Treatment of a broncho-esophageal fistula complicated by severe ARDS.

INTRODUCTION: Broncho-esophageal fistula formation is a rare complication of tuberculosis, most often seen in immunocompromised patients. METHODS AND RESULTS: In this paper, we report the case of a young non-immunocompromised refugee from Somalia diagnosed with open pulmonary tuberculosis complicated by extensive osseous involvement and a broncho-esophageal fistula with consecutive aspiration of gastric contents. The patient rapidly developed a severe acute respiratory distress syndrome (ARDS) requiring venovenous extracorporeal membrane oxygenation (ECMO) therapy for nearly 2 months. The fistula was initially treated by standard antituberculous combination therapy and implantation of an esophageal and a bronchial stent. Long-term antibiotic treatment was instituted for pneumonia and mediastinitis. 7 months later, discontinuity resection of the esophagus was performed and the bronchial fistula covered by an intercostal muscle flap. DISCUSSION: This case illustrates that tuberculosis should always be suspected in patients from high-incidence countries in case of lung involvement and that an interdisciplinary approach including long-term intensive care management can enable successful treatment of tuberculosis with severe, near-fatal complications.

[Surgical Therapy of Acquired Unilateral Diaphragmatic Paralysis: Indication and Results]. / Chirurgische Therapie bei erworbener einseitiger Zwerchfelllähmung: Indikation und Ergebnisse.

Unilateral elevation of the diaphragm may be due to various causes and requires further elucidation when the aetiology is unknown. Elevation of the diaphragm is often caused by diaphragmatic paralysis, either due to damage to the phrenic nerve or to the phrenic muscle. Patients typically complain of increased respiratory distress when lying down, bending or swimming. Basic diagnostic testing consists of a chest X-ray, as well as spirometry and computer tomography of the neck and chest. In many cases, no cause can be identified for the diaphragmatic paralysis. In symptomatic patients, diaphragm plication leads to fixation and thus to a reduction in the paradoxal respiratory movement of the paralysed diaphragm. In a large majority of studies, this results in significant and lasting improvement in vital capacity and respiratory distress. Spontaneous recovery of diaphragm paralysis is possible, even after several months, so a waiting period of at least 6 months should elapse before diaphragmatic plication is performed, if the clinical situation allows. The procedure can be performed minimally invasively, with low morbidity and mortality. When cutting the phrenic nerve, a nerve suture is recommended, if possible, or otherwise diaphragm plication during the procedure, especially in the case of pneumonectomy. This review provides an overview of the causes, pathophysiology, symptoms, diagnosis, therapy and results of diaphragmatic plication in acquired, unilateral diaphragmatic paralysis in adults, and suggests an algorithm for diagnostic testing and therapy.

[Management of Hemoptysis: Results of an Algorithm-Based Interdisciplinary Treatment Scheme]. / Management von Hämoptysen: Ergebnisse einer algorithmusbasierten interdisziplinären Versorgung.

INTRODUCTION: Hemoptysis is a worrying symptom for the majority of patients, is frequently a sign for a severe disease and can develop into a life-threatening situation. Various therapeutic methods and medical specialties can be involved in the management of these patients. Guidelines or evidence-based recommendations on this issue are not available. Based on our long-term experience and considering all established diagnostic and therapeutic means, we propose an algorithm to manage this condition. PATIENTS AND METHODS: This is a retrospective analysis of a cohort from a single thoracic surgical institution. Data regarding the used diagnostic and therapeutic methods with focus on outcome parameters are presented. Based on our experience and the published data we discuss the proposed algorithm. RESULTS: Between 01.2009 and 12.2013, 204 patients were hospitalised and treated for hemoptysis. Malignancies were the most frequent (50 %) cause of hemoptysis, followed by infectious/inflammatory diseases (25 %), cardiovascular disorders (6 %), rare (12 %) and unclear (7 %) circumstances. In 71 cases the bleeding stopped spontaneously, in 124 (61 %) one invasive measure (interventional bronchoscopy 43, bronchial artery embolisation 34 or operation 12) or a combination of methods (35 combinations of two or all three methods) were necessary to stop the hemoptysis. Six patients died without intervention. The bronchial artery embolisation showed a 79 % success rate and a morbidity of 11 %. Lung resections were performed in 30 cases (morbidity 43 %, mortality 0 %). The mortality directly due to massive hemoptysis was 4.5 %. CONCLUSIONS: Even small hemoptysis can be the warning signal for serious conditions and immediate diagnostic evaluation and therapy, preferentially in an inpatient setting, is often mandatory. A prompt diagnostic bronchoscopy is advocated. The therapeutic method of first choice is non-surgical for the most cases (interventional bronchoscopy, bronchial artery embolisation). Lung resections retain an important role in the management of hemoptysis and are the only available therapy for some diseases. It is advisable to delay surgery until the bleeding is controlled and the patient is stabilised. Best results for managing hemoptysis can be achieved with a multidisciplinary approach (interventional bronchoscopy, angiology and thoracic surgery) in a high expertise centre.

