Management of anastomotic leaks after oesophagectomy and gastric pull-up.

OBJECTIVE: To evaluate the effectiveness of endoscopic and surgical intervention in treating anastomotic leaks after oesophagectomy. BACKGROUND: Anastomotic leak after oesophagectomy is a severe complication associated with significant morbidity and mortality. This study aimed to analyse our experience with the management of anastomotic leak after oesophagectomy. METHODS: A retrospective study evaluated the treatment outcome and duration of treatment in patients with anastomotic dehiscence or conduit necrosis after oesophagectomy from November 2008 to November 2021. RESULTS: The group consists of forty-seven patients. Twenty-one (44.7 %) patients had dehiscence of the neck anastomosis, twenty patients (42.6 %) had dehiscence of the chest anastomosis, and six (12.8 %) patients had conduit necrosis. Nineteen patients with dehiscence were primarily treated by endoscopic insertion of a self-expanding metal stent with perianastomotic drainage; the other patients were primarily treated surgically. Mortality associated with anastomosis dehiscence was 27.7 % (thirteen patients). Stent use in treatment was a statistically significant parameter regarding the length of hospital stay and mortality. CONCLUSION: Self-expanding metal stents can reduce leak-related morbidity and mortality after oesophagectomy and may be considered a cost-effective treatment alternative (Tab. 2, Fig. 2, Ref. 21).

Lung Cancer Screening Initiative in Slovakia: Guidelines of screening implementation.

Lung cancer (LC) represents a major healthcare issue worldwide. It is the leading cause of cancer-related mortality in Slovakia and European Union. Data from multiple randomized controlled trials have shown significant evidence of a mortality benefit in LC using screening with low-dose computed tomography of the chest (LDCT). Therefore, European healthcare authorities, relevant expert societies, and professional organizations recommend implementing national LC screening (LCS) programs in their member countries. This article outlines the basic methodology, guidelines, and practical aspects of LCS implementation strategies in Slovakia. We describe fundamental principles to identify asymptomatic high-risk patients reduce false positive and false negative results, decrease benign resection rates, and avoid unnecessary invasive procedures. The efficacious utilization of public resources to secure the highest possible quality standards of LDCT plays a crucial role in successfully implementing a nationwide LCS program (Tab. 1, Fig. 4, Ref. 31). Text in PDF www.elis.sk Keywords: lung cancer, screening, early detection, smoking cessation.

Bilateral thoracoscopic cardiac sympathetic denervation in patients with refractory ventricular tachyarrhythmias non­responsive to other treatment.

OBJECTIVES:  To explore the efficacy and safety of bilateral thoracoscopic cardiac sympathetic denervation (BTCSD) as an underutilised last­resort surgical technique for patients with ventricular tachyarrhythmias and electrical storm non-responsive to other treatment. BACKGROUND:  Patients with refractory ventricular tachycardia, ventricular fibrillation, and electrical storm are at high risk of sudden cardiac death. In some patients, suboptimal results are achieved despite treatment with anti-arrhythmic drugs, implantable cardioverter-defibrillator and cardiac catheter ablation. Minimally invasive surgery affecting the stellate ganglions and sympathetic chain is an additional alternative treatment modality that may help avoid heart transplantation. METHODS:  We present our experience of 3 patients who were treated with this technique for the first time in Slovakia in cooperation with the National Institute for Cardiovascular Diseases. Publications on this issue are scarce despite its potential for specific patients. Modifications to avoid complications derived from our experience of sympathectomies for hyperhidrosis are introduced, and improvements are proposed to promote this technique. RESULTS:  All patients showed a reduction or cessation of arrhythmias and ICD shocks with no periprocedural complications. CONCLUSION:  Our experience showed that BTCSD is a safe and feasible technique with a low complication rate and promising results. The limitation of this paper is the low number of patients in our group (Tab. 1, Fig. 3, Ref. 25).

Uniportal thoracoscopic sublobar anatomical resections for small pulmonary nodules.

