Treatment Responses in Histologic Versus Molecular Diagnoses of Lung Rejection.

Histologic evaluation of allograft biopsies after lung transplantation has several limitations, suggesting that molecular assessment using tissue transcriptomics could improve biopsy interpretation. This single-center, retrospective cohort study evaluated discrepancies between the histology of transbronchial biopsies (TBBs) with no rejection (NR) and T-cell mediated rejection (TCMR) by molecular diagnosis. The accuracy of diagnosis was assessed based on response to treatment. 54 TBBs from Prague Lung Transplant Program obtained between December 2015 and January 2020 were included. Patients with acute cellular rejection (ACR) grade ≥ 1 by histology received anti-rejection treatment. Response to therapy was defined as an increase in FEV1 of ≥ 10% 4 weeks post-biopsy compared to the pre-biopsy value. Among the 54 analyzed TBBs, 25 (46%) were concordant with histology, while 29 (54%) showed discrepancies. ACR grade 0 was found in 12 TBBs (22%) and grade A1 ≥ 1 in 42 TBBs (78%). Treatment response was present in 14% in the NR group and in 50% in the TCMR group (p = 0.024). Our findings suggest that low-grade acute cellular rejection is less likely to be associated with molecular TCMR, which might better identify lung transplant recipients who benefit from therapy.

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.

[Surprising findings during thoracic revision due to gunshot injury - a case report]. / Prekvapivý nález pri revizi hrudníku pro strelné poranení - kazuistika.

INTRODUCTION: Gunshot thoracic injuries are not very common in our geographical location, occurring most frequently in the context of criminal activity or as a result of suicidal behavior. CASE REPORT: The authors report the case of a patient who, in a suicidal attempt, caused himself a combined penetrating gunshot injury of the chest with laceration of the lung and a heart gunshot hole, which was diagnosed peroperatively. CONCLUSION: Therapy of gunshot injuries in the era of modern medicine should be comprehensive in multidisciplinary cooperation.Key words: thoracic trauma gunshot injury lung injury heart injury thoracotomy.

[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.

Long-term outcomes and prognostic factors of patients with pulmonary carcinoid tumors.

The aim of the study was to evaluate type of surgery, long-term survival and factors influencing outcome of pulmonary carcinoid tumors. We reviewed our database of 137 patients surgically treated for typical or atypical carcinoid tumors at our department between 1998 and 2013. There were 95 (69%) patients with typical carcinoid (87 N0, 6 N1, 2 N2) and 42 (31%) with atypical carcinoid (26 N0, 8 N1, 8 N2). Patients with atypical carcinoid were older than those with typical carcinoid (median age of 57±8.1 and 50.5±15.8 years, respectively, p<0.00001). The resection performed consisted of 6 (4.4%) pneumonectomies, 110 (80.1%) lobectomies and bilobectomies, 15 (11%) sleeve lobectomies, 2 (1.5%) resections of main bronchus and 4 (3%) wedge resections. Overall 5- and 10-year survival rates for different tumors were as follows: typical carcinoid: 97.2% and 89.9%, respectively; atypical carcinoid 71.1% and 62.2%, respectively. Statistical analyses indicated that histology (typical carcinoid, p<0.00001), age (less than 45 years, p=0.004) and nodal status (N0, p=0.0002) were significant prognostic factors for better prognosis. Histological sub-type and nodal involvement appear as the most important factors influencing the prognosis. Systemic lymphadenectomy is recommended and should always be performed.

[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.

Pneumonectomy for non-small cell lung cancer: predictors of early mortality and morbidity.

BACKGROUND: The aim of this study was to determine independent risk factors affecting postoperative morbidity and mortality after pneumonectomy for non-small cell lung cancer (NSCLC). METHODS: A review of 329 patients having pneumonectomy for NSCLC between January 1, 1998 and July 31,2012 was undertaken. Factors affecting morbidity and mortality were analyzed by univariate and multivariate analyses. RESULTS: The overall 30-day mortality rate was 5.1%. Smoking habits, chronic obstructive pulmonary disease (COPD) status, neoadjuvant therapy and obesity had no statistical influence on the short-term outcome. Coronary artery disease and respiratory failure were identified as risk factors for increased 30-day mortality (p < 0.01). Right pneumonectomy and presence of respiratory failure with mechanical ventilation increased the incidence of bronchopleural fistula (p < 0.01). CONCLUSIONS: Pneumonectomy for NSCLC carries an acceptable operative morbidity and mortality. Coronary artery disease, right pneumonectomy and respiratory failure adversely affect morbidity and mortality after this procedure.

