[Treatment of malignant effusion]. / Sravnitel'naya kharakteristika metodov lecheniya metastaticheskogo plevrita (obzor literatury).

Malignant effusion complicates more than 15% of all cancers in delayed stages of progression. The most common causes of metastatic pleuritis are lung cancer, breast cancer, ovarian cancer, lymphoproliferative diseases or dissemination of gastrointestinal tumors. Malignant effusion is associated with negative prognosis for overall survival regardless of etiology of tumor, significantly complicates the course of the underlying disease, impairs life quality and complicates treatment. Despite various methods for pleural cavity obliteration in recurrent metastatic pleuritis, there is still no a uniform approach to choosing the optimal treatment strategy. We analyzed the main methods of conservative and surgical treatment of recurrent metastatic pleuritic regarding efficacy, risk of recurrence and reproducibility.

[Treatment of primary malignant melanoma of the esophagus]. / Lechenie pervichnoi melanomy pishchevoda.

OBJECTIVE: To present treatment of primary esophageal melanoma in a young patient, as well as review of modern data on this issue. MATERIAL AND METHODS: We describe the results of treatment of a patient with primary melanoma of the esophagus. PubMed, SCOPUS, and elibrary databases were used for the review. RESULTS: We present a rare case of primary esophageal melanoma and variant of radical surgical treatment. The review is devoted to historical information about this nosology, statistical data, options for diagnosis and treatment. CONCLUSION: Such a rare clinical case is of great scientific interest due to the rarity of this disease. In our opinion, a certain register of orphan malignant tumors is necessary for diagnosis and treatment of various rare malignancies.

[Anatomical resection for non-small cell lung cancer: cardiopulmonary exercise testing in assessing the risk of respiratory complications]. / Anatomicheskie rezektsii po povodu nemelkokletochnogo raka legkogo: kardiorespiratornoe nagruzochnoe testirovanie v otsenke riska respiratornykh oslozhnenii.

OBJECTIVE: To assess the role of cardiopulmonary exercise testing in examination of patients with high risk of respiratory complications in anatomical resections for non-small cell lung cancer. MATERIAL AND METHODS: A non-randomized retrospective single-center study was devoted to immediate results of surgical treatment of patients with NSCLC between December 2020 and April 2021. Median age of patients was 65 (84; 30) years, male-to-female ratio - 129 (57%)/98 (43%). All patients were examined according to a unified algorithm recommended by the American (ATS) and European (ESTS) societies of thoracic surgeons. At the first stage, we analyzed airflow rate and performed non-invasive exercise tests (6-minute walk and/or stair test). Resections of lungs were performed in 231 patients, anatomic lung resections - in 227 patients (lobectomy - 199, bilobectomy - 4, segmentectomy - 17, pneumonectomy - 7). We excluded 4 patients who underwent non-anatomic lung resections (marginal resections). RESULTS: Among 236 patients referred for anatomical lung resections, 34 (14.4%) ones were selected for cardiopulmonary testing. Selection was based on low exercise tolerance and/or severe decrease in predictive respiratory parameters (FEV<50%). Patients were divided into 4 groups depending on peak oxygen consumption. There were 5 (2%), 10 (29.4%), 11 (32.3%) and 8 (23.5%) patients with extremely high, high, moderate and low risk of respiratory complications, respectively. Surgeries were performed for IA1 (n=6), IA2 (n=50), IA3 (n=37), IB (n=31), IIA (n=19), IIB (n=37), IIIA (n=25) and IIIB (n=4) stages. The overall incidence of postoperative complications was 23% (95% CI: 18-28.8). Complications Clavien-Dindo grade I, IIIA, IIIB, IVA, IVB and V prevailed in both groups. Median postoperative hospital-stay (6 (6; 8) vs. 7 (6; 8) days) and time of pleural drainage (4 (2; 5) vs. 3 (3; 4) days) were similar. Organ-sparing procedures prevailed in the main group (5 (26%) out of 19 (95% CI: 11.81-48.8) vs. 12 (6.7%) out of 180 (95% CI: 3.8-11.3)). Overall mortality (n=231) was 1.7% (95% CI: 0.7-4.4). Mortality throughout the first postoperative year was 24% (95% CI: 12.2-42.1) and 7.4% (95% CI: 4.2-11.3), respectively. CONCLUSION: Cardiopulmonary exercise testing makes it possible to objectively assess exercise tolerance and identify high-risk patients for respiratory complications. These data are valuable when planning the treatment of patients with non-small cell lung cancer.

