[Surgical treatment of esophagotracheal and esophagobronchial fistulas]. / Chirurgische Versorgung ösophagotrachealer und -bronchialer Fisteln.

BACKGROUND: Esophagotracheal and esophagobronchial fistulas are pathological communications between the airway system and the digestive tract, which often lead to major pulmonary complications with a high mortality. Endoscopic treatment is the primary therapeutic approach; however, in cases of failure early surgical treatment is obligatory. METHODS: This article describes the clinical course of patients with esophagotracheal and esophagobronchial fistulas treated in this hospital over a period of 10 years. Patients were retrospectively analyzed with respect to the etiology of fistulas, management, in particular to the operative procedures, complications and outcome. RESULTS: Between 2009 and 2019, a total of 15 patients with esophagotracheal and esophagobronchial fistula were treated in this hospital. Of these 12 underwent an endoscopic intervention, of which 5 were successful. In total, eight patients needed surgical intervention, six of the eight surgically treated patients recovered fully, one had a recurrent fistula, which was successfully treated by subsequent endoscopy after surgery and one patient died. DISCUSSION: Management of esophagotracheal and esophagobronchial fistulas is challenging. This retrospective analysis reflects the published data with a success rate of endoscopic treatment in approximately 50%. Surgical intervention should be carried out after unsuccessful endoscopic treatment or if endoscopic treatment is primarily not feasible. Direct closure with resorbable sutures or reconstruction with alloplastic or allogeneic material should be preferred. For larger defects or high proximal esophagotracheal fistulas local transposition of muscular flaps or free muscular flaps play a major role. During operative closure of high intrathoracic or cervical fistulas, intraoperative neuromonitoring can be useful to prevent nerve damage.

[Video-assisted mediastinoscopic surgery]. / Videoassistierte mediastinoskopische Chirurgie.

Introduced in the 1990s, videomediastinoscopes dramatically improved imaging of the mediastinal structures, and made mediastinoscopy more standardized, user-friendly, and accessible to trainees. Not surprisingly they have been replacing conventional mediastinoscopes for routine biopsy and staging procedures. However it was development of the two-bladed spreadable videomediastinoscope by Linder and Dahan that allowed increased exposure, bimanual dissection, and thus the development of new minimally invasive surgical techniques. The best documented method is video-assisted mediastinoscopic lymphadenectomy (VAMLA), which enables extremely accurate staging and definitive mediastinal surgery.

Neoadjuvant chemoradiotherapy of stage III non-small-cell lung cancer.

Twenty to 30% of patients with non-small-cell lung cancer (NSCLC) in stage III are not resectable primarily with 5-year survival less than 10%. Since the majority of patients die from metastases, efforts have been made in the past to improve prognosis by application of neoadjuvant chemoradiotherapy regimens followed by subsequent resection. In a phase II study performed between 1993 and 1998, 93 patients in stage III (IIIA, 16%; IIIB, 84%) received an induction chemotherapy consisting of two cycles cisplatin (100 mg/m2) and vindesine (3 mg/m2) with subsequent sequential radiotherapy of 36 Gy. Sixty-five patients demonstrated partial or complete remission. Sixty underwent surgery; in 49 of them complete resection was possible. Five-year survival in the whole group was 24%, and that in the surgical cohort 39%. Six patients had no residual tumor. Postoperative N0 status was associated with a 5-year survival of 75%, and stage N1-3 with 13%. Thirty-day mortality was 7% postoperatively. Neoadjuvant chemoradiotherapy can significantly improve long-term survival in stage III NSCLC with an acceptable therapy-induced mortality.

Resection of pulmonary metastases from renal cell carcinoma.

Between 1980 and 1995, 77 patients underwent complete resection of pulmonary metastases from a renal cell carcinoma after exclusion of a primary tumor recurrence and other metastatic localizations. 30-day mortality was 3%. The Median follow-up was 34 months (M). Cumulative 5-year survival (5-YS) was 39%. Prognostic criteria are the duration of the disease-free interval (DFI) and the number of metastases. Patients with a DFI > or = 48 M had a 5-YS of 46% compared to 26% for a DFI of < 48 M. Patients with a solitary metastasis had a 5-YS of 49% compared to 19% for multiple metastases. There was no significant difference in terms of sex, kind of access, kind of operation, and unilateral or bilateral affection. Since metastases from renal cell carcinomas are almost resistant to chemotherapy and radiotherapy and immunotherapy at present does not considerably improve long-term survival, surgical resection currently is the only effective therapeutic access in renal cell cancer metastasized to the lung.

Mediastinoscopic ultrasonography (MUS).

