Broncho-pleural fistula following vacuum-assisted closure therapy.

We report a case of bronchopleural-cutaneous fistula following long-term vacuum-assisted closure therapy to manage a sternal dehiscence after coronary artery bypass surgery.

Recombinant activated factor VII administration after pulmonary embolectomy: case report.

Bleeding management in cardiac surgery could be a great challenge for the surgeon and a life-threatening moment for the patient. Despite the fact that recombinant activated factor VII is now widely accepted as a useful adjunct in the management of postcardiotomy coagulopathy, its use in the course of recent thromboembolic event is rarely described. We hereby present a case of rescue recombinant activated factor VII administration to manage a severe coagulation disorder during surgical pulmonary embolectomy performed under cardiopulmonary bypass.

TLR2 in pleural fluid is modulated by talc particles during pleurodesis.

The aim of this study was to examine the role of TLR2 molecule in pleural space during thoracoscopic talc pleurodesis period in patients with malignant pleural effusion. We analyzed TLR2 molecule in soluble form as well as on membrane of granulocytes in pleural fluid. Pleural fluid examination was done at three intervals during pleurodesis procedure: 1st-before the thoracoscopic procedure, 2nd-2 hours after the terminating thoracoscopic procedure with talc insufflation, 3rd-24 hours after the thoracoscopic procedure. We reported significant increase of soluble TLR2 molecule in pleural fluid effusion during talc pleurodesis from preoperative value. This increase was approximately 8-fold in the interval of 24 hours. The changes on granulocyte population were quite different. The mean fluorescent intensity of membrane TLR2 molecule examined by flow cytometry on granulocyte population significantly decreased after talc exposure with comparison to prethoracoscopic density. To estimate the prognostic value of TLR2 expression in pleural fluid patients were retrospectively classified into either prognostically favourable or unfavourable groups. Our results proved that patients with favourable prognosis had more than 3-fold higher soluble TLR2 level in pleural fluid early, 2 hours after talc pleurodesis intervention.

Comparison of Efficacy and Safety of Non-Regenerated and Regenerated Oxidized Cellulose Based Fibrous Haemostats.

PURPOSE: Various forms of local haemostats are increasingly used routinely in surgical procedures. Our work is the first comparison of the efficacy and safety of non-regenerated and regenerated oxidized cellulose based fibrous haemostats. METHODS: The haemostatic efficacy and safety of fibrous haemostats based on ONRC and ORC were compared in a randomized multicenter study. The primary endpoint was successful haemostasis within 3 minutes of application and no need for surgical revision within 12 hours after the procedure for recurrent bleeding. RESULTS: There was a significant difference in the rate of successful haemostasis in 3 minutes that was achieved in 82% and 55% in the ONRC and ORC groups, respectively (confidence interval 99%; p = 0.009). Mean time to haemostasis was 133.9 ± 53.95 seconds and 178.0 ± 82.33 seconds, in the ONRC, and ORC group, respectively (p = 0.002). Revision surgery for re-bleeding was necessary in 0 (0%), and 1 (2%) of patients in the ONRC, and ORC group, respectively. No adverse events were reported. CONCLUSION: Fibrous haemostat based on ONRC was non-inferior compared to fibrous haemostat based on ORC when used in accordance with its intended purpose, and was safe and efficient.

Controlled hemostasis in thoracic surgery using drugs with oxidized cellulose.

The authors demonstrate the possibility of improving surgical results by the reduction of perioperative bleeding in thoracic surgery associated with extended resection procedures. We focused on patients in whom the expected perioperative blood loss was greater than 500 ml. The first group consisted of patients with lung cancer stage III A after neoadjuvant chemotherapy had been indicated to extend the resection procedure. The second group consisted of patients with chest wall and mediastinum tumors of various etiologies. The third group consisted of patients with post-inflammatory thoracic complications in whom combined decortication and pleurectomy was necessary. By the using the local hemostyptic Traumastem TAF on the basis of oxidized cellulose, it is possible to minimize the perioperative blood loss, thus sparing the blood derivative requirement and enabling surgeons to provide the desired treatment even to high-risk patients.

Chylothorax--a rare complication after cardiac surgery (a case report).

Chylothorax is a rare but severe complication of cardiac surgery. The authors present the case of a 76-year-old woman suffering from ischemic heart disease, after coronary artery bypass grafting that included a left internal mammary artery pedicle graft. On the ninth postoperative day the left-sided fluidothorax developed. The results of biochemical analysis were consistent with the chyle. Combined treatment with pleural drainage and total parenteral nutrition was effective.

CT-guided biopsy of the mediastinal masses. Can anatomical relationships predict complications?

