Pneumonectomy for non-small cell lung cancer: predictors of early mortality and morbidity.

BACKGROUND: The aim of this study was to determine independent risk factors affecting postoperative morbidity and mortality after pneumonectomy for non-small cell lung cancer (NSCLC). METHODS: A review of 329 patients having pneumonectomy for NSCLC between January 1, 1998 and July 31,2012 was undertaken. Factors affecting morbidity and mortality were analyzed by univariate and multivariate analyses. RESULTS: The overall 30-day mortality rate was 5.1%. Smoking habits, chronic obstructive pulmonary disease (COPD) status, neoadjuvant therapy and obesity had no statistical influence on the short-term outcome. Coronary artery disease and respiratory failure were identified as risk factors for increased 30-day mortality (p < 0.01). Right pneumonectomy and presence of respiratory failure with mechanical ventilation increased the incidence of bronchopleural fistula (p < 0.01). CONCLUSIONS: Pneumonectomy for NSCLC carries an acceptable operative morbidity and mortality. Coronary artery disease, right pneumonectomy and respiratory failure adversely affect morbidity and mortality after this procedure.

Predisposing factors of atelectasis following pulmonary lobectomy.

BACKGROUND: The aims of our study were to investigate postoperative atelectasis complicating pulmonary lobectomy, identify risk factors and evaluate its relationship to other postoperative complications. MATERIAL AND METHODS: From January 2004 to April 2007, 412 patients underwent pulmonary lobectomy. We performed a retrospective analysis of our prospective database. Post-lobectomy atelectasis (PLA) was defined as an ipsilateral opacification of the remaining lobe with an ipsilateral shift of the mediastinum on the chest radiography, requiring bronchoscopy. RESULTS: The incidence of PLA was 6.6%, comprising 29% of all postoperative pulmonary complications seen. There was no statistically significant difference in patient age, gender, ASA score, cardiovascular co-morbidity or operation time for the PLA group versus the group without this complication. Current smokers were at a higher risk for PLA, but this incidence did not reach statistical significance. Chronic obstructive pulmonary disease (COPD) was the only preoperative variable increasing the risk of PLA (p < 0.05). Patients undergoing a right upper lobectomy, either on its own or in combination with a right middle lobe resection, had a significantly higher incidence of PLA when compared with all other types of resection (p < 0.05). CONCLUSIONS: Patients with COPD and those undergoing right upper lobe resection have an increased risk of PLA. In this group of patients we should use pre-operative (cessation of cigarette smoking, treatment of airflow obstruction in patients with COPD), intra-operative (duration of operation) and postoperative (intensive physiotherapy and effective postoperative pain control) measures to decrease the risk of PLA. Although often solitary, PLA is associated with a longer hospital stay.

[Impact of neoadjuvant chemotherapy on postoperative complications following pneumonectomy]. / Vliv neoadjuvantní terapie na pooperacní komplikace po pneumonektomii.

BACKGROUND: The risks of complications in patients undergoing pneumonectomy after preoperative chemotherapy for nonsmall cell lung cancer remain controversial. We reviewed a consecutive series of patients having undergone pneumonectomy in a single centre. MATERIAL AND METHODS: This retrospective study included 292 patients operated from January 1, 1998 through December 31, 2008. Group 1 included patients those who received preoperative chemotherapy and pneumonectmy (57 patients, 19%), and group 2 included patients who underwent pneumonectomy alone (235 patients, 81%). The main objectives were 30-day and 90-day mortality rates, and major postoperative complications. RESULTS: There was no statistically significant difference in patients' age, gender, cardiovascular co morbidity, histology and side of pneumonectomy between these two groups. Overall 30-days and 90-days mortality rates were 5.5 % and 8.6%, respectively. Postoperative mortality at 30 days was 5.2% in group 1 and 5.6 % in group 2 (p = 0.16), and 10.5% for group 1 and 8.1% in group 2 at 90 days (p = 0.8). Incidence of empyema was 5.2% in group 1 and 3.0% in group 2 (p = 0.12); incidence of bronchopleural fistula was 3.5 % in group 1 and 3.0% in group 2 (p = 0.10); incidence of postoperative respiratory failure was 3.4% in group 1 and 3.0% in group 2 (p = 0.75). CONCLUSION: Preoperative chemotherapy does not significantly increase postoperative morbidity and early mortality after pneumonectomy in our experience.