Correct pre-therapeutic T4 staging is mandatory for neo-adjuvant studies and for the decision on surgical therapy of high-risk patients. T4-staging of centrally located lung-cancer by means of non-invasive imaging techniques is either of low accuracy (CT and NMR) or important regions are not accessible due to air interference with the tracheo-bronchial tree (trans-esophageal-endosonography, TEE). We here describe for the first time the new technique of mediastinoscopic ultrasonography (MUS). A fingertip ultrasound probe is introduced through the video-mediastinoscope. The probe lies in front of the tracheo-bronchial tree and in direct contact with the vena cava and pulmonary artery. This position allows examining those regions that are not accessible with TEE. In a pilot study with 12 patients, visualization of central vessels and their relation to the tumor was excellent and without artifacts. In 3 patients, MUS did not confirm the T4 stage predicted by CT Scan. Those three patients underwent successful pneumonectomy (R0-resection) while the other nine patients received induction treatment. MUS is a promising addition to CT scanning, NMR, and transesophageal ultrasound in staging of centrally located tumors.

Thoracoscopic surgery spontaneous pneumothorax and nodules of the lung.

Indications and principles of the surgical procedure should be the same for endoscopic and open surgery. Those performing endoscopic surgery should be familiar with the corresponding open procedure, thus being capable to manage complications. Unbiased decision for endoscopic or open procedure might be compromised by lack of experience in one of them. Keeping this in mind, the trauma of surgical access for treatment of some diseases may be diminished by the thoracoscopic approach. There are only few established or almost established indications for thoracoscopic surgery. Since January 1990, we have gained some experience with spontaneous pneumothorax and nodules of the lung. Our patients have been followed-up carefully and the future results will have to be compared with those obtained by conventional surgery (thoracotomy). Our surgical technique and early results will be described in the following.

[Thoracoscopic operation of secondary spontaneous pneumothorax]. / Thoracoskopische Operation des sekundären Spontanpneumothorax.

Since January 1990 we have treated 49 patients with spontaneous pneumothorax (35 primary and 14 secondary cases) by thoracoscopic operation. All patients entered a prospective trial. Those with secondary pneumothorax are discussed here. There have been no major complications. Conversion rate however has been high with 4/14 (29%). Three more patients (21%) not suitable for thoracotomy suffered from persistent air leaks. The other 7 patients needed postoperative drainage for less than 6 days in average. VATS could nevertheless be an alternative to thoracotomy for avoiding prolonged suction treatment in patients with secondary pneumothorax as patients showed no complications or disadvantage after conversion to thoracotomy.

[Use of an endoscopic stapler for transanal widening of anastomotic stenosis]. / Einsatz eines endoskopischen Klammerschneidegerätes zur transanalen Erweiterung einer Anastomosenstenose im Rectum.

Postoperative anastomotic stenosis of the colorectal region are reported in 0.5-13%. We present one patient with a benign anastomotic stenosis after resection of the sigmarectum who was treated using the linear cutter Endopath ELC 35.

[Video-assisted thoracoscopic access in pleural empyema compared with mere chest tube drainage]. / Der videoassistiert-thoracoskopische Zugang zum Pleuraempyem im Vergleich zu Drainagetherapie oder Thoracotomie.

Video-assisted thoracoscopic (VAT) debridement is gaining importance in the fibrino-purulent phase of empyema thoracis. However, evaluation of this access compared with mere chest tube drainage or thoracotomy remains unsatisfactory. A total of 356 parapneumonic empyemas from 1986 to 1997 were retrospectively analyzed concerning the results after primary treatment (chest tube 225, thoracotomy 80, VAT 51). The three groups did not differ significantly for gender and associated diseases. Median age of the chest tube drainage group (54 years) was higher than for thoracotomy (43.5 years) or VAT (39 years). Median duration of chest tube treatment after thoracotomy (7 days) was shorter than after VAT (13 days) or chest tube drainage (20 days) (P < 0.0001). The more invasive procedures were also superior to the lesser invasive treatment concerning duration of postoperative hospitalization, recurrence rate and treatment failures. In spite of its better results thoracotomy will be pushed back by VAT in the treatment of empyema thoracis. Acceptance of VAT is reflected in rising numbers of admissions. Based on these retrospective results we are planning a prospective multicenter trial to evaluate the indication for VAT in empyema thoracis.

[Thoracoscopic operation of primary spontaneous pneumothorax]. / Thoracoskopische Operation des primären Spontanpneumothorax.

