Circulating apelin, IL22RA2 and VEGF in pre-capillary pulmonary hypertension.

Cytokines can modulate vascular remodelling and the adaptation of the right ventricle in pre-capillary pulmonary hypertension (PH). However, detailed data on the circulating levels of cytokines in patients are limited. We measured blood cytokine concentration in 39 treatment-naïve patients (pulmonary arterial hypertension: N = 16, chronic thromboembolic PH: N = 15, PH due to lung disease: N = 8) and 12 control subjects using enzyme-linked immunoassays. Apelin concentration >1,261 ng/mL identified patients with PH (66% sensitivity and 82% specificity), and in patients it was related to systolic pulmonary arterial pressure (PAP) (r = 0.33, P = 0.04), right atrial pressure (r = 0.38, P = 0.02), cardiac index (r = -0.34, P = 0.04), and right ventricular stroke work index (r = -0.47, P = 0.003). IL22RA2 concentration correlated with mean PAP (r = -0.32, P = 0.04) and serum N-terminal pro B-type natriuretic peptide level (r = -0.42, P = 0.01). VEGF concentration increased in patients upon clinical improvement (N = 16, P = 0.02). Circulating apelin is a novel biomarker of pre-capillary PH. Apelin and IL22RA2 levels are related to right ventricular function upon diagnosis of PH.

[Indications and perioperative results of completion pneumonectomy]. / A komplettáló pneumonectomia javallatai és perioperatív eredményei.

Introduction: Completion pneumonectomy (CP) means the removal of the entire residual lung tissue after previously performed lung resection. Mortality and morbidity of CP are higher when compared to those of standard pneumonectomy. In this article, we give an overview on indications and perioperative results of CP. Method: We analysed the perioperative results of CP performed during a period of 15 years in a retrospective manner, based on the patients' medical records, descriptions of surgeries and histological findings. We divided the indications into three groups: rescue surgery for complications in the early postoperative period (rescue: rCP), incomplete resection verified by histological results (pathological: pCP) and conventional surgeries performed in the late postoperative period (conventional: cCP). We classified the complications according to an international scale. Results: The overall surgery-related morbidity of 102 patients was 70.5% (minor: 36.27%, major: 34.23%), the mortality was 16.6%. There were no lethal complications during the surgical procedures. rCP: 24 patients (18 men, 6 women, 46-77 years, average 61.7 years). Intervals between operations: 10.87 days (0-32 days). Indications: necrosis or abscess formation (8 cases), bronchial fistula (5 cases), insufficient or blocked anastomosis (3 cases), massive haemoptysis (3 cases), intrathoracic bleeding (2 cases), non-expanding lung (3 cases). Overall morbidity: 79.19%. Nine patients died (37.5%). pCP: 7 patients (5 men, 2 women), 45-66 years (average: 56.3 years). Primary surgery: 6 lobectomies, 1 bilobectomy. Intervals between operations: 1-5 months (average: 2.84 months). Three patients did not develop complications, four had anaemia requiring blood transfusion, one empyema requiring fenestration, one died (14.28%) due to intrathoracic bleeding. There were no tumours in the removed lung tissues in cases of four patients. cCP: 71 patients (22 women, 44 men, 29-79 years (average: 60.3 years). Intervals between operations: 34 days - 40 years (average: 6.7 years). Histological findings of the previous surgeries: primary lung tumour (64 patients), metastases of tumours in other organs (1 patient), bronchiectasia (1 patient) and tuberculosis (5 patients). Indications of cCP: late bronchial fistula (2 patients), verified or suspected tumour (65 patients), other (4 patients). Histological findings with primary lung tumour in the patient's history: 32 new tumours, 15 local recurrences, 9 metastases, 2 metastases or recurrences, 7 non-malignant. Histological findings without malignancy in the patient's history: 3 new tumours, 1 tuberculosis and 2 chronic inflammations. Overall morbidity was 76.2%, mortality within 30 days or in the hospital 9.8%. Conclusions: Morbidity and mortality are the highest after rCP, but these patients usually do not have any other chance for healing. We have not performed repeat surgery for incomplete tumour resection in the last 10 years. Comparing our results to the international data, the morbidity after cCP is high, the mortality is similar.

