Treatment Responses in Histologic Versus Molecular Diagnoses of Lung Rejection.

Histologic evaluation of allograft biopsies after lung transplantation has several limitations, suggesting that molecular assessment using tissue transcriptomics could improve biopsy interpretation. This single-center, retrospective cohort study evaluated discrepancies between the histology of transbronchial biopsies (TBBs) with no rejection (NR) and T-cell mediated rejection (TCMR) by molecular diagnosis. The accuracy of diagnosis was assessed based on response to treatment. 54 TBBs from Prague Lung Transplant Program obtained between December 2015 and January 2020 were included. Patients with acute cellular rejection (ACR) grade ≥ 1 by histology received anti-rejection treatment. Response to therapy was defined as an increase in FEV1 of ≥ 10% 4 weeks post-biopsy compared to the pre-biopsy value. Among the 54 analyzed TBBs, 25 (46%) were concordant with histology, while 29 (54%) showed discrepancies. ACR grade 0 was found in 12 TBBs (22%) and grade A1 ≥ 1 in 42 TBBs (78%). Treatment response was present in 14% in the NR group and in 50% in the TCMR group (p = 0.024). Our findings suggest that low-grade acute cellular rejection is less likely to be associated with molecular TCMR, which might better identify lung transplant recipients who benefit from therapy.

Robotic distal pancreatectomy - the first experience.

INTRODUCTION: Minimally invasive distal pancreatectomy (MIDP) includes both laparoscopic and robotic distal pancreatectomy (RDP). MIDP is often adopted first due to the absence of the requirement of a complex reconstruction. In recent years, an increase in the use of robotic surgery has been noted. METHODS: The authors present initial experience with RDP and retrospective analysis of data from prospectively collected database. RESULTS: Between September 2021 and October 2022 five patients undergoing RDP with splenectomy performed in the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University and Motol University Hospital were included from a prospectively maintained database. The age was from 20 to 70 years. No conversion was required. One patient underwent reoperation due to staple-line hemorrhage. Postoperative hospital stay was from 4 to 14 days. The follow-up period was from 2 to 14 months. CONCLUSION: Our first experience demonstrates RDP is a safe and efficacious approach for tumors of pancreatic body and tail in selected patients. A larger number of patients is needed to obtain more accurate results.

Volvulus 8 years after bariatric surgery.

INTRODUCTION: Bariatric surgery is a widespread branch of surgery because of the increase in obesity in population. It is one way to achieve long-term weight loss effect in obese patients. Like other surgeries, bariatric surgery has many complications including ileus and volvulus in small intestine. It is an acute state in surgery and usually leads to a revision surgery. CASE REPORT: 58 years old woman who underwent mini-gastric bypass in 2014. She was admitted to our department because of manifestation of ileus on the second day after TEP of the hip joint. There was a typical sign of volvulus on the CT scan. She was operated on the same day. The reinsertion of enteroenteroanastomosis and denotation of the small intestine, desufflation of the large intestine, and reconstruction of new enteroenteroanastomosis was needed. After the surgery, the patient was without any complications. The bowel function recovery was slower postoperatively. CONCLUSION: Diagnosis of volvulus is not easy because of non-specific clinical symptoms. In this case report, the volvulus occurred 8 years after the primary surgery. Symptoms developed because of paralytic ileus after hip replacement.

Surgical therapy of chronic lung allograft dysfunction.

Lung transplantation has become a standardized and widely accepted treatment modality for selected end-stage lung diseases. Many factors influ- ence the long-term survival of patients after lung transplantation. One of the most important is clearly the development of chronic lung allograft dysfunction (CLAD). This review summarizes current knowledge of the histopathology of CLAD and its clinical characteristics. It also describes lung re-transplantation as the only causal therapy, its possible complications, and outcomes in standard and high-urgency patients awaiting a suitable organ with extracorporeal membrane oxygenation support. Fundoplication is an important surgical modality potentially leading to an improvement of the patients' condition. The indications and outcomes of this surgical procedure are discussed in a separate chapter. In addition, several nonsurgical treatment options aimed at slowing the progression of CLAD are outlined, as well as ongoing research focused on extending the life of these patients.

