Interventional management of recurrent malignant pleural effusion: state of the art in 2021.

OBJECTIVE: This narrative review aims to describe and compare different interventional methods for the management of recurrent malignant pleural effusion and offers perspectives for the future era. BACKGROUND: Dyspnea as a result of the recurrent malignant pleural effusion is one of the main factors decreasing the quality of life in patients with oncologic diseases. To date, there is no strict guideline for the management of malignant pleural effusions. RESULTS: Several different techniques are available to prevent production of the effusion or to provide intermittent drainage, however, the principle of these methods remains palliative. The choice of treatment in any patient depends mainly on the preferences of the patient, speed of the fluid production, expandability of the lung, and predicted survival of the patients. The interventional methods of managing malignant pleural effusions are described in detail, including thoracocentesis, chemical pleurodesis, talc poudrage pleurodesis, slurry pleurodesis, thoracoscopic procedures, indwelling pleural catheters, implantable pleural ports, and pleuroperitoneal shunting. CONCLUSION: Pleurodesis and fully implantable devices such as pleural ports may become the most useful techniques in the future, mainly because of better comfort for the patients and no need for repeated pleural punctures (Ref. 55).

Neutrophil-to-lymphocyte ratio, past, present and future perspectives.

In the review we analyzed short history of the establishment of a novel hematological parameter for systemic inflammation and stress coined as a neutrophil to lymphocyte ratio (NLR). Today NLR is widely used across almost all medical disciplines as a reliable and easy available marker of immune response to various infectious and non-infectious stimuli. We analyzed the immunological and biological aspects of dynamic changes of neutrophil granulocytes and lymphocytes in circulating blood during endocrine stress, dysbalance of autonomic nervous system and systemic inflammation. NLR reflects online dynamic relationship between innate (neutrophils) and adaptive cellular immune response (lymphocytes) during illness and various pathological states. NLR is influenced by many conditions including age, rice, medication, chronic disease like coronary heart disease, stroke, diabetes, obesity, psychiatric diagnosis, cancer of solid organs, anemia and stress. A normal range of NLR is between 1-2, the values higher than 3.0 and below 0.7 in adults are pathological. NLR in a grey zone between 2.3-3.0 may serve as early warning of pathological state or process such like cancer, atherosclerosis, infection, inflammation, psychiatric disorders and stress. NLR is used as a reliable and cheap marker of ongoing cancer-related inflammation and a valid indicator of prognosis of solid tumors. Majority of meta-analyses have explored the prognostic value of NLR in various solid tumors and have found out the cut-off value of NLR above 3.0 (IQR 2.5-5.0). We summarized its privilege in oncology: NLR may be used for stratification of cancer, correlates with the tumor size, stage of tumors, metastatic potential and lymphatic invasion. NLR has independent prognostic role regarding overall, cancer free and cancer-specific survival. It is useful for monitoring oncological therapy, including biological and immune check point inhibitors treatment. NLR is a very sensitive indicator of infection, inflammation and sepsis, validated in numerous studies. Clinical research confirmed the sensitivity of NLR for diagnosis/stratification of systemic infection, sepsis, bacteremia as well as its robust predictive and prognostic value. NLR should be investigated daily, and follow-up its absolute values and dynamic course in acute disease or critical illness. The severity of critical illness, the level of stress and serious inflammation is expressed by dramatic increasing of NLR values above 11 ≥ 17, or even higher than 30. Improving the clinical course of sepsis, critical illness, lower risk of mortality are associated with decline of NLR values below 7. NLR is helpful in differentiating more severe disease versus milder one. NLR is cheap, simple, fast responding and easy available parameter of stress and inflammation with high sensitivity and low specificity, it should be used routinely in emergency departments, ICUs, in acute medicine including surgery, orthopedics, traumatology, cardiology, neurology, psychiatry and even oncology. Dynamic changes of NLR precede the clinical state for several hours and may warn clinicians about the ongoing pathological process early. NLR is a novel perspective marker of cellular immune activation, a valid index of stress and systemic inflammation, which open a new dimension for clinical medicine, for better understanding of the biology of inflammation, coupling and antagonism between innate and adaptive immunity and its clinical consequences for health and disease (Tab. 8, Fig. 3, Ref. 151). Keywords: neutrophil-to-lymphocyte ratio, systemic inflammation, immune-inflammatory response, endocrinne stress.

Physiologic risk factors for early acute kidney injury in severely injured patients.

