal Cancer

Background Pulmonary metastasectomy is a commonly performed surgery in patients with controlled metastatic colorectal cancer (CRC). We reviewed our long-term single institution experience with lung resections for colorectal metastases to assess the factors influencing patient survival. Materials and Methods A cohort of 220 patients (138 men and 82 women; median age, 59 years) who underwent complete pulmonary metastasectomy for CRC with curative intent between 1972 and 2014 was retrospectively analyzed. The impact of factors related to primary tumor, metastases, and associated therapy on patient survival was assessed. Results Two postoperative inhospital deaths occurred. The median interoperative interval was 26 months. The overall 5-year survival rate after pulmonary metastasectomy was 49.4%. In univariable analysis, bilateral pulmonary metastases (log rank p = 0.02), multiple metastases (log rank p = 0.005), and stage IV UICC (the International Union Against Cancer) CRC at the time of initial presentation (log rank p = 0.008) were significantly associated with poor outcome. Multivariable Cox analysis demonstrated that stage IV CRC (p = 0.02) and multiple metastases (p = 0.0019) were statistically significant predictors of survival after the pulmonary metastasectomy. There was no significant difference in survival between patients with high versus low preoperative carcinoembryonic antigen serum level (p = 0.149), high versus low preoperative carbohydrate antigen 19-9 serum level (p = 0.291), and primary tumor location in rectum versus colon (p = 0.845). Conclusion Patients with unilateral metastasis and stages I to III primary tumor benefited most from pulmonary metastasectomy for CRC.

Video-assisted technique for resection of a large mediastinal hemangioma

We present a video-assisted technique (VATS) for resection of a large tumor located in the posterior mediastinum in a 16-year-old patient. A large vascular mass in the upper and middle posterior mediastinum, encasing the great vessels and extending to the aorto-pulmonary window, was completely resected under video-assistance using a 5-cm large working incision. The tumor dissection was performed using special videoscopic instruments and electrocautery under respect of the great vessels and vascular pedicles. The VATS technique combined with specially designed endoscopical instruments is offering today the possibility of safe resection even in large mediastinal tumors, thus avoiding late functional complications and/or the morbidity associated with large thoracotomy incisions.

Videothorakoskopisches Sympathikus-Clipping bei einem Patienten mit Lobus venae azygos. Intraoperatives Management zur Vermeidung von potenziellen Komplikationen

INTRODUCTION Sympathetic clipping in the presence of an azygos lobe is a rare combination. Anatomical relations between the sympathetic trunk and the mesoazygos impede surgical handling and can be associated with potential complications. INDICATION We report the case of a 25-year old woman with grade III palmoplantar and axillary hyperhidrosis with azygos lobe incidentally found on preoperative chest X-ray. METHOD Our intraoperative video shows a step-by-step approach to the sympathetic trunk in the presence of the azygos lobe, involving thoracoscopic looping and precise clip application onto the sympathetic trunk. Video-assisted reposition and expansion of the accessory lobe to avoid potential complications have been demonstrated. CONCLUSION Videothoracoscopic sympathetic clipping in patients with lobus azygos is technically challenging. Potential complications can be avoided by coordinated surgical management.

Prognostic significance of the lymph node involvement around the main bronchus. The intermediate group really early N2 disease

Introduction: N1 and N2 diseases represent heterogeneous patient groups with variable survivals. Some studies showed prognostic differences between intralobar and extralobar (hilar and interlobar) N1 disease. The prognosis of the extralobar N1 disease was similar to the single station N2 disease. Some authors designated metastases around the main bronchus as an intermediate group. The aim of our study was to investigate the prognostic significance of intermediate group in comparison to the single station N2 disease and to skipping metastasis in relation to tumor characteristics. Methods: From 1990 to 2007, a total of 850 patients underwent surgical resection for NSCLC: 252 (30%) had either N1 or N2 disease. We retrospectively evaluated 231 (95.8%) hospital survivors who underwent complete resection with mediastinal lymph node dissection on our institution. Results: The 5-year survival of patients with N1 and N2 diseases was 45% vs. 37%. Survival rate did not significantly differ between intralobar vs. extralobar N1 disease or intermediate group (46%, 43% and 43%). According to N2 disease metastases in subcarinal stations and the aortic-pulmonary window showed significantly better survival than in paratracheal stations (36% and 55% vs. 24%, p=0.002). The survival associated with skipping metastasis was significantly better on the left side (50% vs. 35%, p=0.003). Adenocarcinomas were located more on the right side (19% vs. 8%, p=0.003) resulting in extended lymph node involvement. Conclusion: The clinical significance of the intermediate group remains unclear. Their prognostic influence depends on type and extent of lymph node involvement, tumor histology and location.