Robotic-assisted minimally invasive esophagectomy - our first experience.

INTRODUCTION: Minimally invasive esophagectomy is associated with lower postoperative morbidity and better quality of life compared to open esophagectomy in patients with comparable oncological outcomes. Robotic-assisted surgery represents the next step in the development of mini- mally invasive surgery. We aim to present the results of a pilot cohort of patients undergoing robotic-assisted minimally invasive esophagectomy (RAMIE). METHODS: An initial cohort of patients with RAMIE was retrospectively analyzed. Operative characteristics, histopathological results, postoperative course, incidence of complications, and postoperative mortality were evaluated. RESULTS: From 3/2022 to 6/2023, a total of 31 patients underwent RAMIE at our institution, including hybrid RAMIE (robotic abdomen, open chest) in 11 and total RAMIE in 20 patients. Most patients were male, had locally advanced tumors, predominantly adenocarcinoma and neoadjuvant treat- ment. Thirty patients had Ivor-Lewis and one patient had McKeown esophagectomy. The median total operative time was 495 minutes and median blood loss was 200 mL. R0 resection was achieved in 87% of patients. A median of 26 lymph nodes were removed. Postoperative Clavien-Dindo ≥3 complications occurred in 9 (29%) patients. Four (13%) patients required reoperation. Anastomotic leak was found in 5 (16%) and pneumonia in 9 (29%) patients. The median hospital stay was 9 days. One patient died in the postoperative period. Thirty-day and 90-day mortality rates were 0% and 3.2%, respectively. CONCLUSION: Our initial experience shows that RAMIE is a safe surgical procedure and we consider its implementation at our institution to be success- ful. After overcoming the learning curve, we hope to reduce the operative time and increase the medical benefit for the patient.

Robotic pulmonary segmentectomy, initial experience in the Czech Republic.

INTRODUCTION: The initiation of lung cancer screening in Czechia and diagnosis in earlier stages has been reflected by an increasing demand for anatomical lung segmentectomy. The purpose of this study was to describe early results of the first robotic-assisted thoracoscopic segmentectomies performed in the country. METHODS: Our institution has performed 151 robotic anatomical lung resections since the initiation of the screening program in August 2020, which enabled us to attain the status of a proctoring and case observation centre. The robotic segmentectomy program was initiated after completing 70 robotic lobectomies. We performed a retrospective analysis of the results of our first 20 patients indicated for robotic segmentectomy. RESULTS: Median age of the patients was 60, with 11 females and 7 males. The most common indications included primary lung malignancy (n=13), pulmonary metastasis (n=2) and benign lesions (n=3). We performed 11 simple segmentectomies, 6 complex (S2, S3, S1a+2, S10 on the right) and one right S6 segmentectomy with bronchoplasty. The mean number of harvested lymph nodes for NSCLC was 20, the mean blood loss was 25 mL (from 10 mL to 100 mL), and the mean operative time was 200 minutes. All resection margins were tumour-free. There was no conversion to thoracotomy. Two patients were excluded as they required conversion to robotic lobectomy given that their lesions were localized close to the intersegmental plane. One complication (recurrent laryngeal nerve paralysis) occurred in 1 patient. Mean chest tube duration was 1.9 days and length of stay 3.9 days. CONCLUSION: Our experience suggests that implementation of the robotic segmentectomy program after completion of the robotic learning curve provides promising outcomes. Robotic technology and preoperative planning facilitate this technically demanding procedure especially when bronchoplasty is required.

Biportal robotic pulmonary lobectomy, initial experience - case report.