BACKGROUND: The evaluation of the predictive value of the neutrophil gelatinase-associated lipocalin (NGAL) for an early acute kidney injury (AKI) development in severely injured patients. Determination of the time-dependent roles of trauma-related physiologic markers of tissue hypoxia, systemic inflammation and rhabdomyolysis in AKI development. METHODS: 81 adult patients were screened for the presence of AKI for eight consecutive days following the injury. Arterial levels of plasma NGAL, lactate, interleukin-6, procalcitonin, and myoglobin were investigated at 24 hours (T1), 48 hours (T2), and 96 hours (T3) after the injury. RESULTS: The incidence of AKI was 32.1 %. Patients with AKI were older, but no significant difference in injury severity was observed. NGAL levels were significantly higher in the AKI group at T1, T2, and T3 when compared to the non-AKI group. Lactate levels were significantly higher in the AKI group at T2 only, and IL-6 levels were significantly higher in the AKI group at T2 and T3. Procalcitonin and myoglobin levels were significantly higher in the AKI group at T1, T2, and T3, when compared to the non-AKI group. Positive correlations were found between plasma NGAL and all screened physiological factors at all defined time points. CONCLUSION: Development of AKI after blunt trauma is very complex and multifactorial. Activation of the systemic inflammatory response and rhabdomyolysis (high concentration of myoglobin) were strongly involved in AKI development. Blood NGAL levels after injury were significantly higher in patients, who developed posttraumatic AKI. Plasma NGAL, lactate, procalcitonin, interleukin-6, and myoglobin had potential to be useful parameters for risk stratification and prediction of AKI after trauma (Tab. 6, Ref. 40).

Rationale Use of Neutrophil-to-lymphocyte ratio for early diagnosis and stratification of COVID-19.

Coronavirus disease is caused by a virus that is the cause of a potentially fatal disease worldwide. Coronavirus is a pathogen that primarily affects the human respiratory system. Coronavirus 2019 (COVID-19) has been named WHO since February 11, 2020. The first cases of COVID-19 were reported in December 2019. In January 2020, COVID-19 infection was identified in hospitalized patients in Wuhan, China. We analyze the role of neutrophil-lymphocyte ratio (NLR) in viral infection with special emphasize on novel corona virus disease-COVID-19. NLR may be used for early detection and may reflect progression to the more severe illness leading to SARS-CoV-2. In the mini review we investigate the use of NLR as a surrogate marker for diagnosis and stratification of COVID-19.Clinical symptoms such as pneumonia, acute respiratory distress syndrome, acute heart damage have led to death. In some cases, multiple inflammations have been observed. Treatment with interferon inhalation showed no clinical effect and the condition worsened instead (Tab. 5, Fig. 1, Ref. 18). Keywords: neutrophil-to-lymphocyte ratio, corona virus SARS-CoV-2, COVID-19.

Epiduroscopic intervention in patients with a failed back surgery syndrome.

BACKGROUND: Epiduroscopy is a percutaneous endoscopic technique with an interesting diagnostic and therapeutic potential. AIM: The study was aimed to evaluate the effectiveness of this modern minimally invasive method in treating pain together with the accompanying neurological symptoms of patients with a failed back surgery syndrome (FBSS). RESULTS: In the retrospective multicentre clinical study, we monitored the effect of epiduroscopic performance in 40 patients with FBSS before epiduroscopy and after 6 and 12 months. The results of the study indicated a significant improvement in back pain after 6 months, at p<0.05. At the same time, a significant improvement was observed in pain radiating to the lower limbs after 6 and 12 months at p<0.05, as well as a significant improvement in the Oswestry Disability Index of the limbs after 6 months and after 12 months (p<0.05). CONCLUSION: The current summarised results indicate a significant positive effect of epiduroscopy in the treatment of chronic back pain with a reduction in radiating pain to the lower extremities and an increase in patients' quality of life after the procedure (Tab. 2, Fig. 1, Ref. 23).

Gastric cancer with liver metastasis.

