A Modified Calculation Improves the Accuracy of Predicted Postoperative Lung Function Values in Lung Cancer Patients.

PURPOSE: Preoperative pulmonary function testing is mandatory for non-small cell lung cancer (NSCLC) surgery. The predicted postoperative FEV1 (ppoFEV1) is used for further risk stratification. We compared the ppoFEV1 with the postoperative FEV1 (postFEV1) in order to improve the calculation of the ppoFEV1. METHODS: 87 patients voluntarily received an FEV1 assessment 1 year after surgery. ppoFEV1 was calculated according to the Brunelli calculation. Baseline characteristics and surgical procedure were compared in a uni- and multivariate analysis between different accuracy levels of the ppoFEV1. Parameters which remained significant in the multinominal regression analysis were evaluated for a modification of the ppoFEV1 calculation. RESULTS: Independent factors for a more inaccurate ppoFEV1 were preoperative active smoking (odds ratio (OR) 4.1, confidence interval (CI) 3.6-6.41; p = 0.01), packyears (OR 4.1, CI 3.6-6.41; p = 0.008), younger age (OR 1.1, CI 1.01-1.12; p = 0.03), and patients undergoing pneumectomy (OR 5.55, CI 1.35-23.6; p = 0.01). For the customized ppoFEV1 we excluded pneumonectomies. For patients < 60 years, an additional lung segment was added to the calculation. ppoFEV1 = preFEV1 × [Formula: see text]. For actively smoking patients with more than 30 packyears we subtracted one lung segment from the calculation ppoFEV1 = PreFEV1 × [Formula: see text]. CONCLUSION: We were able to enhance the predictability of the ppoFEV1 with modifications. The modified ppoFEV1 (1.828 l ± 0.479 l) closely approximates the postFEV1 of 1.823 l ± 0.476 l, (0.27%) while the original ppoFEV1 calculation is at 1.78 l ± 0.53 (2.19%). However, if patients require pneumectomy, more complex techniques to determine the ppoFEV1 should be included to stratify risk.

Endovascular Management of Complex Fenestration-Associated Aneurysms: A Single-Institution Retrospective Study and Review of Existing Techniques.

BACKGROUND: Aneurysms associated with fenestrations of intracranial arteries are exceptionally rare findings. Management strategies for these aneurysms are not well-defined, especially regarding endovascular treatment. We sought to investigate the strategies and feasibility of endovascular treatment approaches for various fenestration-associated intracranial aneurysms. METHODS: We performed a retrospective chart review of 2000 aneurysms treated endovascularly, identifying 8 aneurysms located at arterial fenestrations. The technical details and procedural outcomes were reviewed to identify common management approaches, technical nuances, and treatment outcomes. RESULTS: There were 3 (37.5%) aneurysms associated with fenestrations of the basilar artery or vertebrobasilar junction. All 3 were successfully treated with a previously undescribed coil-assisted flow-diversion technique, resulting in complete obliteration. Three (37.5%) aneurysms were associated with fenestrations of the anterior communicating artery. Of those, 2 were successfully treated with stent-assisted coil embolization and 1 with coil embolization alone. One (12.5%) aneurysm was associated with a fenestration of the paraclinoid internal carotid artery and 1 (12.5%) aneurysm found was at the takeoff of the posterior inferior cerebellar artery at a fenestration of the vertebral artery. Both were successfully treated with coil-assisted flow diversion. There were no permanent procedural complications. Major considerations for endovascular management of these aneurysms were the dominance of fenestration trunks, aneurysms arising from the fenestration apex or a fenestration limb, amenability to flow diversion, and anticipation of vascular remodeling. CONCLUSIONS: Fenestration-associated aneurysms are very rare. We have identified common factors to help guide decision-making for endovascular approaches and demonstrate successful aneurysm treatment using these methods.

[Chest wall replacement]. / Thoraxwandersatz.