Since May 1990 we have treated 35 patients with spontaneous pneumothorax and without underlying lung disease by thoracoscopic operation. All patients entered a prospective trial. There have been four recurrences during a minimum follow-up of 7 months (median 19 months). Two complete collapses had had only fibrin glue sealant without any resection of bullae. The others were partial relapses not requiring any treatment. There was a striking high incidence of pain complaints and sensory disturbances (13 out of 29) even months after pleurodesis by coagulation or pleurectomy. Reduced trauma and less postoperative restriction of pulmonary function together with low recurrence rates suggest a more liberal indication in patients with their first manifestation of the disease. Nevertheless indication and choice of pleurodesis should be restrictive and be studied further for its specific complications.

[Endoluminal therapy of the trachea and bronchus]. / Die endoluminale Therapie in Trachea und Bronchus.

The application of endoscopic techniques is common in the treatment of tracheal and bronchial diseases today. Bronchoscopic interventions are used in both elective and emergency situations. Laser therapy for malignant tumors is purely palliative in most cases and should only be performed in nonsurgical patients. However, 30% of lung cancers cause obstruction in the trachea and main bronchi. Benign tumors and tracheal stenoses could require laser recanalization or the implantation of stents, if surgery will be the second step or will not be possible. In patients with foreign body aspiration, massive hemoptysis, or severe obstruction of the trachea, emergency bronchoscopy is necessary. A more recent type of bronchoscopic intervention is the treatment of bronchial stump or anastomosis insufficiency as well as minimal iatrogenic injuries using spongiotic fillings or stent implantation. The use of therapeutic bronchoscopy requires great experience in rigid and flexible bronchoscopy, the possibility of high-frequency jet ventilation as well as laser and argon application, and the possibility to implant different types of stents. More advanced bronchoscopic interventions should only be done if a department of thoracic surgery exists, in view of the potential need to control complications or perform further treatment. Especially the bronchoscopic treatment of tracheal stenosis should be performed by the thoracic surgeon himself or in close contact with a thoracic surgeon who is experienced in tracheal resections.

[Tumor dissemination after thoracoscopic resection of malignant pulmonary coin lesions]. / Tumordissemination nach thoracoskopischer Resektion von malignen Lungenrundherden.

We report about two cases of tumor dissemination after thoracoscopic wedge resection of malignant nodules of the lung. In the first case, a metastasis at the extraction site was observed after thoracoscopic resection of a metastasis of the lung. In the second case we diagnosed a pleural carcinosis after thoracoscopic wedge resection (and additional open lobectomy and lymph node dissection) of a pT2 N0 lung cancer. The patient died 12 months after the operation. The indication for thoracoscopic resection of malignant nodules of the lung should be restricted for peripheral tumors smaller than 2 centimetres.

[Tracheobronchial necrosis. Following descending necrotizing mediastinitis]. / Tracheobronchiale Nekrose. Folge einer deszendierenden nekrotisierenden Mediastinitis.

Mediastinitis is a bacterial or non-bacterial infection of the mediastinum. Descending necrotizing mediastinitis (DNM) is a rare but life-threatening complication. The mostly feared form of mediastinitis very often has a fatal outcome. We report on a patient with tracheobronchial necrosis following DNM and emphasize the paramount importance of early and complex surgical therapy combined with immediate intensive care treatment. This case describes the intensive medicine and anaesthetic management, which was complicated by the tracheobronchial-pleural fistula and in particular by the respiratory therapy.

Intraoperative thoracic sonography.

In contrast to its use in other surgical disciplines, intraoperative sonography has so far been of minor importance in thoracic surgery. The technique of intrathoracic, intraoperative, ultrasonic examination was applied in 85 patients with different indications: in 61 patients during thoracoscopy, in 24 patients during open thoracic surgery. 6 patients eventually underwent a combination of both procedures. In order to improve the intrathoracic maneuverability of the sonographic probe we developed an electrically controllable handle for the probe. The examinations showed a high sensitivity of thoracoscopic ultrasonography for localization of intrapulmonary tumors. In addition, ultrasound was applied to assess the operability of central tumors. The sound frequency available so far for intraoperative application allows a safe distinction of non-infiltrating tumors from vascular structures; the reliable identification of an infiltration mostly requires a higher resolution. If our experiences are confirmed by further application of the method, explorative thoracotomies will surely be partly replaced by explorative thoracoscopic interventions. Ultrasonography has also proved to be useful in visualisation of mediastinal lymph-nodes and tumors, with the possibility of assessing their size.

Video-assisted thoracoscopic pleurodesis. A survey conducted by the German Society for Thoracic Surgery.