Surgical treatment of gastric cancer with liver metastasis (GCLM) is currently a frequent topic of discussion at professional surgical symposia. There is a low number of patients and a lack of large clinical multi-center studies describing the benefits of this treatment approach. The article describes a patient with GCLM, growing through stomach wall serosa, invading the spleen hilum, distal part of pancreas with metastasis to S7 of the right liver lobe. The patient had total gastrectomy performed with D2 lymphadenectomy, distal pancreatectomy with splenectomy, resection of diaphragm and RFA of the metastatic lesion in S7 of the liver. Post-surgery course was free of complications, followed by adjuvant chemotherapy. 2 years after the surgery, the patient is in full remission, free of any relapse. Liver resection or RFA is not commonly used in the gastric cancer with liver metastasis (GCLM). At present, there is no direct marker available to define the degree of biological aggressiveness of the tumor (indicating or contra-indicating the surgical treatment), therefore we are left to rely on indirect prognostic factors: cancer invasion in the gastric wall serosa, presence of 3 and more liver metastases, size of metastasis exceeding 50 mm (Fig. 2, Ref. 13).

Impact of intracranial pressure measurement on survival in patients with severe traumatic brain injury.

OBJECTIVE: The aim of the study was to assess (i) a group of patients with established intracranial pressure (ICP) sensor in severe brain injuries scoring 3 points of Glasgow Coma Scale, (ii) mortality and survival of the patients within periods of 7, 30, 180 and 270 days; and (iii) predictive value of intracranial pressure and cerebral perfusion pressure for short and long-term survival of patients with traumatic brain injury. MATERIAL AND METHODS: The group consisted of 61 patients with trauma brain injury scoring 3 points of Glasgow Coma Scale, continuously monitored for intracranial pressure cerebral perfusion pressure at the Intensive Care Unit setting in Nové Zámky. Follow-up period was between 7 and 270 days. Measured values and other recorded data were analysed using methods of descriptive and inferential statistics. RESULTS: ICP values below 20 mmHg were associated with a significantly lower risk of death of an individual patient at particular time. Accordingly, cerebral perfusion pressure values above 70 mmHg during 0-2 days were associated with a significantly higher long-term survival. Overall mortality rates within 30 days showed no peaks on survival curves. In the periods of 0-7 days, within 30 days, and between 30 and 180 days we recorded 24, 51 and 2 deaths, respectively. In the period between 180 and 270 days, mortality was zero. CONCLUSION: The survival of trauma brain injury patients depends on the speed and quality of pre-hospital care and adequate follow-up treatment at specialized intensive care units. High levels of intracranial pressure and low cerebral perfusion pressure values in the early period after brain injury are closely related to mortality of patients within 30 days. Intracranial pressure monitoring may help to avoid problems and allow intervention before they become life-threatening (Tab. 4, Fig. 4, Ref. 23). Text in PDF www.elis.sk.

Epidemiology of severe sepsis in intensive care units in the Slovak Republic.

BACKGROUND: We investigated the number, clinical characteristics, and outcomes of ICU patients, who met precise clinical and physiological criteria for severe sepsis (as defined in the PROWESS study) in Slovak intensive care units. We designed an observational cohort epidemiological study with retrospective analysis of prospectively collected data. 12 adult general intensive care units participated in the Slovak Republic between July and December 2002. PATIENTS AND METHODS: Patients included 1,533 adult ICU admissions during the second half of 2002 in 12 adult ICUs. Descriptive statistical methods (independent sample T-test, chi(2) test, and linear Pearson coefficient of correlation) were used. RESULTS: We found that 7.9% of hospitalized critically ill patients met severe sepsis criteria in the intensive care units. The most frequent primary sources of infection were lungs and abdomen. Hospital mortality of severe septic patients was 51.2% (62 pts/121 pts). Most patients (85.1%) were > 40 years of age. Mortality increased with age; mean average age of survivors (53 years) was significantly lower than in nonsurvivors (61 years, p = 0.01). Factors associated with mortality were age over 50 years, three or more dysfunctional organs, and elevated admission and maximum SOFA scores. Survivors had a significantly lower number of sites with organ system dysfunction (MODS 2.56) than nonsurvivors (MODS 3.98). SOFA score seems to be a valuable tool to differentiate survivors from nonsurvivors. All the septic patients had SOFA scores greater than 4 points. Survivors of severe sepsis were characterized with significantly lower admission and maximum SOFA scores (median 8.7 and 9.4 points, respectively) than septic nonsurvivors (median 11.6 and 14.0 points, respectively, p = 0.001). CONCLUSION: We estimate 1,770 cases of severe sepsis hospitalized at Slovak adult intensive care units per year. Hospital mortality for severe sepsis remains very high (51.2%) and is associated with advanced age (over 50 years), number of failing organs and higher admission and maximum SOFA scores.

