Robotic pulmonary segmentectomy, initial experience in the Czech Republic.

INTRODUCTION: The initiation of lung cancer screening in Czechia and diagnosis in earlier stages has been reflected by an increasing demand for anatomical lung segmentectomy. The purpose of this study was to describe early results of the first robotic-assisted thoracoscopic segmentectomies performed in the country. METHODS: Our institution has performed 151 robotic anatomical lung resections since the initiation of the screening program in August 2020, which enabled us to attain the status of a proctoring and case observation centre. The robotic segmentectomy program was initiated after completing 70 robotic lobectomies. We performed a retrospective analysis of the results of our first 20 patients indicated for robotic segmentectomy. RESULTS: Median age of the patients was 60, with 11 females and 7 males. The most common indications included primary lung malignancy (n=13), pulmonary metastasis (n=2) and benign lesions (n=3). We performed 11 simple segmentectomies, 6 complex (S2, S3, S1a+2, S10 on the right) and one right S6 segmentectomy with bronchoplasty. The mean number of harvested lymph nodes for NSCLC was 20, the mean blood loss was 25 mL (from 10 mL to 100 mL), and the mean operative time was 200 minutes. All resection margins were tumour-free. There was no conversion to thoracotomy. Two patients were excluded as they required conversion to robotic lobectomy given that their lesions were localized close to the intersegmental plane. One complication (recurrent laryngeal nerve paralysis) occurred in 1 patient. Mean chest tube duration was 1.9 days and length of stay 3.9 days. CONCLUSION: Our experience suggests that implementation of the robotic segmentectomy program after completion of the robotic learning curve provides promising outcomes. Robotic technology and preoperative planning facilitate this technically demanding procedure especially when bronchoplasty is required.

Biportal robotic pulmonary lobectomy, initial experience - case report.

INTRODUCTION: Thanks to perfect visualization and high maneuverability of instruments, the robotic technique is a preferable type of lung resection, even though the number of required incisions is usually higher compared to the video-assisted approach. This case report presents our initial experience with the reduced-port approach in performing robotic biportal lobectomy. CASE REPORT: The 72-years-old female, examined for hemoptysis, was diagnosed with a carcinoid tumor of the left lower lobe bronchus based on bronchoscopy. The patient underwent a biportal fully robotic left lower lobectomy. The time of operation was 235 minutes, longer compared to the average time of multiportal procedures, i.e. 190±52 minutes, and the blood loss of 100 mL was higher compared to 43±54 mL. The patient was discharged without complications on the third postoperative day. Histological analysis confirmed the diagnosis of a typical carcinoid with tumor free margins and seven tumor free lymph nodes. The patient continues to be followed at the Department of Pneumology, showing no signs of disease recurrence for eight months. CONCLUSION: The robotic biportal approach offers a reduction in chest wall traumatization while maintaining oncological radicality. Although this approach is safe and feasible, limitations in instrument movements necessitate specific training.

The first lung retransplantation with “ECMO bridge” in the Czech Republic - case report.

During the last 23 years of the National Lung Transplant Program in the Czech Republic, more than 500 lung transplantations, 4 retransplantations and one lobar retransplantation have been performed. We present the case report of a female patient with cystic fibrosis who underwent her first bilateral lung transplantation in January 2020. Due to a chronic lung allograft dysfunction, the patient required ECMO support and retransplantation. For the first time in the Czech Republic, a lung retransplantation with “ECMO bridge to (re)transplantation” preoperative support was performed in April 2021. The patient was discharged 39 days after retransplantation in a stable condition. At the day 90 follow-up visit, the patient was in a generally good condition with satisfying spirometric functions.

Video-assisted and robotic-assisted thoracoscopic pulmonary lobectomies, our experience.

