[Comprehensive Preoperative Evaluation of Patients with Lung Cancer]. / Umfassende präoperative Evaluation von Patienten mit Lungenkrebs.

Surgical resection continues to be a mainstay of curative treatment of patients with non-small cell lung cancers stages I - III and some small cell lung cancers. Reported rates of complications and mortality vary considerably. Therefore, a thorough and comprehensive preoperative evaluation of lung cancer patients is crucial in order to select appropriate surgical candidates and to determine their individual risk, including the extent of resection possible. Following available data and guidelines, such evaluation should include: ECOG-scoring, cardiac risk assessment, cerebrovascular assessment, pulmonary risk assessment, including split function analysis, and additional initiation or adjustment of treatment where appropriate; in patients aged ≥ 70 years: functional scoring (IADL). Risk stratification results in three groups: patients at low risk for complications and mortality, patients at increased risk, and patients who usually are not candidates for surgical resection. Finally, in order to support autonomous decisions of patients on optimal treatment based on defined risks, physicians must be familiar with values and preferences of patients as well as their familial and social situation.

[Application of artificial intelligence in thoracic surgery]. / Einsatz künstlicher Intelligenz in der Thoraxchirurgie.

BACKGROUND: The application of artificial intelligence is a relatively new option to enable improved patient treatment in modern medicine and is therefore currently the focus of many research projects. In the clinical practice the application of artificial intelligence so far seems to be confined to the analysis of medical imaging. OBJECTIVE: In which form is the use of artificial intelligence possible in routine daily work in thoracic surgery and is already being practiced? MATERIAL AND METHODS: A search of the currently available literature was performed. RESULTS: Under current conditions artificial intelligence can best be used as part of diagnostics and treatment planning; however, in order to enable a comprehensive use standardization and evaluation of the centralized data collection are necessary. CONCLUSION: At the present time promising study results are available but the implementation into the surgical routine has so far been very difficult.

[Comprehensive Preoperative Evaluation of Patients with Lung Cancer]. / Umfassende präoperative Evaluation von Patienten mit Lungenkrebs.

Surgical resection continues to be a mainstay of curative treatment of patients with non-small cell lung cancers stages I - III and some small cell lung cancers. Reported rates of complications and mortality vary considerably. Therefore, a thorough and comprehensive preoperative evaluation of lung cancer patients is crucial in order to select appropriate surgical candidates and to determine their individual risk, including the extent of resection possible. Following available data and guidelines, such evaluation should include: ECOG-scoring, cardiac risk assessment, cerebrovascular assessment, pulmonary risk assessment, including split function analysis, and additional initiation or adjustment of treatment where appropriate; in patients aged ≥ 70 years: functional scoring (IADL).Risk stratification results in three groups: patients at low risk for complications and mortality, patients at increased risk, and patients who usually are not candidates for surgical resection.Finally, in order to support autonomous decisions of patients on optimal treatment based on defined risks, physicians must be familiar with values and preferences of patients as well as their familial and social situation.

[Lobectomy of Right Lower Lobe Eight Years after Foreign Body Aspiration]. / Unterlappenektomie acht Jahre nach Aspiration einer Pinnnadel.

A young man presented with haemoptysis, eight years after foreign body aspiration. The initial evaluation took place in the emergency department of a general hospital. However, neither chest x-ray nor bronchoscopy were performed. Bronchoscopy performed in our hospital revealed a foreign body in right lower lobe bronchus. Extraction failed because it was embedded in granulation tissue. The chronic atelectasis of right lower lobe and recurrent bronchopulmonary infections during the last years were the indication for lobectomy.

Video-Assisted Thoracoscopic Surgery of Parapneumonic Empyema - a 10-year Single-Centre Experience.