OBJECTIVES: The study aims to compare the thoracoscopic lobectomy and segmentectomy outcomes. BACKGROUND: Lobectomy is considered the standard treatment method for operable non-small cell lung cancer. Recent studies have suggested that segmentectomy seems to be an acceptable alternative to lobectomy for surgical management of early-stage non-small cell lung cancer. MATERIAL AND METHODS: This retrospective study included 475 patients who underwent thoracoscopic anatomical resection at the Thoracic Surgery Department at University Hospital Bratislava for malignant or benign pathology from October 2012 to December 2021. Thoracoscopic lobectomy was offered to 438 patients, and 37 were treated by thoracoscopic segmentectomy. RESULTS: We recorded no difference between groups considering age and gender. The most common findings in the thoracoscopic lobectomy and segmentectomy groups were primary lung cancer (73.44 %) and pulmonary metastases (59.5 %). Thoracoscopic lobectomy was associated with longer operative time (80.00 vs 110.00 min; p<0.001) and postoperative hospital stay (3.00 vs 4.00 days; p<0.001). Both procedures were associated with a similar incidence of both intraoperative (0 % vs 4.8 %; p=0.394) and postoperative complications (16 % vs 23 %; p=0.353). CONCLUSION:  Thoracoscopic segmentectomy is a safe and effective procedure. This technique is a viable alternative to thoracoscopic lobectomy in indicated cases. It is still not accepted as a standard procedure for lung cancer, and we would like to start a discussion on this topic (Tab. 5, Fig. 2, Ref. 20).

A Delphi Consensus report from the "Prolonged Air Leak: A Survey" study group on prevention and management of postoperative air leaks after minimally invasive anatomical resections.

OBJECTIVES: This study reports the results of an international expert consensus process evaluating the assessment of intraoperative air leaks (IAL) and treatment of postoperative prolonged air leaks (PAL) utilizing a Delphi process, with the aim of helping standardization and improving practice. METHODS: A panel of 45 questions was developed and submitted to an international working group of experts in minimally invasive lung cancer surgery. Modified Delphi methodology was used to review responses, including 3 rounds of voting. The consensus was defined a priori as >50% agreement among the experts. Clinical practice standards were graded as recommended or highly recommended if 50-74% or >75% of the experts reached an agreement, respectively. RESULTS: A total of 32 experts from 18 countries completed the questionnaires in all 3 rounds. Respondents agreed that PAL are defined as >5 days and that current risk models are rarely used. The consensus was reached in 33/45 issues (73.3%). IAL were classified as mild (<100 ml/min; 81%), moderate (100-400 ml/min; 71%) and severe (>400 ml/min; 74%). If mild IAL are detected, 68% do not treat; if moderate, consensus was not; if severe, 90% favoured treatment. CONCLUSIONS: This expert consensus working group reached an agreement on the majority of issues regarding the detection and management of IAL and PAL. In the absence of prospective, randomized evidence supporting most of these clinical decisions, this document may serve as a guideline to reduce practice variation.

Tracheal resection and modified T-tube in the treatment of benign tracheal stenosis. A retrospective study of 48 patients.

OBJECTIVE: The objective was to prove efficiency of tracheal resection in the cohort of patients of our clinic and to introduce our own modification of T-cannula as a surgical alternative if tracheal resection is contraindicated. BACKGROUND: Benign tracheal stenosis, the most often represented by post tracheostomy (PTTS) and post intubation (PITS) stenosis, is a rare, but serious and potentially life-threatening medical condition. We present our experience with the management of the patients, who were referred with a benign tracheal stenosis. METHODS: In the retrospective study, patient's outcome was evaluated after tracheal resection or treatment with T-cannula from all the patients presented with a benign tracheal stenosis from January 2015 to January 2021. RESULTS: The cohort consists of forty-eight patients. Thirty-one (64,6 %) patients underwent a tracheal resection and seventeen (35,4 %) were treated with tracheostomy and T-tube insertion. In the series of patients after tracheal resection, we observed no mortality, complications occurred in ten (32,2 %) patients. They were spread proportionally; anastomotic complications were noticed in 5 (16,1 %) patients, as well as non-anastomotic complications. CONCLUSION: Tracheal resection is a safe and effective procedure with good results. T- tube insertion presents a surgical alternative if bronchoscopy is unavailable or failed (Tab. 4, Fig. 2, Ref. 20).

Surgical treatment of descending necrotising mediastinitis caused by odontogenic infection: a retrospective analysis of 20 patients.