INTRODUCTION: The use of video-assisted (VATS) and robotic-assisted (RATS) thoracoscopic surgery for anatomical pulmonary resections has been rapidly increasing. This study aimed to analyze our results of minimal invasive lobectomies to safely introduce these techniques to our practice. METHODS: Starting these new programs we followed the recommended steps including case observations and a proctoring. We retrospectively analyzed the data of our 7-year experience with VATS lobectomies and 1-year experience with RATS lobectomies. RESULTS: 128 minimal invasive lobectomies were performed between 4/2015 and 4/2021 in our center. The mean age of our patients was 64.7±10.5 years; 61 (47.7%) were women and 67 (52.3%) were men. Pulmonary malignancy was the main indication in 116 (90.6%) patients, including 2 patients with localized small cell lung cancer (SCLC). In 12 (9.4%) cases we operated for bronchiectasis and benign lung lesions. Stage I lung cancer was found in 57 (66.3%), stage II in 22 (25.6%) and stage III in 7 (8.1%) patients. We performed 110 VATS and 18 RATS lobectomies with a clear shift from triportal VATS to uniportal VATS and RATS in the last years. The mean operative time was 166±55.5 minutes and a conversion was approached in 8 (6.2%) cases (4 bleedings - less than 300 ml in all cases, 3 oncological cases, 1 case for a technical reason). The median postoperative length of stay was 4 days. CONCLUSION: VATS and RATS lobectomy has become a standard approach for early stages of lung cancer. Respecting the rules of introducing VATS and RATS including proctoring offers safety without any negative impact on survival or oncological radicality.

Starting the first robotic lobectomy program in the Eastern Europe during Coronavirus disease-2019 pandemic.

BACKGROUND: We report our experience in starting RATS (robotic-assisted thoracic surgery) lobectomy program during COVID-19 pandemic. METHODS: Data from 20 consecutive cases undergoing RATS lobectomy between August 2020 and April 2021 were prospectively accumulated into our database. RESULTS: The mean operational time was 235±69 minutes (median 210, range 175 to 370). Conversion-to-open rate was 5 %. One patient was converted to an open procedure during surgery due to surgical bleeding. One patient (5 %), with sever chronic obstructive pulmonary disease (COPD), had prolonged air leak with chest drainage 11 days and conservative treatment. Morbidity rate was 10 % (2 patients). Estimated costs of RATS lobectomy in our department were $9,590 (range $8,250-$12,730). 30-days mortality was 0%. CONCLUSIONS: Safe robotic surgery is based not only on improved robotic equipment, but also on good technical skills and medical knowledge. It requires training of the entire operating room team. The learning curve is steep, involving port placement, use of the correct robotic arms, availability of the proper instrumentation, and proper patient positioning (Tab. 2, Ref. 28).

Malignancy after lung transplantation.

INTRODUCTION: Lung transplantation has become a successful life-saving treatment for patients with end-stage pulmonary disorders. Long-term survival outcomes after lung transplantation have been improving with increasing experience. Malignancies occupy the third position among the causes of death, particularly between years 5 to 10 from lung transplantation. The risk factors include predominantly high doses of immunosuppressive therapy, older age, infections caused by oncogenic viruses and smoking history. METHODS: We retrospectively evaluated all patients undergoing lung transplantation between 2010 and 2019. The aim of this study was to analyze the incidence, type and location of tumors, time from detection, survival time and cause of death in patients with malignant tumors after lung transplantation. RESULTS: In total, 308 lung transplantations were performed at the 3rd Department of Surgery of the 1st Faculty of Medicine, Charles University and University Faculty Hospital in Motol between 2010 and 2019. Posttransplant malignancy was diagnosed in 32 patients; a tumor was detected in the explanted lung in 5 patients. Lung cancer was the most frequent tumor in our study and was found in 13 patients (37%); 6 patients (17%) had a nonmelanoma skin cancer; and posttransplant proliferative disease developed in 4 patients (12.5%). The incidence rate of other types of malignancy was low. Mean of survival after diagnosis was 152 days. CONCLUSION: Life time administration of immunosuppressive therapy in lung transplanted patients plays a key role in the prevention of rejection but on the other hand it represents a risk factor for cancer development. Oncological management of posttransplant cancer is based on reduction of immunosuppressive therapy, combined with surgical resection of solid organ tumors and other types of cancer therapy. Oncology screening tests should be done regularly as a method of prevention, and for an early detection of any tumor.

[Ruptures of the diaphragm]. / Ruptury bránice.