[Mediastinitis: Clinical Presentation and Therapy]. / Mediastinitis: Klinik und Behandlungsoptionen.

Acute infection of the mediastinum remains a condition with high morbidity and lethality rates. The manifestation and course of the illness vary widely depending on the cause of infection. Lack of knowledge or awareness of the illness and mostly unspecific clinical symptoms often delay diagnosis and thereby the start of adequate therapy. Computed tomography (CT) of the neck and thorax is the method of choice for diagnostics and control of therapeutic success. An early diagnosis with immediate surgical debridement and drainage of all infected tissue compartments, as well as strict sepsis therapy, are decisive for the prognosis.

[Lung cancer: is surgery an option for persisting N2 after induction therapy?]. / Lungenkarzinom: Gibt es eine Indikation zur Resektion bei persistierendem N2 nach neoadjuvanter Chemotherapie?

BACKGROUND: Induction chemotherapy followed by surgical resection has been a treatment option for stage IIIA3 N2 non-small cell lung cancer since publication of some small randomised trials during the 1990s. Later on other studies suggested a poor prognosis in cases of persistent N2 disease, so surgical treatment for these patients was not recommended. This study analyses the outcome of patients with persisting N2 disease and tries to identify prognostic parameters within that group of patients. METHODS: We conducted a retrospective cohort study with 50 patients after induction therapy for stage IIIA N2 NSCLC. We analysed the influence of the postoperative lymph node involvement as well as the number of involved lymph nodes on the overall survival. RESULTS: 50 patients with potentially resectable stage IIIA N2 were included in the analysis. In 25 cases (50 %) a persisting N2 remained after induction therapy with cisplatin/gemcitabine, 11 patients had a mediastinal downstaging. 14 patients did not qualify for surgery because of disease progression or comorbidities. The resection consisted in 29 cases of a lobectomy or bilobectomy; two times pneumonectomy was necessary and 4 segmentectomies and one atypical resection were performed. The median survival of patients with persisting N2 (ypN2) was 14.6 months, if mediastinal downstaging was achieved (ypN0/1) it was 22.3 months (p = 0.172). The number of involved mediastinal lymph nodes was a significant prognostic factor. If less than 6 lymph nodes were involved the mean survival was 17.5 months, while it was 8.6 months in patients with more than 6 involved lymph nodes (p < 0.01). CONCLUSIONS: The median survival for patients with persisting N2 disease is less favourable compared to patients with mediastinal downstaging. However, the long-term survival for patients with less than 6 involved lymph nodes is 17.5 months. Therefore surgical resection for these patients seems to be justified. After induction therapy a rigorous restaging should be performed to rule out persisting multilevel N2 disease.

[Postoperative pain in the acute phase after surgery: VATS lobectomy vs. open lung resection - results of a prospective randomised trial]. / Schmerzen in der frühen postoperativen Phase: VATS-Lobektomie vs. offene Lungenresektion - Ergebnisse einer prospektiv-randomisierten Studie.

INTRODUCTION: Minimally invasive procedures, e.g. video-assisted thoracoscopic lobectomy, are less traumatic and thus one may expect a lower level of postoperative pain compared to open procedures. This assumption is supported by several studies/metaanalyses. However, confirmation by larger prospective randomised studies is lacking. In the present study we analysed 2 groups of patients with lobectomy for early-stage lung cancer performed by VATS or by antero-lateral thoracotomy. MATERIAL AND METHODS: 66 patients with early-stage NSC lung cancer were randomised to VATS lobectomy (A) or open resection (B). Two patients from A were excluded. The 2 groups were equally large (n = 32). All patients received the same analgetic therapy regime during and after surgery. We defined the early postoperative period as the first 10 days after operation and evaluated the intensity of pain (assessed by NAS) and the medication. Data acquisition was performed until discharge or the 10th postoperative day. RESULTS: 21 values for mean NAS were calculated for both groups and each situation (at rest or under movement). For 8 a significant difference resulted in favour of VATS. In open thoracotomy the postoperative pain level was acceptable (NAS < 4) due to our well established pain control management. Also, 3 categories of patients with a very low pain profile were defined: patients with NAS not over 4 at any point, patients without any pain (NAS = 0) after a certain point or patients discharged without any pain. The VATS procedure showed a higher proportion of patients in all 3 categories: 17 in A vs. 7 in B had a max. NAS of 4 during the course; 20 vs. 11 were free of pain at certain times and 22 vs. 12 were discharged without pain. For both groups a painless postoperative course was achieved on day 6 (range, 4-10 days for A/3-10 for B). The medication was adjusted according to intensity. A difference was seen in favour of VATS for Sufentanil + Ropivacain via PDK and for Piritramid i. v. CONCLUSIONS: Regardless of procedure (VATS vs. open) pain control can be achieved with an adequate analgetic regime. For VATS during the first days a lower amount of medication is required. The VATS group showed a higher proportion of patients with very low postoperative pain profile: patients with pain score always under 4 and patients without pain at certain points before the 10th postoperative day or at discharge.