The optimal surgical reconstruction of chest wall defects especially in the context of posttraumatic, oncological and congenital etiologies has a large impact on the recovery of the patients. Regardless of the etiology, various complications, such as a generally impaired respiratory physiology in an unstable thorax or decreased pulmonary clearance associated with acute and chronic pulmonary infections, may impair the recovery of affected patients. The postoperative occurrence of an intrathoracic dead space may lead to a difficult to treat empyema. Each thoracic wall defect must be accurately assessed and treated according to size, depth and location on the chest. The complexity of this condition and the resulting complications require the highest degree of surgical care which should be interdisciplinary both preoperatively and postoperatively.

First case report of a curative wedge resection in epithelial-myoepithelial carcinoma of the lung.

Epithelial-myoepithelial carcinoma is a well differentiated malignant neoplasm, which originates from the salivary glands. The primary pulmonary manifestation is rare-about 30 cases have been reported worldwide. In the literature, anatomical resection has been described as the standard surgical approach. In the presented case, a wedge resection was performed, with no evidence for tumor relapse in the follow-up reevaluation after 24 months. This is the first case report of a primary pulmonary epithelial-myoepithelial carcinoma that has been treated with a non-anatomical wedge resection and lymph node dissection as a curative approach.

[Role of Laser Resection in Pulmonary Metastasectomy]. / Die Rolle der Laserresektion in der Lungenmetastasenchirurgie.

Objectives This review presents laser resection as treatment option in pulmonary metastasectomy and summarizes the current evidence. Moreover, it includes the comparison of laser resection and common techniques used in lung metastasectomy. Methods We performed a systematic literature research in Medline and the Cochrane library to detect case series and even randomized trials. All included studies underwent qualitative analysis. Results Laser metastasectomy is a safe procedure. Data regarding relevant clinical end points as hospitalization, duration of chest tube drainage and long-term survival are heterogeneous and still controversial. Laser enucleation decreases the resection volume. Therefore, it leads to a significant reduction of parenchymal loss. Survival rates after laser metastasectomy are equal to the outcome after resection using other techniques. Conclusions Laser resection is a parenchyma-sparing method. Hence, it offers radical metastasectomy even in case of multiple pulmonary lesions or impaired lung capacity.

[Pulmonary metastasectomy in renal cell carcinoma]. / Lungenmetastasenchirurgie beim Nierenzellkarzinom.

BACKGROUND: In patients with isolated meta- or synchronous pulmonary metastases from renal cell cancer, lung metastasectomy could be an appropriate treatment option after successful treatment of primary cancer. OBJECTIVES: Presentation of lung metastasectomy as a treatment option in patients with pulmonary metastatic renal cell cancer and the postoperative outcome. Description of alternative treatment modalities focusing on "targeted therapies". MATERIALS AND METHODS: Systematical literature research and qualitative analysis of studies on patients undergoing lung metastasectomy after primary nephrectomy published since 01 January 2000. We assessed operative findings, survival data, and prognostic factors. RESULTS: Pulmonary metastasectomy results in a median postmetastasectomy survival of 26-94 months. The 5­year survival rates vary between 33 and 58%. The patients' prognosis depends on a prolonged disease-free interval and complete resection of all suspected metastases. In particular, number and location of lung metastases should play a minor role for the indication for lung metastasectomy. CONCLUSIONS: Pulmonary metastasectomy should be considered the treatment of choice in selected patients with successfully resected primary cancer showing no evidence of extrapulmonary metastases and having guaranteed operability and complete resection.

Surgical limitations in convexity meningiomas en-plaque: Is radical resection necessary?

Meningiomas-en-plaque (MEP) comprise 2.5% of all meningiomas. While they typically arise in the sphenoid wing, convexity MEP are comparatively rare and are often confused with meningeal sarcoidosis, osteoma, tuberculoma, or fibrous dysplasia, with very little information published in the literature. We conducted a literature review on PubMed of English-only articles using a keyword search. All studies that described reports of convexity MEP were reviewed for patient demographics, presenting symptoms, radiological reports, surgical management, recurrence rates, histopathological presentation, post-operative complications, and follow-up. This resulted in 12 papers comprising 22 cases of convexity MEP. Seventeen (77%) of the 22 patients were female with an average age of 53.2years. Intitial presenting symptoms included headache in 12/20 (60%), hemiparesis in 5/20 (25%), and visual symptoms in 1/20 (5%). Of the 14 patients who underwent surgical resection, only four were reported as gross total resection. Twelve reports had associated pathology reports, with all 12 tumors graded as World Health Organization Grade I. Convexity MEP, while rare, present a challenge with regard to correct diagnosis and subsequent resection. The easier accessibility of these meningiomas predicts higher surgical success rates and incidence of total resection, though care must be taken to ensure gross total removal of tumor, dural attachments, and any overlying hyperostotic bone. Though hyperostosis is frequently observed with this variant of meningioma, it is neither exclusive nor wholly indicative of MEP. Due to its rarity in both clinical practice and the literature, further studies are warranted to identify modern imaging means to correctly diagnose this condition.