INTRODUCTION: Thanks to perfect visualization and high maneuverability of instruments, the robotic technique is a preferable type of lung resection, even though the number of required incisions is usually higher compared to the video-assisted approach. This case report presents our initial experience with the reduced-port approach in performing robotic biportal lobectomy. CASE REPORT: The 72-years-old female, examined for hemoptysis, was diagnosed with a carcinoid tumor of the left lower lobe bronchus based on bronchoscopy. The patient underwent a biportal fully robotic left lower lobectomy. The time of operation was 235 minutes, longer compared to the average time of multiportal procedures, i.e. 190±52 minutes, and the blood loss of 100 mL was higher compared to 43±54 mL. The patient was discharged without complications on the third postoperative day. Histological analysis confirmed the diagnosis of a typical carcinoid with tumor free margins and seven tumor free lymph nodes. The patient continues to be followed at the Department of Pneumology, showing no signs of disease recurrence for eight months. CONCLUSION: The robotic biportal approach offers a reduction in chest wall traumatization while maintaining oncological radicality. Although this approach is safe and feasible, limitations in instrument movements necessitate specific training.

Starting the first robotic lobectomy program in the Eastern Europe during Coronavirus disease-2019 pandemic.

BACKGROUND: We report our experience in starting RATS (robotic-assisted thoracic surgery) lobectomy program during COVID-19 pandemic. METHODS: Data from 20 consecutive cases undergoing RATS lobectomy between August 2020 and April 2021 were prospectively accumulated into our database. RESULTS: The mean operational time was 235±69 minutes (median 210, range 175 to 370). Conversion-to-open rate was 5 %. One patient was converted to an open procedure during surgery due to surgical bleeding. One patient (5 %), with sever chronic obstructive pulmonary disease (COPD), had prolonged air leak with chest drainage 11 days and conservative treatment. Morbidity rate was 10 % (2 patients). Estimated costs of RATS lobectomy in our department were $9,590 (range $8,250-$12,730). 30-days mortality was 0%. CONCLUSIONS: Safe robotic surgery is based not only on improved robotic equipment, but also on good technical skills and medical knowledge. It requires training of the entire operating room team. The learning curve is steep, involving port placement, use of the correct robotic arms, availability of the proper instrumentation, and proper patient positioning (Tab. 2, Ref. 28).

Video-assisted and robotic-assisted thoracoscopic pulmonary lobectomies, our experience.

INTRODUCTION: The use of video-assisted (VATS) and robotic-assisted (RATS) thoracoscopic surgery for anatomical pulmonary resections has been rapidly increasing. This study aimed to analyze our results of minimal invasive lobectomies to safely introduce these techniques to our practice. METHODS: Starting these new programs we followed the recommended steps including case observations and a proctoring. We retrospectively analyzed the data of our 7-year experience with VATS lobectomies and 1-year experience with RATS lobectomies. RESULTS: 128 minimal invasive lobectomies were performed between 4/2015 and 4/2021 in our center. The mean age of our patients was 64.7±10.5 years; 61 (47.7%) were women and 67 (52.3%) were men. Pulmonary malignancy was the main indication in 116 (90.6%) patients, including 2 patients with localized small cell lung cancer (SCLC). In 12 (9.4%) cases we operated for bronchiectasis and benign lung lesions. Stage I lung cancer was found in 57 (66.3%), stage II in 22 (25.6%) and stage III in 7 (8.1%) patients. We performed 110 VATS and 18 RATS lobectomies with a clear shift from triportal VATS to uniportal VATS and RATS in the last years. The mean operative time was 166±55.5 minutes and a conversion was approached in 8 (6.2%) cases (4 bleedings - less than 300 ml in all cases, 3 oncological cases, 1 case for a technical reason). The median postoperative length of stay was 4 days. CONCLUSION: VATS and RATS lobectomy has become a standard approach for early stages of lung cancer. Respecting the rules of introducing VATS and RATS including proctoring offers safety without any negative impact on survival or oncological radicality.

The first lung retransplantation with “ECMO bridge” in the Czech Republic - case report.