Hypertrophic obstructive cardiomyopathy-left ventricular outflow tract shapes and their hemodynamic influences applying CMR.

Hypertrophic cardiomyopathy (HCM) is one of the most common genetic cardiac disorders and is characterized by different phenotypes of left ventricular hypertrophy with and without obstruction. The effects of left ventricular outflow tract (LVOT) obstruction based on different anatomies may be hemodynamically relevant and influence therapeutic decision making. Cardiovascular magnetic resonance (CMR) provides anatomical information. We aimed to identify different shapes of LVOT-obstruction using Cardiovascular Magnetic Resonance (CMR). The study consisted of two parts: An in-vivo experiment for shape analysis and in-vitro part for the assessment of its hemodynamic consequences. In-vivo a 3D depiction of the LVOT was created using a 3D multi-slice reconstruction from 2D-slices (full coverage cine stack with 7 slices and a thickness of 5-6 mm with no gap) in 125 consecutive HOCM patients (age = 64.17 +/- 12.655; female n = 42). In-vitro an analysis of the LVOT regarding shape and flow behavior was conducted. For this purpose, 2D and 4D measurements were performed on 3D printed phantoms which were based on the anatomical characteristics of the in-vivo study, retrospectively. The in-vivo study identified three main shapes named K- (28.8%), X- (51.2%) and V-shape (10.4%) and a mixed one (9.6%). By analyzing the in-vitro flow measurements every shape showed an individual flow profile in relation to the maximum velocity in cm/s. Here, the V-shape showed the highest value of velocity (max. 138.87 cm/s). The X-shape was characterized by a similar profile but with lower velocity values (max. 125.39 cm/s), whereas the K-shape had an increase of the velocity without decrease (max. 137.11 cm/s). For the first time three different shapes of LVOT-obstruction could be identified. These variants seem to affect the hemodynamics in HOCM.

[The use of Deep Inferior Epigastric Vessels to Revascularise Free Flaps for Reconstruction of Complex Oncosurgical Defects of the Thigh and the Abdomen]. / Epifaszial verlagerte tiefe inferiore epigastrische Gefäße als Anschlussgefäße für die mikrochirurgische Rekonstruktion komplexer onkochirurgischer Defekte des Abdomens und des Oberschenkels.

BACKGROUND: The resection of large soft-tissue sarcoma requires reconstruction with free flaps. The choice of recipient vessels is crucial for the success of surgery. PATIENTS: We report four cases with large soft-tissue sarcomas with complex anatomical relationships: two tumors of the thigh surrounding the femoral neurovascular structures and two tumors of the abdomen with infiltration of the thorax and the abdomen. All cases received multimodal interdisciplinary treatment. The anterolateral thigh (ALT) flap and the latissimus dorsi (LD) flap were employed twice for defect coverage in this series. In all cases the deep inferior epigastric (DIE) vessels were transposed to the subcutaneous compartment and used as recipient vessels. RESULTS: The mean duration of surgery was 694 ±â€…149 minutes. The mean weight of the tumor specimen was 3069 ±â€…1267 g. Three flaps healed primarily and one exhibited a minor necrosis, which was treated by excision and secondary suture. There were no cases of abdominal herniation due to the transposition of vessels. CONCLUSION: Transposition of DIE-vessels to the subcutaneus compartment is a good alternative for free flap revascularisation in this patient group. In this position, the vessels are easily accessed and used for microsurgery. This technical modification increases the reconstructive possibilities in large and previously irradiated surgical defects.

[Perioperative management of antiplatelet therapy in thoracic surgery. A survey of German hospitals]. / Perioperative Thrombozytenaggregationshemmmung in der Thoraxchirurgie. Eine Umfrage an deutschen Kliniken.