[Reexpansion pulmonary oedema after drainage of a long-term spontaneous pneumothorax - a case report]. / Reexpanzní edém plíce po drenázi dlouhotrvajícího spontánního pneumotoraxu - kazuistika.

Reexpansion pulmonary oedema is a rare but possibly lethal complication of thoracic drainage for pneumothorax. Morbidity and mortality of this complication remains high (up to 20% of lethal cases) and as such deserves our attention. We report a case of ipsilateral left-sided pulmonary oedema following chest tube insertion in a 42-year-old male patient with spontaneous pneumothorax. Pneumothorax can be expected to last for up to 3 weeks (from the first presentation of sudden dyspnoea and chest pain). The pathophysiology of this lung affection has not yet been completely elucidated; the crucial role is probably played by damage to the endothelium which is followed by increased endothelial permeability during ischemia-reperfusion injury in a rapidly reexpanding lung. The main risk factors for the development of RPE are young age (the younger the patient, the higher the risk), the female sex, the degree of lung collapse, a pneumothorax that lasts more than 24 hours, a reexpansion of the lung in less than ten minutes, the use of a suction system, and - in cases of a pleural effusion - an evacuation volume of more than 2000 ml. Although in patients with these risk factors the administration of initial negative pressure should be avoided, this procedure remains common practice in pneumothorax treatment in the Czech Republic. Thoracic surgeons are more likely to use the suction system than pulmonologists (70% versus 52%). RPE manifestation ranges from benign clinical course (patients are free of complaints with only pathological chest radiography findings) to potentially lethal rapid respiratory failure with circulatory shock. Most patients develop RPE within 1 hour of expansion and the ipsilateral lung is affected. Only rarely can pulmonary oedema be bilateral, or in the contra-lateral lung. Treatment of RPE is supportive and depends on the individual patients condition, ranging from mere monitoring to mechanical ventilation for serious cases. Positive pressure mechanical ventilation and the utilization of positive end-expiratory pressure (PEEP) remains the gold standard of treatment.

[Timeline trends in surgery of bronchogenic carcinoma]. / Casové trendy chirurgické terapie bronchogenního karcinomu.

BACKGROUND: The aim of our study was to determine how patient preoperative status and outcomes of resection have changed over last 12 years. MATERIAL AND METHODS: This retrospective study of prospective database included 1412 patients operated from January 1,1998 through December 31,2009. Patient characteristics and outcomes were compared for two time periods (1998-2003 and 2004-2009). RESULTS: We performed 985 lobectomies with 30-days mortality 1.8% and 300 pneumonectomies with 30-days mortality 5.7%. Median of survival of all 1412 patients was 4.3 year and 5-year survival was 45%. The percentage of female patients, lobectomies and adenocarcinoma increased over time, as well as age of our patients. Outcome improved over time, with significant decrease in 30-days mortality after pneumonectomy (8.2% vs. 2.3%, p = 0.029). The overall 3-year survival improved in patients with III. stage (30 % vs. 40%, p = 0.012). CONCLUSION: Our study identified time trends which are in-line with increased incidence of lung cancer among women and with improvement of preoperative evaluation, preoperative and postoperative care

Risk factor analysis for early mortality and morbidity following pneumonectomy for non-small cell lung cancer.

OBJECTIVES: The purpose of this report is to analyze factors affecting morbidity and mortality following pneumonectomy for non-small cell lung cancer (NSCLC). METHODS: We reviewed our institutional experience with all consecutive patients undergoing pneumonectomy for NSCLC from 1998 to 2010. Patients were analyzed with regard to hospital mortality and morbidity and long-term outcome. RESULTS: There were 310 patients following pneumonectomy. Overall 30-day mortality rate was 5.5 %. Chronic obstructive pulmonary disease, induction therapy, smoking habits and obesity had no statistical influence on short-term outcome. Coronary artery disease and respiratory failure were identified as risk factors for increased 30-day mortality (p<0.01). Right pneumonectomy and presence of respiratory failure with mechanical ventilation increases the incidence of bronchopleural fistula (p<0.01). CONCLUSIONS: Patients with right pneumonectomies are at increased risk. Coronary artery disease and respiratory failure adversely affect morbidity and mortality after this procedure (Tab. 3, Ref. 19). Full Text in free PDF www.bmj.sk.