AIM: To retrospectively evaluate the technical features, feasibility, efficacy, accuracy and appropriate complications of CT-guided biopsies of mediastinal masses and correlate them with anatomical relationships in the mediastinum. METHODS: Over the course of ten years, 81 percutaneous biopsy procedures in 78 patients for tumors sizes 27 - 189 mm in diameter (median length 57.5 mm) were performed using only local anesthesia. These interventions were done under the guidance of computed tomography. The patients were men in 30 cases and women in 48 cases, aged 19 to 90 years. RESULTS: In 78 cases (96.3%) results were either true positive or true negative; in only 3 cases (3.7%, 3 biopsies of 2 tumors in 2 patients) were histological findings false negative. In 2.3% of the patients, complications were revealed in the anterior part of the mediastinum, 43.7% occurred in the middle region, and 14.3% in the posterior region of the mediastinum. Statistical data analysis verified there was a 3.74 times chance of an increase in complications in the middle mediastinal section in correlation with other anatomical localizations. In only one case was therapeutic intervention for complication necessary. For all other cases, a conservative approach was suitable. CONCLUSION: Percutaneous CT guided biopsies of the mediastinal tumors has a high accuracy rate in establishing the correct diagnosis. Masses in the middle mediastinum are associated with statistically higher incidences of postprocedural complications, which are not serious.

Deceleration thoracic aortic ruptures in trauma center level I areas: a 6-year retrospective study.

OBJECTIVES: This retrospective study aimed to analyze the trend of mortality due to thoracic aortic ruptures caused by deceleration injuries that occurred within the catchment area of Hradec Kralove University Hospital. MATERIALS AND METHODS: The study sample comprised 175 patients who had sustained thoracic aortic ruptures caused by deceleration injuries and were transported to Hradec Kralove University Hospital in 2009-2014. The small proportion of patients enrolled in this retrospective study were diagnosed and treated at the emergency department (ED). However, the overwhelming majority of the sample comprised of patients who died at the accident scene and later underwent an autopsy at the Institute of Forensic Medicine in our hospital. RESULTS: Of 175 patients, 150 underwent an autopsy. Of these, 139 individuals (79%) died at the incident scene, and 11 (6%) were transported to the ED and later died of their injuries. A total of 36 patients were admitted to the hospital; 29 were admitted primary (11 later died), and 7 were transferred. No deaths occurred in the group of secondary admissions. Thus, 31% of all patients hospitalized died following transport to the hospital. Of 175 patients, 15% (or 69% of all hospitalized patients) survived their injuries. Among patients who died as a result of thoracic aortic injury, no unexpected deaths were recorded (i.e., no deaths among patients with survival probability more than 50% = PS > 0.5). CONCLUSION: Our results suggested that the lethality of thoracic aortic injuries might be minimized by transporting triage-positive patients directly to trauma centers. Accurate diagnoses and treatments were supported by admission chest X-rays, a massive transfusion protocol, and particularly, CT angiography, which is not routinely included in primary surveys. An additional prognostic parameter was clinical collaboration between an experienced trauma surgeon, an interventional radiologist, and a vascular or thoracic surgeon.

Possibilities of combined surgical treatment of lung tumours and heart diseases.

The purpose of the study was a retrospective evaluation of the outcome of surgical therapy of lung cancer in patients where there was concomitant cardiac disease and who underwent a cardiac operation either because of ischemic heart disease or because of valvular disease. These patients were operated on at various time intervals (two to ten months) after their cardiac operation. Some patients had their lung cancer surgery after the cardiac operation because of the high risk of possible cardiac postoperative complications; in one patient the lung operation preceded the cardiac one.

Case: unusual migration of osteosynthetic material.

The authors present a rare and unusual case of complication, migration of osteosynthetic material for stabilization, titanium rod, which was used for stabilization of comminutive fracture of the first lumbar vertebra. This rod migrated from the retroperitoneal space to the pleural cavity. The removal of this rod was carried out by videothoracoscopy.

Predictive value of systemic and local inflammation parameters in talc pleurodesis assessment.