[Risk factors of atelectasis following pulmonary lobectomy]. / Rizikové faktory vzniku atelektázy po plicní lobektomii.

BACKGROUND: The aim our study was to determine incidence and predisposing factors of atelectasis following pulmonary lobectomy. METHODS AND RESULTS: Retrospective study of our prospective database included 282 patients. Postlobectomy atelectasis (APL) was defined as ipsi- or contralateral atelectasis with whiteout of the involved lobe or segment on the chest radiograph requiring bronchoscopy. Postlobectomy atelectasis occurred in 18 (6.4%) patients. Chronic obstructive pulmonary disease (COPD) remained the only preoperative variable predicted of APL (p < 0.05). Patients undergoing right upper lobectomy (RUL), either alone or in combination with the right middle lobe had a significantly greater incidence of APL when compared with all other types of resections (p < 0.05). CONCLUSIONS: Postlobectomy atelectasis is an important postlobectomy complication occurring in 6.4% of all lobectomies. Patients with COPD and undergoing RUL are at the higher risk for APL and prophylactic measures to prevent it are necessary.

[Variations of primary spontaneous pneumothorax management]. / Variace lécby primárního spontánního pneumotoraxu.

OBJECTIVE: The aim of our study was to determine the current practice and variation among pulmonologists, general and thoracic surgeons treating primary spontaneous pneumothorax (PSP) in the Czech Republic. METHODS: A pneumothorax questionnaire was mailed to 153 chiefs of departments of general surgery, pneumology and to thoracic surgeons (55 pulmonologists, 75 general surgeons, 23 thoracic surgeons). Mail contained the survey questionnaire and cover letter requesting the recipients' participation and explaining the purpose of the research. National survey questionnaire included questions on PSP management, chest tube attachment preferences and its removal management RESULTS: Ninety seven respondents (63%) answered the survey. This included 28 pulmonologists (28/55, 52%), 48 general surgeons (49/75, 64%) and 20 thoracic surgeons (20/23, 87%). Sixty nine percent of respondents treat first PSP with chest tube, 6% by aspiration. Seventy four percent of respondents insert chest tube in the second intercostal space midclavicular line and 22% in the fourth intercostal space midaxillary line. Nearly 71% of pulmonologists use < 18F chest tube, 85% of thoracic surgeons insert a 20-24F chest tube. Active suction use 56% of respondents. Seventy four percent of physicians clamp chest tube prior its removal. Thirty nine percent of respondents pull out a chest tube at the end of inspirium, and 33% at the end of expirium. CONCLUSIONS: Marked practice variations exist among physicians treating spontaneous pneumothorax. Variations exist not only between pulmonologists and surgeons, but also in the group of surgeons itself.

Induction therapy in lung transplantation: initial single-center experience comparing daclizumab and antithymocyte globulin.