OBJECTIVES: Analysing the results of patients with odontogenic descending necrotising mediastinitis (DNM) treated predominantly by transcervical approach. BACKGROUND: Odontogenic DNM is a rare but serious complication of dental disease and dental procedures. METHODS: Retrospective evaluation of 20 patients who underwent surgery for odontogenic DNM. RESULTS: The mean age was 33.95±12.24 years, and 18 patients (90 %) were men. Type I and diffuse form of DNM were identified in 8 (40 %) and 12 (60 %) patients, respectively. The mean time between the onset of symptoms and surgery was 7.16±4.23 days. The transcervical approach was used in 16 patients, combined cervicotomy and subxiphoid incision in three patients, and cervicotomy and posterolateral thoracotomy was used in one patient. Four patients were reoperated. The mean mediastinal drainage duration and postoperative length of stay (LOS) were 17.05±10.27 days and 20.70±10.87 days, respectively. Fourteen (70 %) patients received mechanical ventilation with a mean duration of 8.86±9.55 days. Comorbidities were present in five (26 %) patients; there were complications in 17 (85 %) patients. In-hospital mortality reached 5 % (1 patient). Thirty-five teeth were extracted. Lower mandibular molars represented 21 (62 %) of extracted teeth. Submandibular and submental spaces were the most affected by the presence of deep neck infection (five and four cases, respectively). CONCLUSION: This study supports the role of transcervical mediastinal drainage as an alternative approach in the surgical treatment of odontogenic DNM (Tab. 4, Fig. 2, Ref. 30).

Non-intubated Thoracoscopic Surgery-Pros and Cons.

Pulmonary resection by video-assisted thoracoscopic surgery with single-lung ventilation has become a standardized modality over the last decades. With the aim to reduce surgical stress during operation procedures, some have adopted a uniportal approach in pulmonary resection as an alternative to multiportal VATS. The ERAS program has been widely spread to achieve even better outcomes. In 2004, Pompeo reported the resection of pulmonary modules by conventional VATS under intravenous anesthesia without endotracheal intubation. Within less than a decade thereafter, complete VATS pulmonary resections under anesthesia without endotracheal intubation had been reported for a range of thoracoscopic procedures. Avoiding tracheal intubation under general anesthesia can reduce the incidence of complications such as intubation-related airway trauma, residual neuromuscular blockade, ventilation-induced lung injury, impaired cardiac performance, and postoperative nausea. Numerous studies can be found especially from Asian countries, focusing on comparison of intubated and non-intubated procedures showing that non-intubated VATS could reduce the rate of postoperative complications, shorten hospital stay and decrease the perioperative mortality rate, indicating that non-intubated VATS is a safe, effective and feasible technique for thoracic disease. However, if we look closely at all studies, it is obvious that there are no significant differences between intubated and non-intubated surgery in terms of the standard procedures and maneuvers. In non-intubated procedures it can be less comfortable for the surgeon to manipulate in the thoracic cavity, but the procedural steps remain the same. All the differences between the intubated and non-intubated operation procedure are found in perioperative management of the patient. The patient is still in deep anesthesia during the procedure and hypecapnia can occur. It is easier to manage this if the patient is intubated. In addition, if a complication occurs during the operation and intubation is required, this can cause an emergent situation, which means that not all patients are suitable for such a procedure, especially those with severe emphysema, obese patients and those with a problematic oropharyngeal configuration-Mallampati score. Moreover, studies on non-intubated thoracic surgery point to shortened hospitalization, faster recovery etc. But there are also studies on intubated uniportal VATS procedures in combination with ERAS protocol showing shortened hospitalization and better outcome for patients. Currently, especially with the use of optical intubation canylas, totally intravenous anesthesia (TIVA), BIS and relaxometer, anesthesia is safe for avoiding airway injury, hypercapnia, and there is minimal risk of residual curarization as well as one of the postoperative lung complications such as microaspiration and atelectasis. In addition, the patient recovers rapidly from anesthesia and can be verticalised and mobilized a couple of hours after the operation. It is desirable to take into consideration what type of patient and what lung disease is suitable for non-intubated technique and what is more convenient for intubation.

Uniportal video-assisted thoracic surgery lobectomy: a consensus report from the Uniportal VATS Interest Group (UVIG) of the European Society of Thoracic Surgeons (ESTS).