During the last 23 years of the National Lung Transplant Program in the Czech Republic, more than 500 lung transplantations, 4 retransplantations and one lobar retransplantation have been performed. We present the case report of a female patient with cystic fibrosis who underwent her first bilateral lung transplantation in January 2020. Due to a chronic lung allograft dysfunction, the patient required ECMO support and retransplantation. For the first time in the Czech Republic, a lung retransplantation with “ECMO bridge to (re)transplantation” preoperative support was performed in April 2021. The patient was discharged 39 days after retransplantation in a stable condition. At the day 90 follow-up visit, the patient was in a generally good condition with satisfying spirometric functions.

Concomitant thyroid disease in patients operated for primary hyperparathyroidism.

INTRODUCTION: Parathyroid and thyroid diseases are ones of the most common endocrine diseases, but simultaneous surgical treatment of both endocrine systems is still under discussion. METHODS: We retrospectively evaluated 1,574 patients operated for primary hyperparathyroidism at the 3rd Department of Surgery, 1st Faculty Medicine, Charles University and University Hospital Motol in Prague with the thyroid and parathyroid ultrasound reports available. The patients were divided into two groups - with and without thyroid surgery. RESULTS: Thyroid surgery was performed in 34% of patients with primary hyperparathyroidism. Group 2, where thyroid surgery was performed, showed a higher proportion of reported abnormal thyroid sonographic findings (74%), a higher proportion of bilateral throat exploration (69%) and a longer hospital stay (3.3 days). CONCLUSION: A patient indicated for surgery for parathyroid disease should also be indicated for possible thyroid surgery.

Role of extracorporeal life support in thoracic surgery.

Besides the conventional extracorporeal circulation, commonly used in cardiac surgery, the methods of extracorporeal life support (ECLS) have been applied ever more frequently in thoracic surgery in recent years. The most commonly used modalities of such supports include extracorporeal membrane oxygenation (ECMO) and the Novalung interventional lung assist device (iLA). Successful application of ECLS has led to its more frequent use in general thoracic surgery, especially as a tool to treat hypercapnia and to ensure oxygenation and haemodynamic support. However, these methods are essential in lung transplant programmes; without their help, in most cases, it would not be possible to perform the transplantation or prevent the severe complications associated with critical primary graft dysfunction. Additionally, the extracorporeal circulation also facilitates the performing of specific surgical procedures that would not be feasible under standard conditions or would be associated with an inadequate risk. The application of extracorporeal life supports can fundamentally increase the level of resection when treating advanced intrathoracic malignancies that are in close contact with the heart and large vessels or even directly extend into them. Without the possibility of resecting such structures en bloc, together with the tumour, and, thus, achieving an R0 resection, these malignant tumours are often directly contraindicated for surgery or are operated non-radically, i.e. unsuccessfully. Complete tumour resection is the most important prognostic factor in the surgery.

History of thyroid surgery.

The authors present an outline of the development of thyroid surgery from the ancient times to the beginning of the 20th century, when the defini-tive surgical technique have been developed and the physiologic and pathopfysiologic consequences of thyroid resections have been described. The key representatives, as well as the contribution of the most influential czech surgeons are mentioned.

Retrosternal goiter.

INTRODUCTION: Retrosternal goiter is an enlarged thyroid mass of which more than 50% is located in the mediastinum. Indications for surgery of retrosternal goiter include ineffective pharmacological treatment, mechanical syndrome, suspicion of malignancy and thyrotoxicosis. Computed tomography is the gold standard in the diagnosis of retrosternal goiter. The surgery can be performed from a cervical incision, using sternotomy or thoracotomy. METHODS: The aim of our study was to evaluate our own group of retrosternal goiters. In 2011-2019, 1739 thyroid surgeries were performed at the 3rd Department of Surgery, University Hospital Motol, Prague. We retrospectively followed the age, gender, retrosternal spreading, postoperative complications (especially hypocalcemia, bleeding and dysphonia) and the definitive histological finding. RESULTS: Retrosternal goiters were presented in 202 (19.2%) of the total of 1739 thyroid surgery patients. Sternotomy was performed in 31 patients. Women (61%) predominated over men (39%). The mean operating time was 125 minutes. We did not detect any serious postoperative bleeding necessitating surgical revision. Temporary hypocalcemia was observed in 10 patients (32%) based on laboratory testing. Unilateral iatrogenic vocal cord paresis was observed in 6 patients (19.4%) and was permanent in 3 patients (9.3%). One patient passed away soon after the operation, nevertheless the death was related to a simultaneously planned cardiothoracic procedure. CONCLUSION: The retrosternal goiter can be removed using the cervical approach in most cases. Total thyroidectomy using sternotomy is associated with higher morbidity and mortality, higher blood loss and longer hospital stay; nevertheless, it does not increase the risk of long-term postoperative complications. Procedures requiring sternotomy or thoracotomy should be done at centers experienced in these types of procedures.