UNLABELLED: Acute and chronic rejection remain unresolved problems after lung transplantation, despite heavy multidrug immunosuppression. Because acute rejection is associated with inferior outcomes in lung transplantation, we have routinely employed antithymocyte globulin (ATG) or daclizumab as adjuncts to reduce the incidence of rejection episodes. METHODS: We performed a controlled clinical trial of the two therapies to evaluate differences in postoperative rejection, infection, bronchiolitis obliterans syndrome (BOS) and host survival. Twenty-five consecutive lung transplant patients received ATG (n = 12; group 1) or daclizumab (n = 13; group 2) as an induction agent. The groups showed similar demographics and immunosuppression protocols, differ only in induction agent. RESULTS: No differences were observed in the immediate postoperative outcomes, such as length of hospitalization, ICU stay, or time on ventilator. There were no significant differences in the number of episodes of acute rejection, freedom from BOS, or infections. Freedom from acute rejection was significantly greater with daclizumab than with ATG (P = .037). The 1-year survival for group 1 was 67% and for group 2, 77% (P = .584). CONCLUSIONS: Daclizumab constitutes a safe and effective form of induction immunosuppressive therapy. Using a two-dose administration schedule, daclizumab prolonged the time without acute rejection compared to ATG. The differences in the incidence of infectious complications, acute rejection, or BOS as well as the short-term or long-term results were not significantly different. The results of the study justify the further use of daclizumab as an induction agent in patients following lung transplantation.

Initial single-center experience with sirolimus after lung transplantation.

BACKGROUND: Standard immunosuppression after lung transplantation includes calcineurin inhibitors, mycophenolate mofetil, and steroids. Long-term survivors of lung transplantation are often confronted with chronic kidney disease, by definition related to the intake of calcineurin inhibitors. Sirolimus has been increasingly proposed as an alternative immunosuppressive agent due to its absence of nephrotoxicity, which could be used in selected patients. METHODS: We prospectively administered sirolimus as an alternative to calcineurin inhibitors in 10 lung transplantation recipients with persistent drug nephrotoxicity. They were switched from tacrolimus to sirolimus. Four patients also had bronchiolitis obliterans syndrome. The conversion scheme consisted of an immediate stop of tacrolimus and an 6 to 8-mg loading dose of sirolimus, followed by 4 mg/d. After 5 days, the sirolimus dose was adjusted to maintain trough levels between 12 and 18 ng/mL or 6 and 12 ng/mL for combined sirolimus and tacrolimus. Patients were monitored for renal and graft function as well as clinical status. RESULTS: A significant decrease in creatinine was observed after 1 week of treatment (P = .011). Azotemia decreased after 1 month, remaining stable (P < .01). Pulmonary function tests did not show significant modification from before sirolimus, inception in patients with or without bronchiolitis obliterans syndrome. There were seven infections. One patient died of complications related to bronchiolitis obliterans. CONCLUSION: Sirolimus was a useful alternative immunosuppressant, allowing significant tacrolimus withdrawal in transplant recipients with renal impairment. Sirolimus administration allowed recovery of renal function with low morbidity; it was useful for rescue of chronic renal impairment after lung transplantation.

[Pulmonary resections and prolonged air leak]. / Prolongovaný únik vzduchu po plicních resekcích.

BACKGROUND: The aim of our study was to determine risk factors for prolonged air leak after pulmonary resections. METHODS AND RESULTS: Two hundred and five patients were operated at our department between January 2003 and March 2004. Prolonged air leak (PAL) was defined as an air leak lasting 7 days or more of postoperative chest tube drainage. PAL occurred in 17 (8.3%) patients and it lasted 10.1+/-3.5 days. COPD remained the only variable predicted for PAL (p<0.05). This complication significantly prolongs the length of hospitalization (p<0.01). CONCLUSIONS: COPD patients have significantly higher risk for PAL following pulmonary resection. Intraoperative prevention of the air leak requires meticulous surgical technique, stapler use and application of pericardial bovine strips.

[Comparison study on the use of tubular and spiral thoracic drains following lung resections. A prospective study]. / Porovnání pouzití trubicových a spirálních hrudních drénu po plicních resekcích. Prospektivní studie.