[Treatment of adult intrapulmonary sequestration with video-assisted thoracoscopic lobectomy]. / Felnottkori intrapulmonalis sequestratio kezelése videothoracoscopos lobectomiával.

INTRODUCTION: Surgical removal is the gold standard method for the treatment of pulmonary sequestration (PS); nowadays, video-assisted thoracoscopic lobectomy (VATS) is more frequently applied in the surgical treatment of malignant pulmonary tumours and appears to be suitable also in case of benign pulmonary diseases. We are the first in Hungary, who report three, radiologically identified intralobar PS treated with VATS. METHOD: Surgeries were performed in general anaesthesia with double-lumen separated ventilation in lateral decubitus position through two ports (1.5 cm camera port and 5-6 cm axillary working port, protected by a plastic ring). Results and cases: Two of the patients presented with the symptoms of haemoptysis and pneumonia, and the third patient after radiological screening (one 37 years old woman and 2 men, 39 and 46 years old). The nutritive artery was identified on the CT scans in all cases. We removed the right lower lobe in two cases and the left lower lobe in one case without major complications. CONCLUSION: We recommend the video-thoracoscopic lobectomy for the treatment of PS as a suitable treatment option.

Effectiveness of pulmonary rehabilitation and correlations in between functional parameters, extent of thoracic surgery and severity of post-operative complications: randomized clinical trial.

BACKGROUND: Pulmonary rehabilitation can be effective in perioperative condition. Our aim was to examine whether the changes of functional markers are significant and search connections between these values and the severity of postoperative complications. METHODS: A total of 238 chronic obstructive pulmonary disease (COPD) patients underwent perioperative pulmonary rehabilitation with thoracic surgery. Health status and the following parameters were examined: lung function (FEV1, FVC), chest kinematics [chest wall expansion (CWE)], 6-minute walking test (6MWT), breath holding time (BHT), grip strength (GS) and exercise capacity. Patients were separated into three groups: 72 patients had preoperative rehabilitation only (PRE group), 80 had only postoperative rehabilitation (POS group), and 86 patients underwent pre- and postoperative rehabilitation as well (PPO group). Postoperative complications were classed as "severe" and "not severe". We evaluated the changes in functional parameters. Significance was recognized at P<0.05. Connections in between variables and severity of complications were analyzed. RESULTS: Pulmonary rehabilitation resulted significant changes of all examined parameters in all three groups. The direction of changes were favourable, so all of the changes can be considered to be improvement [PRE: CWE: 4.2±2.3 vs. 5.8±2.2 cm; FEV1: 63.2±15.6 vs. 70.1±16.6%pred; 6-minute walking distance (6MWD): 392.9±93.5 vs. 443.2±86.6 m; FVC: 83.1±15.9 vs. 90.9±15.6%pred; POS: CWE: 2.9±1.4 vs. 5.0±2.0 cm; FEV1: 56.4±15.6 vs. 64.6±16.0%pred; 6MWD: 354.7±90.7 vs. 437.0±96.0 m; FVC: 66.2±18.7 vs. 76.1±17.7%pred; PPO: preoperatively: CWE: 4.0±2.1 vs. 5.6±2.6 cm; FEV1: 58.2±15.1 vs. 67.0±14.6%pred; 6MWD: 378.3±90.5 vs. 441.3±86.4 m; FVC: 82.4±16.7 vs. 93.3±16.7%pred; postoperatively: CWE: 2.7±1.5 vs. 4.4±2.2 cm; FEV1: 47.4±13.0 vs. 53.4±14.7%pred; 6MWD: 341.4±115.9 vs. 403.3±98.4 m; FVC: 63.6±16.9 vs. 72.6±18.6%pred; P<0.05]. BHT, GS, dyspnoea and health status were also improved significantly. By discriminant analysis 5 of the variables proved to have discriminative value: kilometers travelled via cycle ergometer at the onset of the preoperative rehabilitation, gender, FEV1 after preoperative rehabilitation, extent of the operation and 6MWD before preoperative rehabilitation. These 5 parameters can predict severe complications correctly in 72.5% of all cases. CONCLUSIONS: Pulmonary rehabilitation can reduce the functional depletion caused by the thoracic surgical operation. Identification of more predictive factors of severe complications can help making preoperative risk stratification more precisely.