Time trend in the surgical therapy of lung cancer.

BACKGROUND: The purpose of our study was to clarify results of surgery for non-small cell lung cancer (NSCLC) and its time trends. METHODS: We retrospectively reviewed our prospective database of patients who underwent surgery for NSCLC between 1998 and 2009 in our institution. Patients were divided into two equal 6-year periods according to the year of surgery (1998-2003 and 2004-2009). RESULTS: One thousand, four hundred and twelve patients underwent operation for NSCLC. We performed 985 lobectomies with 30-days mortality of 1.8 % and 300 pneumonectomies with 30-days mortality of 5.7 %. Median of survival of all 1412 patients was 4.3 year and 5-year survival was 45 %. The percentage of female patients, lobectomies and adenocarcinomas increased over time, as well as the age of our patients. Outcome improved over time, with significant decrease in a 30-days mortality after pneumonectomy (8.2 % vs 2.3 %, p=0.029). The overall 3-year survival improved in patients with stage III (30 % vs 40 %, p=0.012). CONCLUSION: Outcomes of lung resection for NSCLC improved over time despite a worsening of some elements of preoperative status. The shift in histological distribution was associated with an increasing proportion of patients with stage I, a lower operative mortality and better 3- and 5-year survival. These trends are due to improvement of preoperative evaluation, preoperative and postoperative care (Tab. 1, Fig. 2, Ref. 9). Full Text in free PDF www.bmj.sk.

[Lung transplantation]. / Transplantace plic.

Lung transplantation is an effective life-saving therapy for the treatment of a variety of end-stage lung diseases. However, the application of lung transplantation is hindered by multiple factors such as the shortage of organ donors, early graft failure, infection, and chronic graft dysfunction. A novel strategy for donor lung preservation--ex-vivo lung perfusion (EVLP)--that keeps the organ at physiological protective conditions, has shown great promise to increase lung utilization by reassessing, treating, and repairing injured donor lungs prior to transplantation. Infections are a major cause of early morbidity and mortality after lung transplantation. Because of the potential association of infections such as respiratory viral infections and gram-negative bacterial infections with bronchiolitis obliterans syndrome, prompt attention to these pathogens is critical. Despite marked improvements in early survival, long-term outcome after lung transplantation is still threatened by bronchiolitis obliterans syndrome. The program of lung transplantation in Czech Republic was started in University Hospital Motol in Prague in 1997. Nowadays in Czech Republic is performed about 20 transplants every year with results comparable to other advanced centers. Until September 2011, 175 transplants were carried out in Czech Republic.

Lung transplantation in cystic fibrosis patients in the Czech Republic: initial single-center experience.

BACKGROUND: Lung transplantation is a well established treatment for advanced lung diseases. METHODS: We compared the clinical results of patients with cystic fibrosis (CF) entered into the waiting list with those of patients after lung transplantation. RESULTS: Among 36 patients with CF on the waiting list, 23 underwent lung transplantation, 8 died, 3 are still on the waiting list, and 2 were excluded from the waiting list. The median waiting list time of 0.48 years (range, 0.03-2.37) was insignificantly longer for patients who died compared with transplanted patients (0.97 vs 0.44 years). Mortality of waiting-list patients was 25.8%. The median survival of transplant patients of 7.48 years (range 0.00-10.85 years) was significantly lower among patients who were colonized (BCC) versus those who were not Burkholderia cepacia complex (0.19 vs 7.48 years; P = .041). The 1-, 3-, and 5-year patient survivals after lung transplantation were 72.9, 54.4, and 54.4, respectively. CONCLUSION: The results of patients with cystic fibrosis on the waiting list versus after lung transplantation in our center were similar to those reported in the literature. We confirmed a less favorable prognosis of BCC-colonized patients.