[Malignant Pleural Mesotheliomas]. / Das maligne Pleuramesotheliom.

Malignant pleural mesotheliomas (MPM) are very aggressive tumors, which originate from the mesothelial cells of the pleural surface. The main risk factor associated with MPM is exposure to asbestos. The latency period between asbestos exposure and MPM can be 30-60 years. Clinical symptoms and signs are often nonspecifc. The diagnosis of MPM requires an adequate tissue specimen for pathological examination, and video assisted thoracoscopic surgey (VATS) is associated with the highest diagnostic yield. MPM are histologically classified into epitheloid, sacromatoid and biphasic (mixed) sub-types. Accurate staging with invasive tests, if needed, is an important step before an interdisciplinary team can decide on an optimal (multi-modal) treatment approach. A multi-modal treatment approach (surgery, radiation oncology and chemotherapy) is superior to all approaches relying only on a single modality, if the patient qualifies for it from an oncological and functional standpoint. The goal of the surgical therapy is to achieve macroscopic complete resection. There are two competing surgical approaches and philosophies: extrapleural pneumonectomy (EPP) and radical pleurectomy (RP). Over the last years a paradigm shift from EPP to RP occurred and RP is now often the preferred surgical option.

Diagnostic Gain from Surgical Biopsy for Interstitial Lung Disease - When is it Worth the Risk?

BACKGROUND: History, clinical presentation, lung function testing, radiographs including HRCT and nonsurgical biopsy techniques in most cases provide sufficient information for classification of interstitial lung disease (ILD). However, in a small percentage it is not possible to establish the diagnosis so that lung biopsy may be required. We analyzed under which circumstances a reduction of invasive procedures is reasonable. METHODS: Between January 1997 and December 2009 we examined 3399 specimens from 1299 patients with benign inflammatory and granulomatous diseases in whom ILD was clinically hypothesized. We compared the probability of disease according to Bayes before and after surgery which corresponds to the clinical diagnosis (a priori probability) and the final diagnosis (a posteriori probability). Additionally, procedures, operation related complications and the patients' smoking habits were documented. RESULTS: In 111 patients (8.5 %) surgical evaluation was performed (14 mediastinoscopies, 97 thoracotomies/VATS biopsies). All mediastinoscopies substantiated a epitheloid cell granulomatosis. In 30 % of all VATS procedures a prolonged air leak of more than 4 days was observed. One patient died and one had to get a new chest tube after removal. Changes of a priori/a posteriori probabilities was shown for non-smokers in Wegner's granulomatosis (0.6 vs. 2.2 %) and IPF (16.7 vs. 34.8 %), for smokers in Langerhans' cell histiocytosis (1.4 vs. 7.8 %) and IPF (16.7 vs. 33.3 %). In the majority of cases even a reduction of probability was seen. CONCLUSION: Considering complications and limited diagnostic gain, lung biopsies for diagnosis of ILD should be recommended only in selected patients.

[Liver and lung metastases of colorectal cancer. Long-term survival and prognostic factors]. / Leber- und Lungenmetastasen des kolorektalen Karzinoms. Langzeitüberleben und Prognosefaktoren.