As video-assisted thoracoscopic surgery has been performed for more than five years an inquiry was made to register and if possible to evaluate different pleurodesis procedures in the treatment of pneumothorax in Germany. 19 institutions provided information about 1365 operations. Overall there were 88 recurrences (6.5%). 26 (1.9%) severe bleeding complications or hemothorax and 39 (2.9%) persisting air leaks required further interventions. There were two (0.1%) hospital deaths. Recurrence rates showed a significant (p < 0.001) correlation to the type of pleurodesis used. Talcum pleurodesis had no recurrences and fibrin glue pleurodesis had the highest rate of recurrence (16.4%) both procedures being less frequent. After causal treatment, i.e. resection without any pleurodesis, recurrence rate is inconsistent and was 10.2% overall. Pleural abrasion was followed by a recurrence rate of 7.9% and pleurectomy of 4.4%. Both procedures induced significantly (p = 0.01) more bleeding complications (about 3%) than other procedures (0.4%). Promising was coagulation of the pleura parietalis with a recurrence rate of only 2.7% and a low rate of complications.

[Assessment of current pleurodesis procedures exemplified by pneumothorax]. / Erfassung gängiger Pleurodeseverfahren am Beispiel des Pneumothorax.

This survey addressed common methods of video-assisted thoracoscopic pleurodesis for spontaneous pneumothorax. A questionnaire asking for frequency, recurrence rate and complications of the different methods of pleurodesis was sent to all hospitals that belong to the German Society for Thoracic Surgery. 19 hospitals reported on a total of 1365 operations. 88 recurrences (6.5%), 26 severe bleeding complications (1.9%), 39 persisting air leaks (2.9%) and two hospital deaths (0.1%) had been observed. Pleurectomy and pleural abrasion were the most common procedures but induced significant (p = 0.01) more bleeding complications (3.1% and 2.6%) than all other methods of pleurodesis (0.4%). Overall recurrence rates depended significantly on the chosen procedure (p = 0.0013). Pleurectomy (4.4%) and coagulation of the pleura (2.7%) showed better results than the average. Due to smaller numbers of operations and the widely differing results this significance cannot be shown for the individual recurrence rates of the different clinics. This survey demonstrated a trend towards lower rates of recurrence and complications after coagulation of the pleura parietalis. The retrospective character of the investigation and extremely different recurrence rates for different hospitals demand cautious interpretation of these results.

[Use of preoperative infusion cholangiography before laparoscopic cholecystectomy]. / Nutzen der präoperativen Infusionscholangiographie vor laparoskopischer Cholezystektomie.

In the present study, we intend to evaluate whether intravenous cholangiography, performed on a routine basis in the preoperative period, in addition ultrasonography, history or elevations of serum bilirubin and alkaline phosphatase, provides any supplementary information in detecting patients with asymptomatic calculi in the common bile duct before laparoscopic cholecystectomy is carried out. Therefore, 513 patients were included in a retrospective analysis. From our data, we conclude that preoperative intravenous cholangiography cannot be recommended, when costs and risks and a potential benefit for the patient are considered.

[Implantation metastases following laparoscopic cholecystectomy in gallbladder carcinoma]. / Implantationsmetastasen nach laparoskopischer Cholezystektomie bei Gallenblasenkarzinom.

HISTORY AND CLINICAL FINDINGS: A 66-year-old woman was known to have had cholecystolithiasis for at least 4 years. Laparoscopic cholecystectomy was performed at another hospital where histological examination surprisingly revealed middle-grade differentiated carcinoma of the gall-bladder (pT2, G2). A nodular metastasis of the gall-bladder carcinoma was noted on the abdominal wall 3 months later and excised. Lymph-vessel carcinomatosis was already present. The patient again noticed a tumour in the right mid-abdomen and a further tumour was palpated in the epigastrium 5 months after the operation. INVESTIGATIONS: Laboratory and tumour-marker (CEA, CA 19-9) tests were unremarkable, while sonography and computed tomography were highly suspicious for abdominal wall metastases in the epigastrium and right mid-abdomen. TREATMENT AND COURSE: Both metastases were excised. Laparotomy revealed tumour recurrence in the old gall-bladder bed, as well as extensive peritoneal carcinoma. Two months after the operation she developed jaundice, caused by tumour compression of the choledochal duct. An expanding stent was inserted into the stenosed section of the duct. The patient died 13 months after the first operation from the underlying malignancy with multiple liver metastases and malignant ascites. CONCLUSIONS: Indications for minimally invasive surgery in malignant tumour should be narrowly defined. Because tumour seeding is possible after laparoscopic cholecystectomy with incidentally found carcinoma extensive re-excision should be performed.