INTRODUCTION: The diaphragm is a flat muscle that divides the thoracic and abdominal cavities, and it is one of the most important muscles involved in respiration. Traumas of the diaphragm include its rupture caused by an external force, resulting in blunt or penetrating injuries. Diaphragmatic rupture is associated with the risk of a prolapse (i.e. not a typical hernia) of abdominal organs into the pleural cavity. The rupture may occur due to a blunt injury of the chest or abdomen, or due to penetrating injuries (gunshots, stab wounds, foreign bodies) in the lower part of the chest and epigastrium. Ruptures never heal spontaneously and always require suture of the diaphragmatic defect. Most acute rupture cases are managed using laparotomy; thoracotomy is preferred for lately recognised ruptures to facilitate the removal of adhesions in the thoracic cavity developed between the diaphragmatic defect and a lung. Thirty one patients with diaphragmatic rupture were operated at the 3rd Department of Surgery of the 1st Faculty of Medicine, Charles University and University Hospital Motol between 2006 and 2016. Acute rupture was present in 60% of the cases and chronic in 40%. Right-sided rupture was found in 20% and left-sided in 80%. CONCLUSION: The authors describe surgical treatment of diaphragmatic ruptures. They recommend an early surgical treatment if diaphragmatic rupture is recognized. Generally, the prognosis of the patients depends on availability of professional health care; ideally, these patients should be treated at specialised traumacentres with specialists for abdominal and thoracic surgery. The authors advise against establishing injudicious thoracic drainage in cases where diaphragmatic rupture with herniation of abdominal organs into the thorax may be present.Key words: polytrauma - acute rupture of diaphragm - chronic rupture - suture - patch.

[Development of tracheal resection technique - our experience]. / Vývoj techniky resekcí trachey - nase zkusenosti.

INTRODUCTION: Tracheal resections are very frequent interventions on the trachea in general. In borderline cases where the tracheal resection length is too high, the situation can be resolved by inserting a stent or Montgomerys T cannula. Tracheal stenoses are of benign origin in 94%, and malignant in 6% of cases. We present a summary of tracheal resection interventions for the last 21 years. METHOD: 235 tracheal resections were performed at the authors institution in 1993-2013. In total 221 benign stenosis cases (85 % developed after tracheostomy, 15% developed after intubation) and 14 malignant cases were treated. The patients were divided into two groups: A resection in years 19932002 and B - resection in years 20032013. The comparison of these two time periods is presented with focus on surgical procedures development and recommendations based on experienced complications. RESULTS: Restenosis (early or late) is the most common complication during the process of tracheal resection treatment. Tiny fistulas in the suture can be diagnosed easily by minor air leaking and are treated conservatively without intervention. Fortunately, suture insufficiency is relatively rare. In some cases the restenoses can be resected or treated by stent application or by Montgomerys T-cannula application. Complications were observed in 2% of the treated patients, which is a number presented also by international studies. CONCLUSION: Tracheal resection is definitely an optimal solution for patients suffering from tracheal stenosis. As presented in our study, in the hands of experienced thoracic surgeons tracheal resections is a safe and final solution of tracheal stenosis. KEY WORDS: trachea - stenosis resection.

[The first lung re-transplantation in the Czech Republic]. / První retransplantace plic v Ceské republice.

Nowadays, lung re-transplantation is an acceptable method of treatment in patients with graft failure after lung transplantation. During the 15-year duration of the lung transplant program in the Czech Republic, the first re-transplantation was performed on 1. 8. 2012. This article presents the case report of a female patient with lymphangioleiomyomatosis who underwent single lung transplantation on the left side on 4. 10. 1998. Over 12 years, based on bronchiolitis obliterans syndrome, she developed chronic respiratory insufficiency again. The patient was re-listed on the waiting list and on 1. 8. 2012, successful single-lung transplantation on the right side was performed.Key words: lung re-transplantation bronchiolitis obliterans syndrome organ allocation.

[Thoracic sarcoma, is indication for surgery sensible? case reports]. / Sarkomy hrudníku, má operacní indikace smysl? soubor kazuistik.

Sarcomas form a heterogenous group of diseases. They often affect young patients and their prognosis is uncertain. The only hope for curative treatment of these patients is a surgical R0 resection. Chemotherapy is only indicated for certain types of sarcomas and is often only recommended as part of clinical trials. The article describes 4 different case reports of patients with sarcomas and reflects on the justification of indicating surgical treatment. resection.

[Extragastrointestinal stromal tumor (EGIST)--a case review]. / Extragastrointestinální stromální tumor (EGIST)--kazuistika.