[Radiation navigated reoperations of the thyroid gland in differentiated carcinoma]. / Radiacne navigované reoperácie stítnej zlazy pre diferencovaný karcinóm.

Radiation-navigated reoperations of the thyroid gland for the differenciated carcinoma are reserved for such cases of the thyroid gland reoperations aiming to complete a total thyroidectomy and, also, to extirpate metastatically affected lymphonodes. The authors discuss this part of the above surgical procedure, its therapeutic prospects, as well as its cons. They recommend already the primary surgical procedure on the thyroid gland to be conducted carefully--i.e. to conduct at least a lobectomy of the thyroid gland followed by visualization and examination of the recurrent laryngeal nerve and the parathyroid glands. They recommend the reoperations to be concentrated in specialized centres.

[Completing total thyroidectomy with lymph node dissection using a scintillation probe--case report]. / Dokoncenie totálnej tyroidektómie s disekciou lymfatických uzlín za pomoci scintilacného detektora--kazuistika.

Surgery remains the basic therapeutical method of the thyroid gland papillary carcinoma treatment. It is complemented by the adjacent thyro-eliminating therapy. A remarkable number of the thyroid gland carcinoma cases is still being diagnosed accidentally during the surgery for the thyroid gland benign disorders. The above mentioned patients, then, must undergo a reoperation, in order for the total thyroidectomy (TTE) and the lymphonodes dissection (LU) to be finished. The reoperations should be conducted in specialized clinics by sufficiently proficient teams. Our study reviews a case of a patient who underwent three surgeries on his thyroid gland.

Renal rescue therapy in early stage of severe sepsis: a case study approach.

OBJECTIVE: The aim of this study was to evaluate the efficacy of noradrenaline and furosemide in combination for the treatment of impending acute renal failure in early stage of severe sepsis. DESIGN: observational case study. SETTING: Nine-bed general ICU in university-affiliated cancer institute. PATIENTS: Severe septic cancer patients admitted to the ICU. MEASURMENTS AND RESULTS: 17 severe septic patients with multiorgan dysfunction syndrome (admission SOFA score, mean 9.1+/-3.0 p, and APACHE II score, mean 20.4+/-5.1 p.) received full intensive treatment including volume expansion, hemodynamic support with noradrenaline infusion and low-dose hydrocortisone. Severe sepsis was documented by proven infection, site of infection and high levels of procalcitonin (mean value 69.8 ng/ml, 7.1-588 ng/ml), C-reactive protein (mean 210 mg/l, range 49-370 mg/l) and low total cholesterol levels (mean 2.36 mmol/l, range 1.3-3.9 mmol/l). Acute renal injury and acute renal failure syndrome were detected in 14 patients (82 %) out of 17. The combination of noradrenaline continuous infusion (0.06-0.12 microg/kg/min) and furosemide infusion (10-30 mg/hr) was used for hemodynamic and renal support. We induced polyuria and reverse acute tubular necrosis to nonoliguric acute renal failure in 11 patients (78.5 %) from 14 septic cancer patients with acute renal injury/failure syndrome. We recorded 35.2 % hospital mortality due to the severe sepsis and septic shock. We used no renal replacement therapy. CONCLUSION: We consider renal rescue protocol as an effective method in the treatment for acute renal injury/failure syndrome in early phase of severe sepsis, when it is instituted very early with low/moderate dosage of noradrenaline and furosemide. (Tab. 6, Ref. 29.)

Rescue systemic thrombolysis during cardiopulmonary resuscitation.

The main goal of the cardiopulmonary resuscitation is good neurological outcome. The primary ischaemic insult initiates a multitude of coagulation and inflammatory cascades resulting in cytotoxic brain oedema, necrosis and apoptosis. Thrombolytic agents may have experimentally and clinically significant beneficial effects in non-traumatic cardiac arrest. Prospective clinical trials show that thrombolytic therapy combined with heparin is feasible, safe and effective during resuscitation. We demonstrate three cases of successful systemic thrombolysis during in hospital CPR in cancer patients. Two patients were successfully resuscitated from cardiac arrest with streptase bolus (500.000 IU) and infusion (100,000/hr). One patient with pulmonary embolism and gynecological bleeding were treated with bolus (10,000 IU) and infusion of heparin (1,000 IU/hr) and successfully resuscitated. We observed a very good neurological outcome in all 3 cases following rescue thrombolysis and standard CPR. Two patients were discharged from hospital in good neurological outcome. One patient died on ICU on 10th day due to myocardial re-infarction and biventricular failure. Systemic thrombolysis is safe and effective treatment modality during resuscitative efforts even in cancer patients. In oncological patients with dissemination and/or bleeding heparin therapy should be considered due to better clinical control. (Ref. 17.)