INTRODUCTION: The resection of liver and lung metastases from colorectal cancer has not yet been completely investigated. The aim of this study was to investigate the overall survival and prognostic factors for patients with liver and lung metastases from colorectal cancer. METHODS: A retrospective review of a prospective database of 52 patients with liver and lung metastases from colorectal cancer, undergoing metastasectomy with curative intent from 1999-2009 at a single institution was carried out. RESULTS: The mean overall survival (OS) was 64 months. For synchronous liver and lung metastases the mean overall survival was 63 months (5-year survival 54 %) and for metachronous liver and lung metastases 74 months (5-year survival 58 %, p = 0.451). A poor prognostic outcome was observed in cases of localization of the primary tumor in the rectum (OS 81 vs. 38 months, p = 0.004), with multiple lung metastases (≥ 2 metastases, OS 74 vs. 59 months, p = 0.032) and with disease progression after premetastasectomy chemotherapy (OS 74 vs. 63 vs. 15 months, p < 0.001). No influence on overall survival was detected for bilateral lung metastases, thoracic lymph node metastases, disease recurrence and disease-free interval < 36 months. CONCLUSION: Metastasectomy for liver and lung metastases of colorectal cancer is associated with a good overall survival in selected cases. Patients with liver and lung metastases should not be routinely excluded from metastasectomy and patients with thoracic lymph node metastases should also not be routinely excluded. Negative prognostic factors for survival are localization of the tumor in the rectum, multiple metastases and disease progression after premetastasectomy chemotherapy. Patients with disease progression after premetastasectomy chemotherapy should be excluded from metastasectomy.

[Pulmonary Aspergilloma: Indications for Surgery and Surgical Techniques]. / Aspergillome der Lunge--Indikationen zur Operation und chirurgische Techniken.

Aspergillus species may infect preexisting lung cavities and cause pulmonary aspergillomas, which may lead to life-threatening haemoptysis. The objective of this review article is to summarise current strategies for the management of pulmonary aspergillomas. Symptomatic aspergillomas should be treated surgically, with lobectomy being the treatment of choice. Minimally-invasive approaches may be appropriate in selected cases. The role of perioperative antifungal therapy in immunocompetent patients remains controversial. Antimycotic treatment and embolisation of bronchial arteries may be useful treatment options for inoperable patients.

[Multimodal Treatment of Non-Small Cell Lung Cancer with Cerebral Metastases]. / Multimodale Therapie des zerebral metastasierten nicht kleinzelligen Lungenkarzinoms.

BACKGROUND: The role of surgical treatment of lung cancer with brain metastases remains controversial. The aim of this study was to determine the long-term outcome and to identify potential prognostic factors in patients with cerebral metastatic non-small cell lung cancer (NSCLC). METHODS: The data of patients who underwent a resection of oligometastatic NSCLC with brain metastases from January 1999 to December 2012 were investigated retrospectively at a single institution. Multimodal treatment included resection or radiation surgery of the brain metastases at first, followed by systemic chemotherapy and the surgical treatment of the lung cancer finally. Survival, potential prognostic factors, response to chemotherapy as well as morbidity and mortality were investigated. RESULTS: A total of 105 patients with primary NSCLC and brain metastases was identified. Out of these, 26 patients (18 males, 8 females) were included in the study. Morbidity and mortality rates were 15 and 0 %, respectively. Lobectomies were performed in 15 patients, pneumonectomy in 5 and sleeve lobectomy in 6 patients, respectively. The brain metastases were treated individually by resection (n = 12), stereotactic radiotherapy (n = 11) or whole brain radiotherapy in several combinations. Histological response to chemotherapy was proven in 9.1 %. The 2-year survival rate was 50 % (median survival [MS], 26 months). There were no significant differences of the survival depending on the patients' age, gender, presence of lymph node metastases, number of the brain metastases, type of chemotherapy or response to chemotherapy. Adenocarcinoma as histology of the primary tumour showed a significantly better survival compared to squamous cell carcinoma (MS: 26 vs. 8 months; p = 0.034). Treatment of the brain metastases without any additional whole brain radiation was associated with inferior survival compared to patients with whole brain radiation (mean survival: 17 vs. 73 months; p = 0.005). CONCLUSION: Long-term survival is achievable in highly selected patients with NSCLC and cerebral metastasis by multimodal treatment including resection of the primary lung cancer. Patients with squamous cell carcinoma should be selected carefully for multimodal treatment. Treatment of the brain metastases without whole brain radiation should be avoided.

[Surgical therapy of lung metastases]. / Chirurgische Therapie von Lungenmetastasen.