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract. Due to the presence of thyrosine kinase receptors within the tumor tissue, GIST is thought to originate from gastrointestinal pacemaker cells, the intersticial cells of Cajal. Tumors with the same morphological and imunohistochemical characteristics detected outside the gastrointestinal tract, are called extragastrointestinal stromal tumors (EGIST). Biological characteristics of these tumors is uncertain and the malignancy rates are difficult to predict. Surgical R0 resection in resecable tumors is the only option with the potential for complete cure. Nevertheless, the recurrence rates are high. Adjuvant biological treatment with imatinib, a thyrosine kinase inhibitor, reduces the risk of relapses. Imatinib administration is also the principal treatment method in metastatic GIST disorders. The article offers a short and complex overview of gastrointestinal stromal tumor (GIST) problematics and presents a case report of a patient suffering from EGIST of mesocolon transversum treated by R0 resection which was performed under multidisciplinary cooperation, with a specialist follow up.

Can a photocatalytic air purifier be used to improve the perceived air quality indoors?

UNLABELLED: The effect of a photocatalytic air purifier on perceived air quality (PAQ) was examined in rooms polluted by typical sources of indoor pollution. The rooms were ventilated at three different outdoor air supply rates. The air quality was assessed by a sensory panel when the purifier was in operation as well as when it was off. Operation of the purifier significantly improved PAQ in the rooms polluted by building materials (used carpet, old linoleum, and old chipboard), and a used ventilation filter as well as a mixture of building materials, used ventilation filter and cathode-ray tube computer monitors. The effect corresponded to approximately doubling the outdoor air supply rate. Operation of the purifier significantly worsened the PAQ in rooms with human bioeffluents, probably due to incomplete oxidation of alcohols which are one of the main pollutants emitted by humans. Present results show that the photocatalytic air purifier can supplement ventilation when the indoor air is polluted by building-related sources, but should not be used in spaces where human bioeffluents constitute the main source of pollution. PRACTICAL IMPLICATIONS: The present results suggest that a photocatalytic air purifier can supplement ventilation when the indoor air is polluted mainly by building-related sources, for example in unoccupied buildings outside working hours when ventilation is considerably reduced or turned off and pollutants build up and adsorb on indoor surfaces. The results also suggest that use of a photocatalytic air purifier should be avoided when humans are present and constitute main source of pollution.

[An example of the liver metastases downstaging following chemoport implantation]. / Príklad downstagingu jaterních metastáz po implantaci chemoportu.

The case review describes a case of a patient, hospitalized with T3N0M1 carcinoma of the splenic flexure, with multiple metastases in the both liver lobes. The patient underwent left-sided hemicolectomy with cholecystectomy. Having considered the inoperable liver findings, a chemoport was implanted. The patient underwent 10 chemotherapy cycles with no major complications recorded. The chemotherapy cycle included Campto, Leucovorin, 5FU and, concomittantly, 5FU as a continual 22-hour infusion into the port. After completion of the Cycle 10, the ultrasound and CT findings showed marked regression of the metastases, by half to two thirds. Following consultation at the onco-surgical seminar, extended left-sided hemihepatectomy was performed. The procedure lasted 6 hours, the blood loss was 3.500 ml, the period of warm ischemia was 8 minutes. Based on the oncologists' recommendation, the chemoport was preserved. The latest abdominal ultrasound detected no focal liver changes, a hypechogenic to unechogenic septed formation, v.s. a postoperative hematoma, was detected near the medial liver margin. Based on the conclusion of the oncological assessment, the patient was indicated for adjuvant chemotherapy, containing the same agents, for a period of 2-3 months. The aim of this report is to present a case of downstaging of the originally inoperable finding of the liver metastases.

QT dispersion and T-loop morphology in late pregnancy and after delivery.

The aim of the study was to detect changes of both the QT dispersion and T-loop morphology resulting from the changed spatial position of the heart during pregnancy. Electrocardiographic and vectorcardiographic recordings were obtained from 37 healthy women 19-36 years old in the 36th to 40th week of physiological pregnancy and 2 to 6 days after delivery. The same recordings were obtained from 18 healthy women of the same age. The average QT dispersion (+/- S.D.) in normal subjects was significantly lower (34 +/- 12 ms) than in those in late pregnancy (73 +/- 18 ms) (P < 0.001). The average amplitude of T-loop (Ta) in women in late pregnancy was significantly (P < 0.001) smaller (532 +/- 98 microV) and the width of T-loop (Tw) was wider (21.24 +/- 11.48 deg) than in the control group (793 +/- 114 microV and 7.17 +/- 3.02 deg, respectively). The partial post-partum restoration of all parameters was not significant. In all groups, the QT dispersion was significantly correlated with Tw but not with Ta. According to these results we can conclude that the QT dispersion is an indirect reflection of the complete process of ventricular repolarization, reflected in the morphology of the T-loop.