OBJECTIVES: Evaluation of a standardised management for the treatment of patients with parapneumonic empyema. METHODS: A retrospective 10-year single-centre analysis of all patients with parapneumonic empyema undergoing a standardised thoracoscopic treatment approach. We describe referral and age patterns, microbiological results, overall and stage-dependent success rates, conversion rates, 30-day and in-hospital mortality. RESULTS: From May 2003 to April 2013, 248 patients with parapneumonic empyemas were treated in our centre. Most patients were referred at weekends, and younger patients had advanced stages. The cure rate in stage I was 97.6 % and reached 80.3 % in stage II and 63.1 % in stage III. 6 patients (2.4 %) (all stage III) needed conversion to an open procedure. A revision was required in 19.7 % of cases in stage II and 27.7 % in stage III. 30-day mortality was 4.8 %, in-hospital mortality was 8.1 %. CONCLUSION: A standardised approach, including VATS, is associated with a high cure, low revision and moderate conversion rates. In view of a still considerable mortality, a higher index of suspicion and detection of advanced stages, especially in younger patients, is required to improve outcomes.

Severe Complications of Ultrasound Guided Transbronchial Needle Aspiration--A Case Series and Review of the Literature.

Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) has become essential for the workup of patients with lung cancer and other pulmonary diseases. The emphasis of currently available literature is related to the diagnostic yield of EBUS-TBNA which was found to be high. Complications seem to be rare but such data are scant. We report three cases of complications including mediastinitis, pneumothorax and bleeding and provide a review on the existing literature.

A comparison of percutaneous dilatational tracheostomy versus conventional surgical tracheostomy.

BACKGROUND: Percutaneous dilatational tracheostomy (PDT) and surgical tracheostomy (ST) are widely accepted techniques and frequently performed in clinical practice. We compared PDT with ST tracheostomies in view of the benefits and drawbacks, time of duration, indication and complication rate of the respective procedures. METHODS: The evaluation was based on data from 378 tracheostomies. 209 of these tracheostomies were performed at bedside as PDT in the intensive care unit. These were compared to 169 ST tracheostomies performed in the operating room. All interventions were performed by the same team of surgeons or intensivists, however, at different training levels. RESULTS: The mean duration of the operation was shorter for PDT than for ST (18.2 ± 10 min versus 38.2 ± 14.2 min, p = < 0.001). The PDT was a simpler procedure and performed predominantly by physicians in postgraduate training. The rate of complications was low in both groups (8.6 % PDT, 8.3 % ST, p = 0.909). CONCLUSION: Although both interventions are safe and achieve comparable results, PDT can be applied in a shorter time. PDT is easier to perform and seems particularly suitable for physicians in postgraduate training.

[Pleural empyema - treatment strategies in light of etiology]. / Pleuraempyem - Behandlungsstrategien unter Berücksichtigung der Ätiologie.

The variety of strategies in the treatment of parapneumonic pleural empyema demonstrates the ambiguity for the method of choice. Parapneumonic pleural empyema has been classified into different stages and classes. While the American Thoracic Society (ATS) classification is based on the natural course of the disease, or according to the radiological, physical and biochemical characteristics respectively, the American College of Chest Physicians (ACCP) has categorized the patients with pleural empyema according to the risk of a poor outcome. The British Thoracic Society (BTS) developed a treatment algorithm based on a systematic review of peer-reviewed literature. With regard to this classification the management of parapneumonic and postoperative pleural empyema is based on the stage of the disease. Therapeutic strategies include chest tube alone, chest tube with fibrinolysis, thoracoscopic debridement and decortication in open or minimally invasive techniques, closed empyemectomy, or treatment with thoracomyoplasty, open window treatment or vacuum clothing with negative pressure. The different conservative and operative therapeutic possibilities determinate the central treatment function of thoracic surgery.

Tracheal perforation by an oesophageal stent.

In a 63 year-old female patient with oesophageal carcinoma a tracheal perforation by an oesophageal stent was diagnosed. A first attempt of tracheal stenting was not successful due to spontaneous dislocation of the stent. Therefore, a shorter stent was chosen and correctly placed in a second session. This case report on an oesophagotracheal fistula provides a summary of this complication in advanced oesophageal cancer.

[Pleural empyema and lung abscess: current treatment options]. / Pleuraempyem und Lungenabszess: Aktuelle Therapiekonzepte.