[Transbronchial cryobiopsy for mediastinal lesions: a pilot study]. / Transbronkhial'naya kriobiopsiya limfouzlov i novoobrazovanii sredosteniya: pilotnoe issledovanie.

OBJECTIVE: To describe a novel transbronchial cryobiopsy technique for mediastinal lesions after initial ultrasound assessment and EBUS-TBNA. MATERIAL AND METHODS: Transbronchial cryobiopsy (TBCB) was performed in 35 patients with suspicious mediastinal lesions between November 2020 and September 2022. Age of patients ranged from 22 to 75 years (median 50 [39; 62]). Men-to-women ratio was 13:22. RESULTS: According to morphological data, patients with sarcoidosis (n=13), NSCLC (n=7) and metastases of other tumors (n=3) prevailed. There were patients with B-cell lymphoma (n=1), Castleman disease (n=1) and small cell lung cancer (n=2). Among 15 biopsies for immunohistochemical examination, samples were sufficient for final morphological conclusion in 11 (73.3%) cases (95% CI 48.5-89.1). In 4 (11.4%) cases (95% CI 4.5-26), examination was uninformative. Repeated biopsy was performed in 2 cases, and sarcoidosis of thoracic lymph nodes was confirmed. Sensitivity, specificity and accuracy of transbronchial cryobiopsy were 93.3, 100 and 94%, respectively. There were no clinically significant complications. In one case, chest X-ray revealed pneumomediastinum without need for additional treatment. CONCLUSION: Transbronchial mediastinal cryobiopsy is a perspective method for diagnosis of mediastinal neoplasms. Apparently, this approach may be advisable in patients with suspected sarcoidosis or lymphoproliferative diseases.

[Clinical efficacy of ct-guided transthoracic needle biopsy of peripheral lung lesions]. / Klinicheskaya effektivnost' transtorakal'noi biopsii perifericheskikh novoobrazovanii legkikh pod kontrolem MSKT.

OBJECTIVE: To evaluate the effectiveness of a step-by-step protocol for GT-guided transthoracic biopsy in verification of peripheral lung tumors. MATERIAL AND METHODS: A retrospective analysis of the results of GT-guided transthoracic biopsies of focal lung neoplasms was performed between October 2019 and December 2020. The analysis included the results of 176 biopsies in 158 patients. RESULTS: Primary biopsy was informative in 139 (87.97%) out of 158 patients. There were 155 (88.07%) informative and 21 (11.93%) non-informative biopsies. Lung adenocarcinoma was diagnosed in 41 (25.95%) patients, squamous cell carcinoma in 35 (22.15%) patients, and small cell carcinoma in 9 (5.7%) patients. There were 17 (10.76%) patients with uninformative biopsy results. Sensitivity, specificity and accuracy were 86%, 95.5%, and 87.8%, respectively. PPV was 98.9%, NPV - 58.3%. Various complications occurred after 65 (36.93%) out of 176 biopsies (95% CI 30.15-44.27). Pneumothorax followed by pleural drainage was detected after 8 (4.55%) biopsies. CONCLUSION: Accuracy of a step-by-step protocol for transthoracic biopsy was 88% that is not inferior to similar results in large-scale studies devoted to specialized navigation systems.