Ratio of neutrophil to lymphocyte counts--rapid and simple parameter of systemic inflammation and stress in critically ill.

BACKGROUND: For many years, the intensivists are searching for an easily measurable and available parameter which might reflect the intensity of stress and/or systemic inflammation in critically ill patients following shock, multiple trauma, major surgery or sepsis. Recently, some authors have described the onset of significant lymphocytopenia after polytrauma, major surgery, endotoxaemia and sepsis. We investigate whether serial examination of white blood cell counts may reflect and clarify the immune response to stressful events in critically ill patients. GOAL: We have designed a prospective longitudinal observational study to investigate serial changes in circulating neutrophil and lymphocyte counts following major surgery, unscheduled surgery and sepsis. METHODS: We have investigated the differential white blood cell counts and the clinical course in 90 oncological ICU patients. We compared three groups: group A consisting of 62 patients who underwent scheduled colorectal surgery, group B consisting of 18 patients who underwent unscheduled surgery for abdominal sepsis, group C consisting of 10 medical ICU patients who were treated for severe sepsis and septic shock. The severity of clinical course was expressed by means of SOFA score (group A 0.3-1-1.3 point, group B 2.2-2.9-2.6 point, group C 7.4-8.3-7.7 point) and APACHE II score (group A 3.7-7.6-8.1 point, group B 8.6-11.1-10.5 point, group C 16.3-15.2-14.3 point). Differential white blood cell counts were investigated on blood cell counter SYSMEX SF 3000 in 4 consecutive periods: 1 day one before surgery, 0 the day of surgery or ICU admittance, 1 day one after surgery (or the 1st ICU day), 2nd day following surgery (or the 2nd ICU day). The measured values of neutrophils and lymphocytes were expressed as relative counts (%) of the whole all white blood cell population. RESULTS: The physiologic response of circulating leukocytes to surgical stress in group A is characterized by the onset of marked neutrophilia (62.5% before surgery up to 84.4% after surgery) and significant lymphocytopenia (28.1% before surgery to 10.3% following surgery). We observed a slow decline in neutrophil counts and an increase in lymphocyte counts since the 1st postoperative day. The patients with abdominal infection (group B) had elevated counts of neutrophils already before surgery (83.2%) and low values of lymphocyte counts (9.5%). A further increase in neutrophil counts (89.9%) and marked lymphopenia (7%) were recorded during the post-surgical period in group B. Critically ill patients with severe sepsis or septic shock (group C) had significantly highest values of neutrophil relative counts (94%-93.1%-92.5%, p < 0.05 against group A) and marked lowest values of lymphocyte counts (3.8%-4%-3.7%, p < 0.05 against group A). The severity of clinical course (according SOFA and APACHE II score) correlated with the divergence of neutrophil and lymphocyte counts in the white blood picture (marked neutrophilia and lymphocytopenia). CONCLUSION: In the population of 90 ICU oncological patients, we observed rapid serial changes in white blood cell populations, as a response of the immune system to surgical stress, systemic inflammation or sepsis. Preliminary results show the correlation between the severity of clinical course and the grade of neutrophilia and lymphocytopenia. The ratio of neutrophil and lymphocyte counts (in absolute and/or relative % values) is an easily measurable parameter which may express the severity of affliction. We suggest the term: neutrophil-lymphocyte stress factor, as a ratio of neutrophil to lymphocyte counts, which can be routinely used in clinical ICU practice in intervals of 6-12 and 24 hours. The prognostic value of neutrophil-lymphocyte stress factor should be evaluated in further studies. (Tab. 6, Fig. 5, Ref. 12.)

[Serum neopterin levels in oncology patients in intensive care]. / Hladiny sérového neopterínu u onkologických pacientov v intenzívnej starostlivosti.