INTRODUCTION: Purpose of this prospective study was to compare two types of chest drains- standard bore tubes with new concept of flexible spiral drains. METHODS: From January to March 2005 twenty eight patients after lobectomy or bilobectomy were prospectively randomised. We used two different drains types (flexible spiral- Blake silicon drains, Ethicon) and standard chest drains (Dahlausen GmbH) in all patients. Front drain (diameter 24 Fr) was inserted in the sixth intercostal space anterior axillary line and dorsal one (diameter 28 Fr) in midaxillary line of the sixth intercostal space. Half of the patients had front drain spiral one and second group had a convetional chest tube. Postoperative variables included: tidaling, bubbling, fluid level and its characteristics, wound infection and technical complications of inserted drains. RESULTS: Mean daily amount of fluid in front drains was 61 ml in spiral drains vs. 78 ml in standard drains. Spiral drains were removed after median of 3.7 days, vs. 4.4 days in standard chest tube group. Mean daily amount of fluid of dorsal drains group was 220 ml in spiral drains group vs. 213 ml in standard drains. Spirals drains were removed after median of 4.5 days vs. 3.6 days in standard chest tube group. There was no significant difference in technical complications between drains. CONCLUSION: Spiral drains are as safe and effective as conventional tubes after lung surgery. Their only present disadvantage is low cost-effectiveness compare to standard bore tubes.

Cyclosporine-related neurotoxicity in a patient after bilateral lung transplantation for cystic fibrosis.

Cyclosporine (CsA) is a widely used immunosuppressant following solid organ transplantation. CsA administration is associated with a number of systemic complications, including neurotoxicity. A 33-year-old man with cystic fibrosis, who underwent bilateral lung transplantation, presented with severe neurotoxic symptoms leading to coma in association with CsA administration combined with high doses of methylprednisolone for treatment of an acute rejection episode. After discontinuation of CsA, a quick resolution of his clinical status was observed, as well as of the pathological findings on magnetic resonance imaging (MRI). CsA was replaced with tacrolimus leading to an uneventful course.

[Computer tomography and staging of bronchogenic carcinoma. Prospective study]. / Pocítacová tomografie a staging bronchogenního karcinomu. Prospektivní studie.

BACKGROUND: The aim of our study was to determine validity of computed tomography in staging of non-small cell lung cancer. METHODS AND RESULTS: Sixty-two patients with NSCLC were operated at our department between March and September 2003. Lymph nodes with the shortest diameter over 10 mm on CT were considered abnormal. Primary tumor was correctly determined by CT scans in 77 % of cases, lymph nodes involvement in 63 %. Stage of NSCLC was correct in 53% of all patients. Negative predictive value for N1 and N2 was 80 %, resp. 88 %. CONCLUSIONS: Even with improvement in CT technology, validity of CT in staging of NSCLC remains low. We consider that mediastinoscopy can be avoided in the presence of normal mediastinal CT findings due to high negative predicative value of nodal improvement.

[Is a scalpel required to perform a thoracotomy?]]. / Je nutný skalpel k provedení torakotomie?

The purpose of this prospective study was to determine whether electrocautery as a means of creating thoracic wound result in increased wound infection rates. Seventy-three patients were randomized prospectively into two groups. Group A-coagulation, where the first half of the incision was done with scalpel and the second half with coagulation-fulgurate. Group B-cut mode, where half of incision was done with scalpel and half with blend cut mode. All wound complications were recorded and divided into infectious (grade 1: induration and erythema with no secretion, grade 2: grade 1 and serous secretion, grade 3: contaminated wound with pus formation) and non-infectious complications (haematoma with its evacuation). Scalpel and electrosurgical thoracotomy incision in elective surgery are similar in terms of early and late wound complications when used to perform anterolateral thoracotomy. Therefore, the choice of which method to use remains only a matter of surgeon preference.

[Benign clear cell tumors of the lung--sugar tumors]. / Benigní nádory plic z jasných bunek--sugar tumors.

The authors present the case reports of rare benign clear cells tumors of the lung (CCLT) and drawn attention, that examination from frozen sections can be misleading and definitive histological verification can be done on basis of immunohistochemical analysis and can be different from frozen sections examination.