Polymerization kinetics, glass transition temperature and creep of acrylic bone cements.

Sulfix-6 and Zimmer LVC 60/30 bone cements were selected and the polymerization kinetics and resulting glass transition temperature Tg; creep behaviour in the dry or water-saturated state; and sorption and diffusion of water were studied. The calculation of conversion was based on a comparison of the residual polymerization heat measured by differential scanning calorimetry and the corresponding theoretical value. The conversion reached 99% after 90 min of quasi-adiabatic polymerization starting at 23 degrees C or after 10 min of isothermal polymerization at 37 degrees C. The Tgs of the cements prepared in the former way were about 82 and 100 degrees C, respectively. Creep rate of the bone cements at 37 degrees C decreased with the time of creeping. Sorbed water enhanced the compliance, but reduced the creep rate for long times so that water sorption during the service time may not have detrimental effects on the creep resistance of the cements. Both types of cements contained about 1% of low molar mass substances extractable by water. Measurements of the sorption kinetics of water showed that the diffusion coefficient is 0.14 x 10(-11) and 0.22 x 10(-11) m2/s and 1 yr sorption achieves 2.11% and 2.89% for Sulfix and Zimmer, respectively.

Application of Corynebacterium parvum lysate into the brain of rats--morphological study.

The authors investigated the influence of application of the Corynebacterium parvum lysate (CPL) into the brain of rats with aim to define the resulting morphological changes. Variable amount of the CPL (0.1, 0.35, 0.7 mg) was injected under stereotactic control into frontal lobe of the left cerebral hemisphere. Morphological changes were studied after intervals of 3, 7, 14, and 30 days respectively. CPL lead to inflammatory and reparative changes in direct relations to the administered dosage. The most pronounced reaction was observed on days 3 and 7. Morphological changes were still visible on day 14. There were no valid difference between the application of efficient CPL and the control physiological saline solution (PSS) after thirty days. The authors suggested that CPL is likely to be safe also in human malignant brain tumor therapy.

Preliminary experimental experiences with xenotransplantations.

In our xenotransplantation experiments has been a major aim to induce specific tolerance. The results from the meeting of the donor's and the recipient's immunocompetent systems already in the period of embryonic development and/or the influence of methylprednisolone are described.

[Stereotactically aimed biopsy of vertebral body l2.]. / Stereotakticky cílená biopsie z obratlového tela L2.

The authors describe successful use of an whole-body stereotactic apparatus for collection of pathological tissue samples from the vertebral body L2. Key words: whole-body aiming apparatus, stereotactic biopsy, vertebral body.

[Directed photonucleolysis of the intervertebral disk and its herniation. Preparation for percutaneous laser diskectomy]. / Cílená fotonukleolýza intervertebrálního disku a jeho výhrezu. Príprava k laserové perkutánní diskektomii.

Under model conditions it proved possible, using a whole-body stereotactic apparatus, to focus on a human intervertebral disc and its prolapses and eliminate them by photocoagulation, using a laser. The suitable cannulae have a 3 mm diameter and an output of 6 to 12 W. The necessary lesion is reached in a fractionated manner within 1 minute. Thus the conditions were created for the new technique of percutaneous disectomy which has been done hitherto by means of chemical substances or mechanically by incision and suction.

Histological and biochemical characteristics of kryoprotected embryonic nervous tissue for transplantation purpose.

In clinical and experimental conditions, a biochemical equipment and a histological image of a fresh embryonic nervous tissue and a tissue conserved by deep freezing for transplantation purposes were examined. By repeated examination of neurotransmitters, the contents of dopamine and serotonin were found unchanged by freezing. In a human embryo, serotonin predominates over dopamine, while in chicken embryos, used for xeno-transplantations, it is vice versa. As for the microscopic structure of nervous tissue, no influence of kryopreservation for 4 to 14 days was found.