[Doege-Potter syndrome with giant malignant solitary fibrous tumour of the pleura]. / Doege­Potter-szindróma a mellhártya óriás malignus szoliter fibrosus tumorával.

Infrequent solitary fibrous tumours of the pleura are associated with hypoglycaemia only in a few percent of the cases; this condition is called Doege-Potter syndrome, named after its first descriptors. Our 63 years old male patient has previously undergone clinical treatment for intrathoracic fluid accumulation on the left side caused by a giant tumour-like mass in the lower left lobe detected by CT scan. In the course of further investigations performed due to increasing load-induced dyspnoea, lung core biopsy verified low grade sarcoma in the tumour. Tumour board suggested surgery. The patient was transferred from the intensive care unit into the operation theater due to increasing dyspnoea and repeated hypoglycaemic periods in rapidly worsening general condition. Pneumonectomy and removal of the tumour was performed on the left side. Histology showed solitary fibrous tumour of the pleura corresponding to Doege-Potter syndrome. The patient was discharged without complications and underwent adjuvant chemotherapy due to pleural dissemination of the tumour observed intraoperatively. One year after surgery the patient underwent surgical removal of a locally recurrent tumour. In spite of repeated chemotherapy local and multiplex contralateral pulmonary progression was observed. Three-year survival was noted from the time of the first surgery. Orv Hetil. 2018; 159(41): 149-153.

[Risk stratification before thoracic surgery, perioperative pulmonary rehabilitation]. / A mellkassebészeti mutéti teherbíró képesség megítélése, perioperatív légzésrehabilitáció.

INTRODUCTION: Besides the oncology and operative surgical technics, functional aspects influence the operability of lung cancer. Preoperative risk stratification, evaluation of postoperative complications needs to be considered. AIM: To review international literature and experiences of our institute. METHOD: We focused the literature of risk stratification of thoracic surgery. Lung function, lung mechanics, chest kinematics, exercise physiology were considered. Effectiveness of pulmonary rehabilitation for cardiovascular system, lung mechanics, muscles, exercise capacity and quality of life were evaluated. Laboratory parameters, comorbidities, obesity, cachexia, smoking cessation were considered. RESULTS: Elevated blood sugar, kidney function, reduced albumin level increased the risk. COPD, sleep apnoea, heart failure, obesity and cachexia influences the outcome. Smoking cessation may reduce postoperative complications. Controlled breathing technics, chest wall mobilization, training have favourable effects. Psychosocial support and dietetics are important. CONCLUSIONS: Risk stratification is supported by laboratory parameters, lung function, oxygen uptake and comorbidities. Pulmonary rehabilitation can improve functionality and quality of life. Orv Hetil. 2017; 158(50): 1989-1997.

Effectiveness of perioperative pulmonary rehabilitation in thoracic surgery.