Parapneumonic pleural empyema has been classified into different stages and classes. While the American Thoracic Society (ATS) classification is based on the natural course of the disease, Light has classified pleural empyema according to the radiological, physical and biochemical characteristics, and the American College of Chest Physician (ACCP) has categorised the patients with pleural empyema according to the risk of a poor outcome. According to this classification the management of the pleural empyema is based on the stage of the disease. Therapeutic strategies include chest tube, chest tube with fibrinolysis, thoracoscopic debridement and decortication in open or minimally invasive techniques. Primary lung abscesses develop in previously healthy lung parenchyma and are caused by aspiration. In addition, abscess formation can occur without aspiration, and important differences relate to community-acquired, nosocomial abscesses and those in the immunosuppressed host. 90 % of all lung abscesses can be cured with antibiotic treatment alone, 10 % have to be treated with an interventional catheter or chest tubes and only 1 % require thoracic surgery because of complications independent of the former conservative or interventional treatment strategies.

Diagnosis of peripheral lung lesions by EBUS-guided TBB in routine practice.

OBJECTIVE: To determine the diagnostic yield of EBUS guided TBB performed in routine practice with flexible bronchoscopy and under moderate sedation in ambulatory and hospitalized patients. METHODS: Bronchoscopy was performed under standard conditions in ambulatory and hospitalised patients. Bronchoscopically invisible peripheral pulmonary lesions were located with 20 MHZ-EBUS-probe and transbronchial biopsy was taken using a guiding sheath. Fluoroscopy was additionally performed as required to identify the lesion. RESULTS: 257 patients with peripheral pulmonal lesions were investigated, with malignancy in 70% of those with a diagnosis established. 175/257 (68.1%) of lesions were detected with EBUS. In 139/176 (79.4%) of these lesions, TBB enabled a final diagnosis. The TBB yield depended on lesion size. It was 61.3% in lesions ≤20 mm, 85.5% >20 mm/≤30 mm, and 81.2% in ≥30 mm (p<0.0001). This yield was also affected by the position of the probe (centrally 84.5%, tangentially 57.6%, p=0.01)). Operator experience did not influence the diagnostic yield but considerably shortened investigation time (4.9±3.5 vs. 6.2±4.2 min, p=0.042). Relevant complications occurred in only 1.9% (3 cases of postinterventional pneumothorax). CONCLUSIONS: In an unselected population, EBUS-guided TBB has a high diagnostic yield in peripheral lesions >20 mm whereas its yield decreases considerably in smaller lesions. Complications are very rare. EBUS-guided TBB can successfully and safely be performed by flexible bronchoscopy.

[Successful risk management in flexible bronchoscopy]. / Erfolgreiches Risikomanagement bei der flexiblen Bronchoskopie.

Flexible bronchoscopy is one of the most important diagnostic procedures in respiratory medicine. The investigator operates in a vital organ and therefore must face a broad range of potential complications. This article provides an overview of all important complications associated with flexible bronchoscopy. It is further discussed how this risk can be minimized. A skillfull team, close monitoring and readily available resuscitation facilities are mandatory to avoid and to deal with major complications.

[Video-assisted thoracoscopic surgery (VATS) for the management of parapneumonic pleural empyema]. / Videoassistierte thorakoskopische Chirurgie (VATS) zur Behandlung des parapneumonischen Pleuraempyem.

Parapneumonic pleural empyema has been classified by international societies and by pleural diseases experts into different stages and classes. While the American Thoracic Society (ATS) classification is based on the natural course of the disease, Light has classified pleural empyema according to radiological, physical and biochemical characteristics, and the American College of Chest Physicians (ACCP) has categorised patients with pleural empyema according to the risk of a poor outcome. According to these classifications, the management of the pleural empyema is based on the stage of the disease. The recommended treatment options in (ATS) stage I disease (Light classes I-III, ACCP categories I and II) are therapeutic thoracentesis or tube thoracostomy and antibiotics when necessary. In (ATS) stage II disease (Light classes IV-VI, ACCP category III), thoracoscopy (VATS) is the treatment of choice because it has a higher efficacy than treatment strategies that utilise tube thoracostomy or catheter-directed fibrinolytic therapy alone, whereas in (ATS) stage III disease (Light class VII, ACCP category IV), decortication via thoracoscopy or thoracotomy is the treatment of choice.