BACKGROUND: One option for the palliative treatment of recurrent malignant pleural effusion is powdered talc using thoracoscopy. This paper presents the results of selected systemic and local manifestations of the talc-induced inflammatory reaction using a videothoracoscope. METHOD: A total of 114 patients with repeated malignant pleural effusion were treated at the Cardiac Surgery Clinic in Hradec Kralove from January 2010 to December 2012. Those with a life expectancy more than ≥ 3 months were eligible for talcage surgery. The group was retrospectively divided according to treatment results into Group A (N1 = 98 - successful) and Group B (N2 = 16 - relapsing). The pleural effusion was quantified using ultrasound over 1 year at 3-month intervals. Systemic changes due to the inflammatory reaction (body temperature, serum leukocyte and CRP levels) were evaluated. Local indicators of inflammation included changes in the leukocyte cell population in the effusion and changes in the pleural CRP levels. The dynamics of local expression of membrane receptors TLR-2 and CD-64 on granulocyte and monocyte cell populations in the pleural effusion were also evaluated. RESULTS: The reaction after talcage, included a significant increase in axillary temperature and leukocyte count, 12 h after the procedure. The dynamics were different in the two groups. The dynamics of local inflammatory changes were an early increase in the pleural CRP levels in both groups. The time interval of local inflammatory development and duration was related to the treatment efficacy and showed a significant rise 2 h after talcage in Group A. In Group B the local inflammatory reaction was slower and the rise was only observed 24 h after talc application. A decrease in lymphocyte count and an increase in granulocyte count 2 h after talcage were found. After an initial drop in monocyte level, a rise occurred within 24 h after talcage. Changes in the expression of TLR-2 and CD-64 receptors in relation to their cell carriers were observed depending on time after talcage. CONCLUSION: The differences in the serum and pleural effusion CRP levels suggest that the surgical stress manifests itself locally in the pleural space with a lower intensity and time delay. The TLR-2 and CD-64 receptors exhibit different behaviour depending on the type of cell membrane where they are found. The inverse relation between the granulocyte increase and TLR-2 receptor decrease in the membrane immediately after talcage is a new finding. The dynamics of TLR-2 expression on the monocytes demonstrates a direct proportion between the increasing expression of the TLR-2 receptor and increasing percent fraction of the cell carrier.

New biomarkers in the selection of patients for talcage of pleural cavity in the palliative therapy of malign pleural exudate.

BACKGROUND: Chemical pleurodesis using videothoracoscopically applied powdered talc under general anaesthesia and selective pulmonary ventilation is the most effective method of palliative therapy for malign pleural exudate. Talc produces an intense systemic inflammatory reaction with the development of aseptic pleurisy. The result is obliteration of the pleural cavity provided there is an intense inflammatory reaction in the pleural cavity and good contact of both pleural leaves. The course of the adherence of pleural leaves can be followed using skiascopy. In routine practice, the course of local inflammatory markers is difficult to evaluate. Selection of suitable patients who will respond to this procedure is another principal obstacle of this surgical method. AIM: To evaluate the course of local inflammatory changes in the pleural cavity following application of talc and to quantify their dynamics. Selection of specific biomarkers to predict the intensity of inflammation in the pleural exudate for targeted selection of patients suitable for talcage was the second aim of this study. MATERIALS AND METHODS: 114 patients were retrospectively divided into Group A (N1 = 98) or patients without relapse and Group B (N2 = 16), patients with relapse of exudate formation. The need for repeated thoracic punctures or drainage over the course of a 12-month monitoring period was a criterion of treatment failure. Quantification of the effusion was performed by ultrasonic examination over a one year observational period at 3-monthly intervals. The concentration of soluble CD163 scavenger receptor and soluble Apo/Fas molecule was determined in exudate by ELISA. RESULTS: Soluble receptors in the 2 groups differed significantly. Group B showed higher sCD163 levels before talcage (P0 = 0.00024), faster dynamic decline in 2 h (P2 = 0.0092) and in 24 h (P24 = 0.0087). During monitoring, decrease in group B was statistically significant at 2 h (P2 = 0.056) and at 24 hrs (P24 = 0.0066). CONCLUSION: This pilot study showed that high values of sCD163 and sApo/Fas in the pleural exudate can predict treatment failure. Unsuitable candidates for this type of therapy couldbe selected in this way.

[Surgical treatment of pneumothorax]. / Chirurgická lécba pneumotoraxu.

Complex therapy of pneumothorax is a multidisciplinary task. The point is: the etiology of pneumothorax is different but the resulting risk for the patient is always the same. Therefore, there is necessity of cooperation of several medical branches in causal therapy. The authors present experience with pneumothorax therapy in Cardiosurgical Department in 5-year interval in 101 patients, where they carried out surgical as well as conservative therapy approaches.

[Extended lung resection]. / Rozsírené plicní resekce.