BACKGROUND: Functional condition is crucial for operability of patients with lung cancer and/or chronic respiratory diseases. The aim of the study was to measure changes of functional and quality of life parameters in terms of the effectiveness of perioperative pulmonary rehabilitation (PR). METHODS: A total of 208 COPD patients (age: 63±9 years, man/woman: 114/94, FEV1: 62±14%pred) participated in a perioperative PR program. The indication was primary lung cancer in 72% of the patients. The 68 patients participated in preoperative (PRE) rehabilitation, 72 in a pre- and postoperative rehabilitation (PPO) and 68 patients only in postoperative rehabilitation (POS). PR program included respiratory training techniques, individualized training and smoking cessation. Lung function tests, 6 minutes walking distance (6MWD) were measured before and after the rehabilitation. Quality of life tests [COPD Assessment Test (CAT) and Modified Medical Research Council Dyspnoea Scale (mMRC)] were evaluated as well. RESULTS: There was a significant improvement in FEV1 (PRE: 64±16 vs. 67±16%pred; PPO: 60±13 vs. 66±13%pred before the operation, 48±13 vs. 52±13%pred after the operation; POS: 56±16 vs. 61±14%pred, P<0.05) and 6MWD (PRE: 403±87 vs. 452±86 m; PPO: 388±86 vs. 439±83 m before, 337±111 vs. 397±105 m after the operation; POS: 362±89 vs. 434±94 m, P<0 0001). Significant improvement was detected in FVC, grip strength, mMRC and CAT questionnaires as an effectiveness of PR, also. Average intensive care duration was 3.8±5.2 days with vs. 3.1±3.6 without preoperative PR. CONCLUSIONS: Improvements in exercise capacity and quality of life were seen following PR both before and after thoracic surgery.

A pleura óriás fibrosus tumora légzési elégtelenséggel szövodve.

Surgery of mostly benign giant tumours involving large part of the chest is a special surgical challenge. The problems comprise difficulties of surgical technique, management of the narcosis and postoperative intensive care. An additional peculiarity of our case is the extreme confliction of the otherwise presumably evident indication for surgery. Our 64-years-old male patient has been suffering from increasing dyspnoea on exercise for one and a half years. A chest X-ray performed for other reasons demonstrated a large, expansive structural change in the right thoracic cavity. Lung biopsy performed as part of respiratory investigations, which showed a solitaire fibrous tumour of the pleura. Oncological consultation suggested consideration of surgery. The general condition of the patient worsened rapidly in the course of preassessment; he had to be admitted to ICU due to dyspnoea and atrial fibrillation, where respiratory insufficiency developed and required respiratory therapy. Surgery was performed in this high anaesthetic risk patient, since removal of the tumour was the only chance for surviving. The patient left the hospital healthy after successful surgery and cumbersome postoperative period. He returned to his original job and no recurrence was detected one year after surgery.

[Surgical treatment of acute descending necrotising mediastinitis]. / Az acut descendáló necrotizáló mediastinitis sebészi kezelése.

INTRODUCTION: Acute descending necrotizing mediastinitis (DNM) is a severe septic inflammation of the mediastinum with necrosis, which progrediates rapidly and leads to death without adequate surgical treatment in 80% of cases. PATIENTS AND METHOD: 17 patients were treated with acute DNM between 1999 and 2012 at the Thoracic Surgical Department of Koranyi National Institute and Semmelweis University of Hungary. The infection source was primarily in the head-neck region with dental infections in eight cases, retro/parapharyngeal abscess in four patients, primary collar phlegmone and abscess in one case and two retrotonsillar abscesses. Further, in one case there was a previous operation (mediastinoscopy) in the history and in another case there was "difficult intubation process" (not recognized trachea-laesion) mentioned during abdominal operation. Primary exploration was performed from the neck in nine cases, thoracotomies plus collar incisions were carried out in four cases, athoracotomy only was done in one and orofacial exploration in further three patients. Disease progression could be evaluated by computer tomography which had to be followed by immediate surgery. RESULTS: Four patients needed two operations, five patients underwent exploration three times, while three patients needed 4 interventions four times. More than one anatomical region was explored in 70% of the cases. Based on our experience prognosis is affected by the time elapsed between detection and surgical intervention, age of the patient and comorbidites such as diabetes mellitus. We lost nine patients (53%), eight patients recovered and symptom free (47%). CONCLUSIONS: Successful treatment is based on early diagnosis, urgent elimination of the primary source, adequate exploration of the cervico-facial region, debridement, collar and upper mediastinal drainage. If the inflammation spreads below the azygos vein or the aortic arch, a right thoracotomy should be performed with wide mediastinal exploration, debridement, and thoracic suction-lavage drainage. Treatment should be completed with broad spectrum and targeted antibiotics as well as organ support. Mortality and morbidity can be reduced with prompt and aggressive therapy.