[Enhanced recovery in thoracic surgery]. / Uskorennaya reabilitatsiya v torakal'noi khirurgii.

OBJECTIVE: To present an experience of adapting the accelerated rehabilitation protocol at the thoracic surgery department of the Moscow City Clinical Oncology Hospital No. 1. MATERIAL AND METHODS: An effectiveness of the accelerated rehabilitation program in the city oncology hospital was retrospectively analyzed for the period from February to December 2019. Lung resections were performed in 252 patients with median age 66 (59; 71) years and an equal ratio of men and women (124/128). Primary non-small cell lung cancer was noted in 194 (77%) patients, secondary malignant neoplasms of lungs - in 58 (23%) cases. ASA grading system of anesthetic risk was applied (American Society of Anesthesiologists): grade II - 56 (22.2%) patients, grade III - 203 (75.2%) patients, grade IV - 7 (2.8%) patients. RESULTS: Lobectomy was performed in 147 patients, segmentectomy - in 32, bilobectomy, pneumonectomy and marginal resection - in 1, 3 and 69 cases, respectively. Endoscopic operations made up 13.6% (n=20), 12.5% (n=4) and 78% (n=54). Postoperative 30-day complications occurred in 19 (7.5%) out of 252 patients (95% CI 4.9-11.5). Postoperative 30-day mortality was 1.98% (5 out of 252 patients, 95% CI 0.9-4.6). Median postoperative hospital-stay was 7 (6; 8) days. CONCLUSION: Implementation of fast track protocol requires time and the first results can be assessed after 6-12 months. Continuous monitoring of implementation of the protocol elements by all members of multidisciplinary team, analysis of complications and long-term results are required to realize all potential benefits of this program.

[Combined thoracoplasty using titanium mesh implant in patients with total sternal instability following postoperative sternomediastinitis]. / Kombinirovannaia torakoplastika setchatym titanovym éndoprotezom u patsientov s total'noi nestabil'nost'iu grudiny v iskhode khronicheskogo posleoperatsionnogo sternomediastinita.

OBJECTIVE: To analyze the results of chest wall reconstruction with titanium mesh implant in patients with total sternal instability following postoperative sternomediastinitis. MATERIAL AND METHODS: There were 100 patients with total sternal instability for the period from January 2016 to December 2018. Median of age was 62 (58; 68) years. Male/female ratio was 82/18. All patients were treated in accordance with standardized protocol. Postoperative complications were assessed using Clavien-Dindo scale. Staged surgical treatment including one or more debridement procedures before the final thoracoplasty was performed in 62 (62%) out of 100 patients. Aseptic sternal instability was observed in 38 patients. RESULTS: Follow-up period ranged from 3 weeks to 35 months after the final thoracoplasty. Complicated postoperative period occurred in 15 (15%) out of 100 patients (95% CI 9.3-23.3). One patient died in 9 days after surgery from acute heart failure. Complications without need for redo surgery, postoperative wound suppuration and seroma were noted in 3 patients. Redo surgery was required in 11 patients due to postoperative wound suppuration, eventration after thoracoomentoplasty, intermuscular hematoma and delayed divergence of major pectoral muscles. Removal of mesh implant was performed in 1 out of 100 patient (95% CI 0.2-5.5) in 7 days after surgery due to suppuration. There was no recurrent sternal instability within 30 days. CONCLUSION: Anterior chest wall reconstruction using titanium mesh implant is an effective and safe procedure in patients with postoperative sternal instability following postoperative sternomediastinitis.

[Transsternal occlusion of the main bronchus stump in bronchopleural fistula and non-specific pleural empyema]. / Transsternal'naia okkliuziia kul'ti glavnogo bronkha pri bronkhoplevral'nom svishche i nespetsificheskoi émpieme plevry.