BACKGROUND: Elevated neopterin serum levels are associated with diseases that stimulate the cellular immune response. This includes viral infections, autoimmune diseases, transplant rejection and dissemination of certain types of cancer. T-helper lymphocytes and macrophages play a key role in neopterin synthesis. The degree of activation of Th1-lymphocytes is responsible for the production of interferon-gamma and interleukin-2, which stimulate neopterin production in human macrophages. DESIGN AND METHODS: We have designed a prospective observational study to assess the dynamics of serum neopterin levels in 75 oncological patients during post-surgery period. We measured serum neopterin by means of RIA method (radioimmunoassay) in 50 uncomplicated surgery patients (group A), in 15 complicated surgery patients (group B--abdominal sepsis, peritonitis, ileus) and 10 medical ICU patients (group C). Serum levels of neopterin were measured in 5 consecutive periods: before surgery, after surgery, and on the 1st, 2nd, 3rd postoperative days. RESULTS: In all groups, we observed gradual elevation of serum neopterin. The lowest values of neopterin were measured in group A in patients with uncomplicated course following surgery: 6.75 nmol/l, 7.67 nmol/l, 8.9 nmol/l, 10.82 nmol/l and 13.66 nmol/l. A significant increase in serum neopterin levels was measured in group B in patients with septic complications during perioperative period: 18.9; 23.2; 26.82; 29.53 and 27.32 nmol/l. High values of neopterin were also measured in medical ICU patients with disseminated cancer and sepsis during ICU stay: 26.1; 58.1; 28.7 and 22.5 nmol/l. We concluded that serum neopterin levels were increased during the post-surgery period. We observed a significant increase in serum neopterin in patients with severe systemic infection or sepsis or in patients with cancer progression or dissemination (more than 15-20 nmol/l). Neopterin is a simple, reliable and sensitive parameter of cell-mediated immunity, suitable for early diagnosis of viral, autoimmune and transplantant rejection diseases. Neopterin can be used also for non-specific laboratory monitoring of cancer progression and/or dissemination. (Tab. 3, Fig. 4, Ref. 7.)

[Parameters of energy metabolism in patients after vascular reconstructive surgical procedures]. / Niektoré parametre energetického metabolizmu u pacientov pocas cievneho rekonstrukcného chirurgického výkonu.

Revascularization surgery in patients with peripheral arterial occlusive disease presents an acceptable clinical model for studying the rate of ischaemia-reperfusion injury of cells and other structures of skeletal muscle of the affected extremity. Validity of carefully chosen set of biochemical parameters for determination of this injury during and after surgery as well as in the early and late reperfusion periods and during the readaptation to situation after restoration of blood circulation was verified. Blood samples were taken from the regional common femoral vein which allowed to obtain information directly from the ischaemized extremity. Analyzed biochemical parameters have given useful information about the situation in acid-base regulation, in energy metabolism as well as antioxidant capacity. These parameters were estimated in four time intervals: before aorta cross-clamping (preischaemic phase), then 30 min (early reperfusion) and 18 hours (readaptation period) after aorta-declamping. In the early reperfusion period a marked acidosis and raised carbon dioxide tension, significant increase of lactate and pyruvate levels as well as increased hypoxanthine plasma level were observed. On the contrary, in this period the lowest lipoperoxide level was found, evident in the wake of relative stability of concentration of endogenous antioxidants documented by a constant glutathione redox status that at the first postoperative day even significantly decreased as a consequence of a drop of oxidized and increased of reduced form of glutathione. Therefore, the applied biochemical parameters allow to monitor the ischaemia-reperfusion damage of afflicted region and could be used even in the study of compounds with a protective effect against possible injury of ischaemized and reoxygenized tissues. (Tab. 3, Fig. 4, Ref. 32.)

Transatrial access for left atrial pressure monitoring in cardiac surgery patients.

We describe a simple method for left atrial pressure (LAP) monitoring from the right to the left atrium (LA) by a central line catheter. The anesthesiologist cannulates vena jugularis interna and inserts two central line catheters. One catheter is placed in the vena cava superior and the second single-lumen catheter is placed in the right atrium. The surgeon positions a one-line catheter from the right in the LA during the transatrial surgical procedure. This new access diminishes bleeding complications.

[Alternative use of the EEA stapler in subtotal esophagectomy]. / Alternatívna aplikácia EEA staplera po subtotálnej ezofágektómii.

Authors describe the successful usage of EEA stapling by reconstruction after subtotal oesophagectomy of carcinoma in the middle third of oesophagus. EEA stapling was pushed in transorally and oesophagogastric anastomosis was made. Neither pre- or post-operative complications occurred by this procedure. Patient left the hospital on 14th day afer the operation. Authors consider transoral application of EEA stapling as effective alternative in creation of oesophagogastric anastomosis after subtotal oesophagectomy.