Surgical treatment of lung metastases from extrathoracic malignancies is an established procedure. Pulmonary metastases are common. Generally, lung metastases are located peripherally and are asymptomatic. Involvement of the bronchial system or infiltration of the chest wall can be symptomatic. The indications for resection are an interdisciplinary decision. Metastasectomy can be with curative or palliative intent. Prerequisitess for pulmonary metastasectomy are primary tumor under control, the absence of extrathoracic metastases, the lack of other promising treatment options, the possibility for complete resection and low perioperative risk. Extra-anatomic resections are common. Perioperative morbidity and mortality is low. A cure is possible in selected patients.

[Malignant pleural mesothelioma: comparison of radical pleurectomy und extrapleural pneumonectomy]. / Malignes Pleuramesotheliom: Radikale Pleurektomie und extrapleurale Pneumonektomie im Vergleich.

The role of surgical resection per se and the type of surgery in the management of multimodality treated malignant pleural mesothelioma remains controversial. Patient selection for either extrapleural pneumonectomy or radical pleurectomy depends not only on the cardiopulmonary status of the patient, tumor stage and intraoperative findings but is also strongly influenced by surgeons' preference, experience and philosophy. The aim of this review is to compare extrapleural pneumonectomy and radical pleurectomy with regard to surgical technique, morbidity, mortality and survival.

[Pneumonectomy: an alternative to sleeve resection in lung cancer patients?]. / Pneumonektomie: Eine Alternative zur Manschettenresektion beim Lungenkarzinom?

Lung cancer is localized in the upper lobes in more than half of the cases. The risk of tumor infiltration of centrally located structures, such as bronchi and vessels are enhanced due to the anatomic topography. Pneumonectomy competes with sleeve resection for the surgical resection of centrally located tumors. The present review deals with the question if pneumonectomy should be considered as an alternative to sleeve resection for the treatment of lung cancer. Primary pneumonectomy does not provide any advantage even in advanced nodal disease. Extended lymph node dissection is not a contraindication for sleeve resections. Local recurrence rate is lower after sleeve resections despite the same radicality for both surgical treatment options. Mortality and morbidity rates are significantly lower for sleeve resections. Sleeve resections are associated with prolonged survival and better quality of life even in elderly patients.

[Pneumothorax, what kind of therapy is necessary? A clinical overview]. / Pneumothorax, welche Therapie ist notwendig? Ein klinischer Überblick.

Pneumothorax is defined as the accumulation of air in the pleural space. A distinction is made between a primary (idiopathic) spontaneous pneumothorax (PSP), secondary spontaneous pneumothorax (SSP) as well as between iatrogenic pneumothorax and traumatic pneumothorax. Primary spontaneous pneumothorax (PSP) occurs mainly in otherwise healthy people (mainly tall and thin young men) without any clinical sign of lung disease. In contrast, secondary pneumothorax (SSP) mostly occurs in patients with diagnosed and clinically manifested lung disease and is most frequent in older subjects (> 50 years). Smokers have a higher risk of developing pneumothorax. Most pneumothorax cases require a therapeutic intervention using thorax drainage. Observation alone is recommended for only those few patients suffering from pneumothorax without clinical symptoms. Although simple needle aspiration is often recommended as a first-line treatment, our clinical experience shows no advantage for most of the patients. All patients with symptomatic pneumothorax should be treated with immediate intercostal tube drainage. In the surgical therapy of pneumothorax, VATS (video-assisted thoracic surgery) is the current effective standard treatment. Open posterolateral thoracotomy is the recommend approach rather than the minimally invasive procedure in patient with serious illness or complications. The aim of both interventions is to reduce the recurrence rate of pneumothorax as much as possible.

[Intrathoracic injuries]. / Intrathorakale Verletzungen.

Severe intrathoracic injuries are uncommon but immediately life-threatening. These injuries are mostly associated with polytrauma. After stabilization of polytraumatized patients imaging is a prerequisite for treatment and operation planning. The assessment warrants an interdisciplinary approach primarily between the specialties of anesthesia, trauma surgery and thoracic surgery and further specialties should be involved depending on the injury pattern. This article gives an overview about the current management of the most important intrathoracic injuries.