OBJECTIVE: To present our experience in the treatment of patients with bronchopleural fistula and chronic non-specific pleural empyema after pneumonectomy. MATERIAL AND METHODS: There were 25 patients with chronic pleural empyema following bronchopleural fistula after pneumonectomy. All patients were examined in standard fashion and divided into two groups depending on length of bronchial stump: more or equal to 20 mm and less than 20 mm. Transsternal occlusion of bronchial stump was performed in the 1st group. Pedicled muscle or omental flap was applied for bronchial stump repair in the 2nd group. RESULTS: Follow-up period ranged from 18 to 110 months (median 48 (19; 52) months). Complications were grade daccording to Clavien-Dindo classification. Infectious complications not associated with bronchial stump insufficiency and required antibiotic therapy and/or topical treatment were registered in 6 (24%) out of 25 patients (95% CI 11.5-43.4): suppurative tracheobronchitis, pneumonia, postoperative wound suppuration in 1 (4%), 2 (8%) and 3 (12%) patients, respectively. Overall mortality rate was 2 (8%) out of 25 patients. There were no recurrences after transsternal occlusion of bronchial stump. In the control group, recurrent bronchopleural fistula was noted in 2 (12.5%) out of 16 patients (95% CI 3.5-36). Mean hospital-stay was 13 (13; 16) and 20 (11; 35) days in both groups, respectively (p<0.05). A good and satisfactory result after transsternal occlusion of bronchial stump was achieved in 23 (92%) out of 25 patients (95% CI 75-97.8). CONCLUSION: Transsternal occlusion of bronchial stump is more advisable than tissue flap transposition in patients with chronic pleural empyema followed by BPF and bronchial stump length over 20 mm due to less trauma and good reproducibility.

[Circular tracheal resection for acquired tracheal stenosis: evaluation of early and long-term outcomes]. / Tsirkuliarnaia rezektsiia pri rubtsovom stenoze trakhei: analiz neposredstvennykh i otdalennykh rezul'tatov.

AIM: To present single-center experience and results of surgical treatment of acquired tracheal stenosis. MATERIAL AND METHODS: There were 99 patients with acquired tracheal stenosis for the period from January 2008 to December 2017. Median age was 39 (28; 55) years (range 19-79 years), male/female ratio - 64/35. There were 59 patients with tracheostomy-related stenosis, 31 - post-intubation injury, 6 - posttraumatic stenosis, malignant and idiopathic stenosis was observed in 2 and 1 patients, respectively. Single-stage circular tracheal resection or staged surgical approach were preferred depending on localization and severity of stenosis, respiratory function at admission, severity of concomitant diseases and possibility of prolonged head adduction, presence of tracheostomy and cervical tissues inflammation, functional state of laryngeal structures. RESULTS: Single-stage circular tracheal resection was applied in 44 (44.4 %) out of 99 cases. In 55 (55.6%) patients staged approach was preferred: Montgomery T-tube placement followed by tracheoplasty after 6-12 months - 27 patients; tracheoplasty on prefabricated endotracheal stent - 8 patients; staged endotracheal treatment (including Dumon prosthesis deployment) - 12 patients. In 11 cases circular resection was done as a final stage of treatment. There was no in-hospital mortality after circular tracheal resection. Morbidity included anastomotic dehiscence - 2 (3.6%), recurrent stenosis in 6 months after surgery - 1 (1.8%), granulation tissue growth followed by stenosis - 4 (7.3%), wound infection - 3 (5.5%) cases), postoperative pneumonia - 2 (3.6%) patients, respectively. CONCLUSION: Tracheal resection is preferred for tracheal stenosis management. Alternative techniques are life-saving procedures, but could potentially extent the length of stenosis and delay recovery of the patient.

[Fast-track rehabilitation after anatomical lung resection: prospective single-center non-randomized trial]. / Prospektivnoe odnotsentrovoe nerandomizirovannoe issledovanie uskorennoi reabilitatsii patsientov posle anatomicheskikh rezektsii legkikh.