[Granular cell tumour in a patient with pulmonary tuberculosis]. / Granularzelltumor der Trachea bei einer Patientin mit offener pulmonaler Tuberkulose.

Primary tracheal tumours are rare and often only cause symptoms at a late stage, when the tumour obstructs most of the tracheal lumen. We report the case of a 45-year-old woman with pulmonary tuberculosis and a tumour in the trachea, which had been interpreted as a tuberculous lymph node perforating the tracheal wall. Bronchoscopy revealed a white, glossy, papillomatous lesion in the ventral wall of the trachea, which was identified by histology as a granular cell tumour. After culture conversion of the underlying tuberculosis, which led to the detection of the lesion, the tumour was surgically removed. Granular cell tumours rarely appear in the trachea, they may be multifocal and sometimes follow a malignant course. Complete resection is the treatment of choice and recurrence rates are low.

[Peripheral neuropathic pain relieved by somatosensory rehabilitation]. / Diminution des douteurs neuropathiques périphériques par la rééducation sensitive.

The femoral neuralgia is a rather frequent and invalidating clinical disorder. It takes on many clinical forms because of the anatomical variations of the cutaneous branches of saphenous and femoral nerves. The neuroplasticity of the somato-sensory system has now been determined which allows for a better understanding of the techniques of somatosensory rehabilitation. The authors precisely explain the various stages necessary in the care of patients suffering from femoral neuralgia. The various strategies of somatosensory rehabilitation are mentioned. The authors also present a brief review of the pharmacological treatments of peripheral neuropathic pain. Lastly, the result of the somatosensory rehabilitation of femoral neuralgia (NNT = 1.8) is documented on the basis of a prospective study done on 59 patients.

12-O-retinoylphorbol-13-acetate (RPA) behaves like a retinoid-derivative in binding to retinol-binding-protein: a correlation with its specific action as an incomplete tumor promoter?

12-O-retinoylphorbol-13-acetate (RPA), an incomplete tumor promoter of the phorbol ester type and protein kinase C (PKC) activator, consists of two characteristic structural elements: the phorbol body and the retinoyl ester chain. Therefore, possible binding of the incomplete tumor promoter RPA to the human transport protein retinol-binding-protein (RBP) has been examined by molecular modeling methods and experimental binding studies. The calculated prediction of binding properties was primarily based on a comparative geometrical approach. It was shown that the beta-ionone-ring of RPA was not altered within the binding pocket of RBP (molecular modeling) compared to retinoic acid (X-ray crystallographic data). The torsion angle C5'-C6'-C7'-C8', determining the conformation of the RBP-beta-ionone-ring relative to the isoprene tail, is rotated by 42 degrees for RPA compared to retinol and to retinoic acid, respectively. Combining all the results from force field calculations, MD simulations and geometrical comparisons, the conclusion could be drawn that RPA should be able to bind to RBP. This interaction should be less strong than that with its natural ligand retinol or with retinoic acid. This prediction was proven experimentally. RPA was able to compete with retinoic acid for binding at RBP in human plasma. The binding properties were investigated using 3H-labeled retinoic acid in homologous and heterologous competition studies in a one-dimensional native polyacrylamide gel electrophoresis system. An approximately 2000-fold weaker binding of RPA to RBP as compared to retinoic acid was determined experimentally, confirming the prediction of the molecular modeling approach. The characteristic behaviour of RPA as an incomplete promoter, due to possible binding to PKC and RBP, is discussed.

[Thymus lipoma. A rare entity of the thymus. Case report with special consideration of diagnostic imaging]. / Thymolipom. Eine seltene thymogene Tumorentität. Fallbericht unter besonderer Berücksichtigung der bildgebenden Diagnostik.

This report is on a 37-year-old female patient with an extraordinary large intrapleural tumor on the left, macroscopically originating from mediastinal structures. The tumor was completely removed via transpleural approach without compromising the left lung. It was identified as a thymolipoma with a weight of 2400 g.