[Diagnostic assessment and treatment concepts for thoracic trauma]. / Diagnostik und Behandlungskonzepte beim Thoraxtrauma.

Most patients with chest trauma can be successfully treated with tube thoracostomy and appropriate pain medication. Initial care of these patients is usually straightforward and performed by an emergency doctor or an emergency room surgeon, e.g. a general surgeon. If more extensive therapy of these polytraumatized patients appears to be required, tertiary care should be done in specialized centers or clinics with network structures. An appropriate structured network of surgical centers guarantees sufficient and efficient care of patients with severe chest trauma. In a best-case scenario the specialist disciplines work in a rendezvous system with close cooperation. Early communication with a thoracic surgeon is essential to minimize mortality and long-term morbidity. Improvement in understanding the underlying molecular physiological mechanisms involved in the various traumatic pathological processes and the advancement of diagnostic techniques, minimally invasive approaches and pharmacologic therapy, will contribute to decreasing morbidity of these critically injured patients.

Sleeve resections for the treatment of non-small cell lung cancer.

Parenchyma-sparing sleeve lobectomies were originally developed as a surgical strategy for patients not fit for a pneumonectomy, because of impaired pulmonary function. As promising short- and long-term results were demonstrated, sleeve lobectomy was accepted as an alternative surgical procedure to pneumonectomy. Nowadays, sleeve resections are associated with prolonged long-term survival and better quality of life, compared to pneumonectomy. Therefore, sleeve resections should be performed for centrally located non-small cell lung cancer (NSCLC) whenever technically, anatomically and oncologically possible. In this review, we discuss the current status of sleeve resections in the management of NSCLC.

Pneumonectomy vs. sleeve resection for non-small cell lung carcinoma in the elderly: analysis of short-term and long-term results.

BACKGROUND: Aim of the study was to assess the short- and long-term results of sleeve resections and pneumonectomies for centrally located non-small cell lung cancer (NSCLC) in a cohort of elderly patients. METHODS: We retrospectively reviewed our prospective database of all patients aged ≥ 70 years who underwent sleeve resection (SL group) or pneumonectomy (PN group) for NSCLC between January 1999 and December 2005. Patients' characteristics, morbidity, mortality and survival were analyzed and compared between groups. RESULTS: Sixty patients qualified for the analysis, of whom 31 underwent sleeve resection and 29 had pneumonectomy. Both groups were statistically equivalent with regard to age (73.6 ± 2.4 vs. 74.2 ± 3.6 years), sex, comorbidities, histology, completeness of resection and stage. Presurgical FEV1 was higher in the PN group ( P = 0.02). There were no statistical differences in the morbidity rate (SL: 41.9%, PN: 44.8%), mortality rate (SL: 6.5%, PN: 10.3%), local recurrence (SL: 3.2%, PN: 0%) or distant metastases (SL: 19.4%, PN: 24.1%). The loss of FEV1 was higher in the PN group (27.3%) compared to the SL group (12.0%; P = 0.001). Overall 5-year survival and mean survival for SL patients was 59% and 51.9 months compared to 0% and 30.1 months for the PN patients ( P = 0.038). In patients with stage N2 disease, the type of surgery showed a trend to prolonged long-term survival favoring sleeve resection ( P = 0.096). CONCLUSION: In specialized centers both pneumonectomy and sleeve resection can be performed with acceptable mortality and morbidity rates in elderly patients with centrally located NSCLC. In elderly patients with anatomically suitable NSCLC, sleeve resections offer better functional results and long-term survival irrespective of nodal status.

A 30-year-old woman with only right-sided asthma?