AIM: To present the results of fast track rehabilitation after anatomical lung resection. MATERIAL AND METHODS: Single-center prospective non-randomized trial has included patients for the period December 2014 - December 2016. Conventional protocol was applied in 124 patients, 58 patients after atypical lung resections or pneumonectomy were excluded from the study. Thus, there were 66 patients aged 61 (51; 67) years. Men/women ratio was 37:29. Lobectomy (n=55) and segmentectomy (n=11) were performed for lung cancer, metastatic injury and various inflammatory diseases in 53 (80.3%), 8 (12.1%) and 5 (7.6 %) cases, respectively. ASA risk score was II (16), III (46), IV (4). Video-assisted/open procedures ratio was 42 (63.6%) / 24 (36.4%). RESULTS: 30-day postoperative morbidity was 7.6% (5 out of 66 patients, 95% CI 3.3- 16.5). Pleural drainage tube was removed within the 1st postoperative day in 49 (74.2%) out of 66 patients. Prolonged insufficient aerostasis was observed in 3 patients followed by effective conservative treatment. Overall mortality was 3% (n=2, 95% CI 0.8- 10.4) due to pulmonary embolism and sudden cardiac death. Median of postoperative hospital-stay was 7 (6; 9) days without significant differences between groups of lobectomy and segmentectomy (p>0.05). CONCLUSION: Fast track rehabilitation protocol in thoracic surgery is safe and effective. Further studies are needed to justify early rehabilitation in high risk patients.

[Laparoscopic-assisted harvesting of omental flap in chest wall reconstruction for deep sternal wound infection]. / Laparoskopicheski-assistirovannaia torakoomentoplastika v rekonstruktsii obshirnykh defektov perednei grudnoi stenki.

AIM: To present an experience of laparoscopic-assisted harvesting of omental flap in chest wall reconstruction for deep sternal wound infection. MATERIAL AND METHODS: It was made a prospective analysis of 14 patients aged 39-85 years after laparoscopic-assisted harvesting of omental flap in chest wall reconstruction for the period December 2014 - November 2016. Men/women ratio was 10/4. All patients had deep sternal wound infection grade IV (Oakley-Wright classification). RESULTS: Postoperative complications were observed in 2 (14.3%) of 14 (95% CI: 4.0-39.9%) cases that did not require re-operation. There were no 30-day postoperative mortality and significant complications as acute intestinal obstruction, postoperative ventral herniation and transplant rejection. Mean postoperative hospital-stay was 10.5 (9; 13) days. CONCLUSION: Laparoscopic-assisted harvesting of omental flap is safe method for chest wall reconstruction in patients with severe sternal wound infection associated with soft tissue deficiency and high risk of local complications (bleeding, etc.). Laparoscopy significantly reduces incidence of postoperative complications after omental flap transposition and is feasible in majority of patients.

[Differential approach for chest wall reconstruction for pectus excavatum in adults]. / Vybor metoda korrektsii voronkoobraznoi deformatsii grudnoi kletki u patsientov starshego vozrasta.

AIM: To perform the prospective non-randomized single-center trial of pectus excavatum correction in adults. MATERIAL AND METHODS: For the period March 2012 - March 2016 64 patients aged 18-44 years were treated. Median age was 23 years. Male/female ratio was 41/23. All patients were included into standard survey protocol: chest MDCT, MRI of thoracic spine, pulmonary function test, echocardiography. Quality of life and complications rate after the Nuss procedure (n=50, 78.1%, group 1) and radical thoracoplasty using nikelid-titanium bar (n=14, group 2) were evaluated. RESULTS: There was earlier recovery in the 1st group: 3 (2; 4) and 6 (5; 7) days after minimally invasive and radical thoracoplasty, respectively. Postoperative Dindo-Clavien I-IIIa complications developed in 46 (71.8%) patients. Most of them did not require additional procedures. CONCLUSION: Nuss procedure is safe method and can be performed with good results in adults.