The history of surgical therapy for lung cancer has been dated since the beginning of the last century. There is a long experience of this type of surgical procedure in our cardiosurgical department. In our study there are included extended lung resections. The evaluation of these procedures is based on TNM classification. Extended resections are reserved for those in stage III. The diagnostic capabilities are improving and therefore there are more patients with more favourable stage and on the other hand there are smaller number of extensive operations. We carry out extended lung resections where we expect benefit for these patients. This is also backed up and influenced by improved postoperative care. In our paper there are patients operated in 1997-2002, which were in stage III. 30 days postoperative letality in this small group was 6%. It is certainly higher then in simple resections (0,5%). On the other hand we have to offer surgical treatement when it is feasible, despite of higher risk. Therefore we cannot expect the same results as in the group of patients operated in stage I and II.

[The two-stage surgical stabilization of the chest wall trauma with respiratory insufficiency -- a case report]. / Dvoudobá chirurgická stabilizace hrudní steny pro dechovou nedostatecnost -- kasuistika.

In this report there is described the case of 48-years-old women with nonpenetration chest trauma with respiratory insufficiency. The surgical strategy consisted of two-stage repair of surgical stabilization of the chest wall.

[Bronchopleural fistula after pneumonectomy]. / Bronchopleurální pístel po pneumonektomii.

We retrospectively reviewed the incidence of bronchopleural fistula after pneumonectomy. The records of 844 consecutive patients who underwent pneumonectomy within a period between the January 1962 and December 2000 either for the lung cancer or for benign diseases have been assessed. There were 12 cases of bronchopleural fistula representing an incidence of 1.42 %. All operations were performed using an uniform hand suture technique. Eight fistulas developed in patients who underwent pneumonectomy for lung cancer while four occurred in patients with benign diseases. Bronchial dehiscence was confirmed by bronchography or bronchoscopy in each patient. Resuturing of the stump and single completed muscle flap closure was performed in five patients. In three patients with very small fistulas we used the drainage of the pleural cavity and antibiotics only. Three other patients were treated by thoracoplasty. In one patient bronchoscopy closure by tissue adhesive and bone graft was done. The treatment was successful in nine patients from our set while the other three developed fatal complications.

[Diagnosis and surgical treatment of bronchial carcinoid]. / Diagnostika a chirurgická lécba bronchiálního karcinoidu.

The purpose of this study was to look at the clinical behaviour of bronchial carcinoids and clarify a surgical approach. Over 30 years 61 patients with a final histological diagnosis of carcinoid tumours were assessed for surgery. All patients were retrospectively reviewed for clinicopathological variables, surgical management and outcome. Tumours were considered typical and atypical based on histological features. The mean age at presentation was 46 years (range 11-69). Overall survival in the group of typical carcinoids was 96%, and 67% in the group of atypical carcinoids.

The dynamics of selected local inflammatory markers to talc in the treatment of malignant pleural effusions.

BACKGROUND: Malignant pleural effusions accumulate in the space between the visceral (inner) layer covering the lungs and the parietal (outer) layer covering the chest wall. Larger effusions compress the pulmonary parenchyma resulting in increasing dyspnoea. Treatment is always local and palliative. Among others, chemical pleurodesis using talc can be performed in selected patients. Talc is hydrated magnesium silicate (chemically H2Mg3(SiO3)4) and has been used for pleurodesis since 1935. Videothoracoscopic talc powder insufflation (talc poudrage) is the most effective.However, markers of inflammatory reactions to extraneous substances like talc are not fully understood. The aim of this study was to assess the course of local inflammatory changes in the pleural cavity after talc insufflation. METHODS: The Department of Cardiac Surgery of the Faculty of Medicine and University Hospital in Hradec Kralove, treated 47 patients aged 65 on average; 29 males and 18 females with proven recurrent malignant pleural effusion of various aetiologies from January 2009 to December 2010. They were retrospectively divided into group A (40 patients) without recurring effusion, and group B (7 patients) with recurring effusion and the need for thoracentesis or chest drainage during the 9-month monitoring. RESULTS: Major findings were made in soluble forms of cell receptors. Group B showed statistically higher levels of the anti-inflammatory form of sCD-163 receptor in pleural fluid before the talc poudrage. This showed limited ability to create an adequate inflammatory response to external stimuli. This group also showed lower levels of the inflammatory form of sTLR-2 receptor immediately after the talc insufflation. This revealed low local reactivity to external stimuli. The effect of the treatment was not influenced by morphologic tumour type. No statistically significant differences in postoperative complications were found. This confirmed the safety of both videothoracoscopy and treatment. CONCLUSIONS: There was no correlation between the type of malignant affection and the outcome of the chemical pleurodesis. Patients with relapsing effusion have higher values of concentration of anti-inflammatory sCD-163 in pleural fluid even before the application of talc, and lower levels of concentration of inflammatory sTLR-2 immediately after application of talc.