Centrally located endobronchial tumors present diagnostic and therapeutic challenges. We report the case of a 30-year-old woman presenting with nonspecific respiratory symptoms and wheezing, who was initially diagnosed with asthma, but eventually was found to have a non-secreting typical carcinoid tumor of the right main bronchus. Surgical management with isolated resection of the right main bronchus allowed us to avoid any parenchymal loss. This case is an instructive example showing that not every wheeze is asthma, especially if the wheezing is unilateral. The excellent long-term outcome of our patient highlights the fact that for central carcinoids, parenchyma-saving resection together with systematic lymphadenectomy should be considered the standard surgical procedure.

[Therapy management of chylothorax]. / Therapiemanagement des Chylothorax.

The diagnosis and treatment of chylothorax poses a challenge to the surgeons' daily practice. The leakage of chyle into the thoracic cavity leads to hypovolemia and also to dysfunction of lipid metabolism, electrolyte imbalance, avitaminosis and immunosuppression. If untreated, the disease will have fatal consequences. This article gives a detailed review of the anatomy, physiology, pathophysiology, diagnostics and treatment options in the management of chylothorax.

Parenchyma-sparing bronchial sleeve resections in trauma, benign and malign diseases.

OBJECTIVE: We evaluated our experience with parenchyma-sparing bronchial sleeve resections in trauma, benign and malign disease to determine the operative morbidity, mortality and long-term outcome. METHODS: We retrospectively reviewed our prospective database of all patients who underwent bronchial sleeve resection without parenchymal loss. Clinical data, morbidity, mortality and survival were analyzed. RESULTS: From January 1999 through December 2008, 19 patients (11 male) underwent bronchial sleeve resection without removal of pulmonary parenchyma. Median age was 42.2 +/- 12.2 years (range 18 to 70 years). Indications were carcinoid tumors (n = 14), adenoid cystic carcinoma (n = 1), non-small cell lung cancer (n = 1), blunt chest trauma (n = 2) and stenosis (n = 1). Isolated resection of the bifurcation (n = 4), resection of the bifurcation en bloc with the right main bronchus with reconstruction of a "neo-trifurcation" (n = 1), resection of the right main stem bronchus (n = 6), resection of the bronchus intermedius (n = 2) and resection of the middle lobe bronchus (n = 1) were right-sided procedures. Left-sided procedures included resection of the left main stem bronchus (n = 3) and left main stem bronchus resection en bloc with the upper lobe and lower lobe bronchus (n = 2). Follow-up was complete and ranged from 11 to 108 months (median follow-up 62.7 +/- 28.6 months). Morbidity was 26.4 %. The cure was delayed in 1 out of 19 anastomoses. No anastomotic dehiscence was seen. No mortality occurred. Resections were complete except for the resection of the adenoid cystic carcinoma (n = 1, R1 resection). No anastomotic stenosis or recurrence of cancer occurred in the late outcome. CONCLUSIONS: In properly selected patients, traumatic bronchial ruptures, localized malign or benign disease can be safely resected without parenchymal loss. Excellent morbidity and mortality rates and a good long-term outcome can be achieved.

[Drug-eluting stents: implications for surgery patients]. / Drug-eluting Stents : Auswirkungen für chirurgische Patienten.

Percutaneous coronary intervention (PCI) has a special role in the treatment of coronary heart disease. The insertion of drug-eluting stents (DES) requires dual anti-platelet therapy for at least 1 year which makes planned and emergency surgery difficult. There is a dilemma between high risk of stent thrombosis and perioperative bleeding. There is no evidence-based, bridging therapy option available perioperatively. This complex of problems should be considered whenever PCI is performed. An interdisciplinary approach is obligatory in these imminent conditions to proceed with either interventional or surgical revascularization. Co-existing malignancies and disorders which must be treated surgically should be excluded before PCI. Furthermore, DES and dual anti-platelet therapy produce unanswered forensic questions. On legal grounds it is not possible to proceed with surgery in cases of medication with anti-platelet therapy. Therefore, it is mandatory to discuss the possible answers to this problem with health care lawyers. The patient must be informed about this complex of problems.