Malignancy after lung transplantation.

INTRODUCTION: Lung transplantation has become a successful life-saving treatment for patients with end-stage pulmonary disorders. Long-term survival outcomes after lung transplantation have been improving with increasing experience. Malignancies occupy the third position among the causes of death, particularly between years 5 to 10 from lung transplantation. The risk factors include predominantly high doses of immunosuppressive therapy, older age, infections caused by oncogenic viruses and smoking history. METHODS: We retrospectively evaluated all patients undergoing lung transplantation between 2010 and 2019. The aim of this study was to analyze the incidence, type and location of tumors, time from detection, survival time and cause of death in patients with malignant tumors after lung transplantation. RESULTS: In total, 308 lung transplantations were performed at the 3rd Department of Surgery of the 1st Faculty of Medicine, Charles University and University Faculty Hospital in Motol between 2010 and 2019. Posttransplant malignancy was diagnosed in 32 patients; a tumor was detected in the explanted lung in 5 patients. Lung cancer was the most frequent tumor in our study and was found in 13 patients (37%); 6 patients (17%) had a nonmelanoma skin cancer; and posttransplant proliferative disease developed in 4 patients (12.5%). The incidence rate of other types of malignancy was low. Mean of survival after diagnosis was 152 days. CONCLUSION: Life time administration of immunosuppressive therapy in lung transplanted patients plays a key role in the prevention of rejection but on the other hand it represents a risk factor for cancer development. Oncological management of posttransplant cancer is based on reduction of immunosuppressive therapy, combined with surgical resection of solid organ tumors and other types of cancer therapy. Oncology screening tests should be done regularly as a method of prevention, and for an early detection of any tumor.

Thyroid tumors at the limit of operability.

Comprehensive information about current thyroid carcinoma treatment options depending on its histology and extent of the disease, focusing on locally advanced findings at the limit of operability. Treatment of such a heterogeneous group requires interdisciplinary cooperation. We provide 6 unique case reports including imaging scans, description of the therapy and description of development of the condition.

Treatment of anastomotic leak after Ivor Lewis esophagectomy.

INTRODUCTION: Anastomotic leak (AL) is one of the most serious surgical complications after esophagectomy. Endoscopic, radiological and surgical methods are used in the treatment of AL. The aim of this study was to retrospectively evaluate our therapeutic procedures and results of AL treatment after Ivor Lewis esophagectomy (ILE). METHODS: Retrospective audit of all ILEs performed in the years 20052019. Evaluation of AL treatment results according to Esophagectomy Complication Consensus Group (ECCG) classification and according to the primary therapeutic procedure with a focus on the treatment with esophageal stent. RESULTS: Out of 817 patients with ILE, AL was detected in 80 patients (9.8%): ECCG type I 33 (41%), type II 23 (29%) and type III 24 (30%) patients. Some 33 patients (41%) were treated conservatively. Esophageal stents were used in 39 patients (49%), of which 18 (23%) had concomitant percutaneous drainage and 17 (21%) were reoperated. Reoperation without a stent insertion was performed in 7 patients (9%). Esophageal diversion with cervical esophagostomy was performed in a total of 16 patients (20%). Esophageal stent treatment was successful in 24/39 patients (62%). Airway fistula occurred in 4 patients treated with stent (10%). Endoscopic vacuum therapy was successfully used in three patients after stent failure. Eight patients (10%) died as a result of AL. Mortality of AL type I, II and III was 0%, 4% and 29%. CONCLUSION: Successful treatment of AL requires an individual and multidisciplinary approach. The primary effort should aim to preserve anastomosis using endoscopic and radiological methods. In case of insufficient clinical effect, we recommend not to hesitate with reoperation. If primary therapy fails, the life-saving procedure is a cervical esophagostomy.