OBJECTIVES: Our goal was to report the results of the first consensus paper among international experts in uniportal video-assisted thoracoscopic surgery (UniVATS) lobectomy obtained through a Delphi process, the objective of which was to define and standardize the main procedural steps, optimize its indications and perioperative management and identify elements to assist in future training. METHODS: The 40 members of the working group were convened and organized on a voluntary basis by the Uniportal VATS Interest Group (UVIG) of the European Society of Thoracic Surgeons (ESTS). An e-consensus finding exercise using the Delphi method was applied to require 75% agreement for reaching consensus on each question. Repeated iterations of anonymous voting continued for 3 rounds. RESULTS: Overall, 31 international experts from 18 countries completed all 3 rounds of questionnaires. Although a technical quorum was not achieved, most of the responders agreed that the maximum size of a UniVATS incision should be ≤4 cm. Agreement was reached on many points outlining the currently accepted definition of a UniVATS lobectomy, its indications and contraindications, perioperative clinical management and recommendations for training and future research directions. CONCLUSIONS: The UVIG Consensus Report stated that UniVATS offers a valid alternative to standard VATS techniques. Only longer follow-up and randomized controlled studies will predict whether UniVATS represents a valid alternative approach to multiport VATS for major lung resections or whether it should be performed only in selected cases and by selected centres. The next step for the ESTS UVIG is the establishment of a UniVATS section inside the ESTS databases.

Uniportal VATS lobectomies-masterclass in Bratislava.

On February 5-6, an event on uniportal VATS approach to pulmonary resections took place in Bratislava. It focused on developing uniportal VATS technique. The two-day event gave opportunity to discuss the topic with masters of thoracic surgery such as Prof. Hasan Batirel and Diego Gonzalez, to train basic skills on simulators developed by Dr. Tomaz Stupnik and to watch live surgery performed by Diego Gonzalez. Two patients underwent uniportal VATS lobectomy. This event was another step to advance miniinvasive major pulmonary procedures.

Pseudomalignant myositis ossificans in the breast: A case report.

Myositis ossificans (MO) is characterized by abnormal heterotopic ossification formation, typically involving muscles, tendons, ligaments, fascia, and aponeurosis. It can be categorized into nonhereditary and hereditary types, with the latter being a distinct entity with a separate pathophysiology and treatment approach. The pathophysiology of MO formation remains to be fully elucidated. MO is most commonly observed in muscle tissue as a solitary lesion. The disease has been reported to occur in all ages, including the very young and in atypical locations, including hands, feet, ribs, head and neck. The present case report describes an unusual pseudomalignant form of MO in the breast. The authors discuss the clinical and morphological characteristics of the tumor and its treatment options.

Teachers' gaze over space and time in a real-world classroom.

Reading students' faces and their body language, checking their worksheets, and keeping eye contact is a key trait of teacher competence. The new technology of mobile eye-tracking provides researchers with possibilities to explore teaching from the viewpoint of teacher gaze, but also introduces many new method questions. This study had the primary aim to investigate teachers´ attention distribution over space: the number and durations of several types of their gazes, and how their gaze depends on the factors of students´ gender, achievement, and position in the classroom. Results show that teacher gaze was distributed unevenly across both space and time. Teachers looked at the most-watched students 3-8 times more often than at the least-watched ones. Students sitting in the first row and the middle section received significantly more gaze than those sitting outside this zone. All three teachers made more single gaze visits - looking at the students but making no eye contact - than mutual gazes or student material gazes. The three teachers' gaze distribution also varied substantially from lesson to lesson. Our results are important for understanding teacher behavior in real classrooms, but also point to the relevance of appropriate method design in future classroom studies with eye-tracking.

Urgent segmental resection as the primary strategy in management of benign tracheal stenosis. A single center experience in 164 consecutive cases.

The report is a retrospective review of 238 benign tracheal stenoses of various etiologies treated between 1995 and 2008. To show that urgent segmental resection has complication rates similar to elective resection and, therefore, preoperative dilation is not necessary, we analysed records of patients who underwent either standard segmental resections with anterolateral mediastinal tracheal mobilization, single-suture anastomosis and neck flexion; or insertion of T-tube with oval-shaped horizontal arm. Primary segmental resection was performed in 164 patients (68.9%), including 14 cases with concomitant tracheo-esophageal fistula (TEF). T-tube as an initial treatment suited 74 (31.1%) patients. We encountered two partial and one complete anastomotic disruptions following subglottic resections treated by T-tube insertion and costal cartilage tracheoplasty or permanent tracheostomy. Restenosis rate in segmental resection was 3.1%. No difference in complication rate between urgent and elective segmental resections was experienced. We treated a small number of patients by endotracheal stent insertion but the results were discouraging. Urgent segmental resection without prior rigid bronchoscopy dilation is our strategy of choice whenever possible. As an alternative to dilation we prefer temporary insertion of modified T-tube. Stand-alone endoluminal dilation and stenting has yet to prove its safety and long-term efficacy.