Prospective study on perioperative risks and functional results in bronchial and bronchovascular sleeve resections.

BACKGROUND: Most reports on sleeve resections are based on a retrospective analysis over a long period of many decades. This prospective study addresses the challenging questions associated with sleeve resection. METHODS: In a prospective study, 100 consecutive patients undergoing bronchial or bronchovascular sleeve resection with systematic lymph node dissection were analyzed: operative procedures, extended lymph node dissection, bronchial and vascular complications, functional results, recurrence and survival were recorded. RESULTS: 100 patients (male 78, female 22, age 60.0 +/- 11.9) were enrolled in this study. A R0 resection rate of 99 % could be achieved and pneumonectomies avoided using 9 different surgical techniques. The average number of dissected lymph nodes was 30 on the right side and 33 on the left side. Morbidity and mortality were 39 % and 2 %, respectively. The main indication was non-small cell lung cancer (74 %). The local and distant recurrence rates were 1 % and 16 %, respectively. The overall 5-year survival rate was 87 %. Long-term survival differed significantly between N0 and N1 status ( P = 0.027) and N0 and N2 status ( P = 0.029), but not between N1 and N2 status ( P = 0.754). There were no relevant differences in pre- and postoperative perfusion scans and FEV (1) at 6 months after surgery. CONCLUSIONS: In the hands of experienced surgeons bronchial and bronchovascular sleeve resections are safe operations for high-risk patients. There is no statistical significance between N1 and N2 disease with regard to long-term survival. Systematic lymph node dissection does not lead to increased perioperative risk. Sleeve resections have little effect on pulmonary function. Preoperative FEV (1) and lung perfusion can be achieved by 6 months after surgery.

Pulmonary resection of non-small cell lung cancer: is survival in the elderly not affected by tumor stage after complete resection?

BACKGROUND: Lung cancer is a disease of the elderly. The aim of this study was to investigate the influence of age on the surgical treatment of non-small cell lung cancer. METHODS: We retrospectively reviewed our prospective database of patients older than 75 years of age undergoing pulmonary resection in anatomic units with systematic lymph node dissection for non-small cell lung cancer. Patients were classified as follows: group I (age 75-79 years) and group II (age > 80 years). Morbidity, mortality and survival were analyzed in the overall collective and within both groups, respectively. RESULTS: Between January 1999 and December 2004, 157 patients (group I: 110, group II: 47) were enrolled in this study. 104 lobectomies, 8 bilobectomies, 11 pneumonectomies, 15 sleeve resections and 19 segmentectomies were performed. For all resections mortality and morbidity were 3.8 % and 38.2 %, respectively. There were no significant differences in both groups. The overall 1-year and 5-year survival rates were 83 % and 41 %. Long-term survival was not affected by tumor stage ( P = 0.234) in the present study. CONCLUSIONS: Even extended pulmonary resections for non-small cell lung cancer are feasible in the elderly. Long-term survival is obtainable. Tumor stage does not seem to play a role with regard to survival provided that complete resection of the tumor in anatomic units with systematic, extensive lymph node dissection is performed. Further investigations are necessary to prove this hypothesis in larger series.

[The approach to tumors of the retrocrural mediastinum]. / Zugang zu retrokruralen Tumoren des Mediastinums.

Retrocrural tumors of the lower posterior mediastinum are rare. Most tumors in this region involve lymphatic metastasis of germ cell tumors. Formerly these tumors were resected through a combined thoracoabdominal approach, with division of the diaphragm and effecting an at least partial phrenic paresis. The ventral approach via bilateral subcostal incision with cranial extension avoids this problem and allows a bilateral access to the retrocrural space. From November 1999 to December 2005, using this approach we operated on 12 patients with residual germ cell tumors after chemotherapy. In all cases radical resection was obtained. Intra- or postoperative complications did not occur. All patients are still alive and free of disease.