[18 F]Fluorodeoxyglucose PET/CT and prediction of histopathological response to neoadjuvant chemotherapy for adenocarcinoma of the oesophagus and oesophagogastric junction.

BACKGROUND: The aim of this prospective study was to assess whether [18 F]fluorodeoxyglucose PET can be used to predict histopathological response early in the course of neoadjuvant chemotherapy in patients with adenocarcinoma of the oesophagus and oesophagogastric junction. METHODS: Following the PET response criteria in solid tumours (PERCIST 1.0) as a standardized method for semiquantitative assessment of metabolic response, FDG-PET/CT was performed before (PET1) and after (PET2) initiation of the first cycle of chemotherapy. The relative changes in the peak standardized uptake value (ΔSUL) and total lesion glycolysis (ΔTLG) between PET1 and PET2 were correlated with histopathological response, defined as less than 50 per cent viable tumour cells in the resection specimen. A receiver operating characteristic (ROC) curve analysis was used to identify the optimal cut-off value with the highest accuracy of histopathological response prediction. RESULTS: PET2 was performed a median of 16 (range 12-22) days after the start of chemotherapy. Some 27 of 90 patients who underwent surgery had a histopathological response. There was no association between the median ΔSUL or median ΔTLG and the histopathological response. A post hoc analysis in 47 patients with PET2 performed 16 days or less after the start of chemotherapy showed that ΔTLG, but not ΔSUL, was associated with the histopathological response (P = 0·009). The optimal cut-off value of ΔTLG was 66 per cent or more. CONCLUSION: FDG-PET/CT after the first cycle of chemotherapy does not predict histopathological response in patients with adenocarcinoma of the oesophagus and oesophagogastric junction.

Measurement of intact parathormone during operation for primary hyperparathyroidism.

In this prospective study, the role of the intact parathormone (iPHT) levels for the verification of pathologic parathyroid tissue removal during parathyroidectomy, was analyzed in 441 patients diagnosed with primary hyperparathyroidism. The level of intact parathormone was obtained before the initial incision (baseline level) and 10 minutes after the pathologic parathyroid gland removal (control value). In 80 % of cases, the decrease of intact parathormone was more than 50 % of the baseline level. The comparison of preoperative and postoperative intact parathormone levels can also be used as marker of parathyroid hyperplasia or persistent hyperparathyroidism. This method is necessary mainly for performance of focused, miniinvasive approaches as well as in reoperations. This method is of significant benefit in cases of negative preoperative examination methods. The determination of intact parathormone level increases the success of parathyroidectomy (Ref. 26).

[Pulmonary contusion]. / Plicní kontuze.

Pulmonary contusion is a common finding after blunt chest trauma. It occurs in 23-35% of all cases. Alveolar capillaries are injured due to the trauma, which results in accumulation of blood and other fluids within lung tissue. The fluids interfere with gas exchange, leading to hypoxemia. The consequences of pulmonary contusion include ventilation/perfusion mismatching, increased AV shunts and loss of compliance of lung parenchyma. These physiological consequences are manifested within hours from injury and usually resolve in 7 days. Computed tomography (CT) is a sensitive and main diagnostic tool. Clinical symptoms include hypoxemia and hypercapnia, manifested predominantly during 72 hours from injury. Patients are treated primarily conservatively; surgery may be needed due to haemothorax associated with lung contusion or progression of AV shunts due to localized pulmonary contusion.Key words: pulmonary contusion blunt chest trauma computed tomography.