Sinus thrombectomy for purulent cerebral venous sinus thrombosis utilizing a novel combination of the Trevo stent retriever and the Penumbra ACE aspiration catheter: the stent anchor with mobile aspiration technique.

Intracranial complications of sinusitis are rare but life threatening. We present a case of a 17-year-old woman with sinusitis who deteriorated over the course of 12 days from subdural empyema and global purulent cerebral venous sinus thrombosis. The patient was managed with surgery and mechanical thrombectomy utilizing a novel 'stent anchor with mobile aspiration technique', in which a Trevo stent retriever (Stryker) was anchored in the superior sagittal sinus (SSS) while a 5 MAX ACE reperfusion catheter (Penumbra) was passed back and forth from the SSS to the sigmoid sinus with resultant dramatic improvement in venous outflow. The patient was extubated on postoperative day 3 and was discharged with minimal lower extremity weakness on postoperative day 11. This is the first report using the Trevo stent retriever for sinus thrombosis. It is important to keep these rare complications in mind when evaluating patients with oral and facial infections.

Association of a Distal Intradural-Extracranial Posterior Inferior Cerebellar Artery Aneurysm With Chiari Type I Malformation: Case Report.

BACKGROUND AND IMPORTANCE: Distal extracranial posterior inferior cerebellar artery (PICA) aneurysms are very rare lesions and have not been previously reported in association with a Chiari type I malformation (CMI). CLINICAL PRESENTATION: A 56-year-old woman with a distal, low-lying, intradural-extracranial PICA aneurysm presented with a subarachnoid hemorrhage and was treated with coil embolization. The patient presented again 1 month later with symptoms of a CMI and was found to have tonsillar herniation and a large syrinx that appeared to be exacerbated by the coil mass. The patient was re-treated with a suboccipital craniectomy, C1-2 laminectomy, aneurysm trapping and excision, end-to-end PICA anastomosis, and expansile duraplasty. CONCLUSION: Although just a single case, important teaching points regarding the angiographic appearance of a CMI and treatment options for distal PICA aneurysms that are situated below the foramen magnum can be learned. A low-lying caudal PICA loop should trigger a workup for a CMI. Caution should be taken when using coil embolization for aneurysms in the high cervical spinal canal. Bypass with aneurysm trapping and excision may be a superior treatment option in these cases because the posterior fossa and high cervical canal can be concomitantly decompressed. To our knowledge, this is the only case reported of a distal intradural-extracranial PICA aneurysm associated with a CMI.

Sinus thrombectomy for purulent cerebral venous sinus thrombosis utilizing a novel combination of the Trevo stent retriever and the Penumbra ACE aspiration catheter: the stent anchor with mobile aspiration technique.

Intracranial complications of sinusitis are rare but life threatening. We present a case of a 17-year-old woman with sinusitis who deteriorated over the course of 12 days from subdural empyema and global purulent cerebral venous sinus thrombosis. The patient was managed with surgery and mechanical thrombectomy utilizing a novel 'stent anchor with mobile aspiration technique', in which a Trevo stent retriever (Stryker) was anchored in the superior sagittal sinus (SSS) while a 5 MAX ACE reperfusion catheter (Penumbra) was passed back and forth from the SSS to the sigmoid sinus with resultant dramatic improvement in venous outflow. The patient was extubated on postoperative day 3 and was discharged with minimal lower extremity weakness on postoperative day 11. This is the first report using the Trevo stent retriever for sinus thrombosis. It is important to keep these rare complications in mind when evaluating patients with oral and facial infections.