BACKGROUND: The common practice to stop therapy with acetylsalicylic acid (aspirin) and/or clopidogrel perioperatively is critically discussed in the literature. There are no generally accepted guidelines for the handling of this problem. In this article the present strategy of perioperative antiplatelet therapy applied in German thoracic surgery departments was investigated. METHODS: Questionnaires were sent to the heads of thoracic surgery departments registered in the German Society of Thoracic Surgery (n = 133) inquiring about the handling of aspirin and clopidogrel before elective thoracic surgical procedures. The return ratio was 59% (n = 78). RESULTS: The analysis of the survey results showed a heterogeneous approach. Of the respondents 51-53% reported stopping aspirin therapy before surgery if the patient was taking aspirin due to a bare metal stent (implantation 3 months before). An even larger number of respondents stopped aspirin therapy before surgery if the patient was taking aspirin due to an ischemic insult or due to peripheral arterial disease with infrainguinal stenting (59-63% and 59-65%, respectively). In the case of drug-eluting stent implantation (implantation 3 months before) 34-41% of the respondents completely stopped the dual antiplatelet therapy before surgery and only 6-8% of the surgeons proceeded with surgery under dual platelet inhibition. Of the thoracic surgeons questioned 28% considered the existing data sufficient to manage this problem. Those surgeons who considered the existing data concerning the management of perioperative antiplatelet therapy as adequate had a stronger tendency to continue the antiplatelet therapy perioperatively. The aspirin and clopidogrel therapy was usually stopped 5-7 days preoperatively. CONCLUSIONS: The survey showed that in Germany the majority of thoracic surgeons reduce or stop antiplatelet therapy (given as secondary prophylaxis) before surgical procedures. It can be assumed that patients are therefore exposed to an increased risk of cardiovascular morbidity and mortality.

Developing and communicating a long-term treatment plan for asthma.

The treatment of asthma, according to current guidelines, requires complex treatment regimens that change as clinical conditions improve or deteriorate. We have developed a practical way to communicate long-term treatment plans in chart form in the primary care setting that is easy for patients to follow and use. The chart has been an important element in two interventions that have resulted in positive changes in health behavior and health outcomes in children with asthma. The plan provides recommendations for patients and families to make adjustments in medication based on changes in symptoms or peak expiratory air flow, or both, that are consistent with the Asthma Guidelines Expert Panel Report 2, 1997. The plan also indicates when the number and dosage of drugs should be increased or decreased and when emergency care should be sought, consistent with the Asthma Guidelines. By placing considerable control in the family's hands and by clearly delineating the conditions under which medicines can be reduced or discontinued, the physician provides incentives for families to adhere to the long-term treatment plan for asthma.

Improving care for minority children with asthma: professional education in public health clinics.

OBJECTIVE: Recent studies have shown that lack of continuing primary care for asthma is associated with increased levels of morbidity in low-income minority children. Although effective preventive therapy is available, many African-American and Latino children receive episodic treatment for asthma that does not follow current guidelines for care. To see if access, continuity, and quality of care could be improved in pediatric clinics serving low-income children in New York City, we trained staff in New York City Bureau of Child Health clinics to provide continuing, preventive care for asthma. METHODS: We evaluated the impact of the intervention over a 2-year period in a controlled study of 22 clinics. Training for intervention clinic staff was based on National Asthma Education and Prevention Program guidelines for the diagnosis and management of asthma, and included screening to identify new cases and health education to improve family management. The intervention included strong administrative support by the Bureau of Child Health to promote staff behavior change. We hypothesized that after the intervention, clinics that received the intervention would, compared with control clinics, have increased numbers of children with asthma receiving continuing care in the clinics and increased staff use of new pharmacologic and educational treatment methods. RESULTS: In both the first and second follow-up years, the intervention clinics had greater positive changes than control clinics on measures of access, continuity, and quality of care. For second year follow-up data these include: for access, greater rate of new asthma patients (40/1000 vs 16/1000; P < .01); for continuity, greater percentage of asthma patients returning for treatment 2 years in a row (42% vs 12%; P < .001) and greater annual frequency of scheduled visits for asthma per patient (1.85 vs .88; P < .001); and for quality, greater percentage of patients receiving inhaled beta agonists (52% vs 15%; P < .001) and inhaled antiinflammatory drugs (25% vs 2%; P < .001), and greater percentages of parents who reported receiving patient education on 12 topics from Bureau of Child Health physicians (71% vs 58%; P < .01) and nurses (61% vs 44%; P < .05). CONCLUSION: We conclude that the intervention substantially increased the Bureau of Child Health staff's ability to identify children with asthma, involve them in continuing care, and provide them with state-of-the-art care for asthma.