Palate Lung Nasal Clone (PLUNC), a Novel Protein of the Tear Film: Three-Dimensional Structure, Immune Activation, and Involvement in Dry Eye Disease (DED).

PURPOSE: Palate Lung Nasal Clone (PLUNC) is a hydrophobic protein belonging to the family of surfactant proteins that is involved in fluid balance regulation of the lung. Moreover, it is known to directly act against gram-negative bacteria. The purpose of this study was to investigate the possible expression and antimicrobial role of PLUNC at the healthy ocular surface and in tears of patients suffering from dry eye disease (DED). METHODS: Bioinformatics and biochemical and immunologic methods were combined to elucidate the structure and function of PLUNC at the ocular surface. Tissue-specific localization was performed by using immunohistochemistry. The PLUNC levels in tear samples from non-Sjögren's DED patients with moderate dry eye suffering either from hyperevaporation or tear deficiency were analyzed by ELISA and compared with tears from healthy volunteers. RESULTS: Palate Lung Nasal Clone is expressed under healthy conditions at the ocular surface and secreted into the tear film. Protein modeling studies and molecular dynamics simulations performed indicated surface activity of PLUNC. In vitro experiments revealed that proinflammatory cytokines and bacterial supernatants have only a slight effect on the expression of PLUNC in HCE and HCjE cell lines. In tears from DED patients, the PLUNC concentration is significantly increased (7-fold in evaporative dry eye tears and 17-fold in tears from patients with tear deficiency) compared with healthy subjects. CONCLUSIONS: The results show that PLUNC is a protein of the tear film and suggest that it plays a role in fluid balance and surface tension regulation at the ocular surface.

Surgical therapy for necrotizing pneumonia and lung gangrene.

OBJECTIVE: Necrotizing pneumonia, pulmonary abscess, and lung gangrene are rare complications of severe pulmonary infection with devitalization and sloughing of lung tissue. Pulmonary necrosis is often associated with alcoholism and other chronic disorders with known immunodeficiency. Mortality is significant and both treatment strategies as well as the role of surgery are controversially debated. METHODS: In a retrospective review at a German tertiary referral hospital, 20 patients with pulmonary resection for necrotizing lung disorders were identified since 2008. At hospital admission, all patients suffered from pulmonary sepsis and despite adequate medical treatment progressing parenchymal destruction and devitalization took place. The majority of the patients sustained pleural empyema (13/20) and five patients a persisting air leak. On account of failing medical therapy, eight patients (40%) developed severe sepsis with septic shock and four patients (20%) were already preoperatively ventilated. Chronic alcoholism was present in 10 patients (50%). RESULTS: Gangrene of a complete lung was seen in four cases. Lobar gangrene or necrotizing pneumonia complicated by fulminate abscess was seen in the right lower lobe (8/20), middle lobe (4/20), right upper lobe (2/20), and left lower lobe (2/20). Procedures included pneumectomy (4/20), lobectomy (13/20), and limited resection (3/20). The bronchial stump was reinforced with a pedicle muscle flap in seven cases. There were three postoperative deaths due to septic shock with multiorgan failure. The remaining 17 patients (85%) recovered well and were transferred to rehabilitation clinics specialized on pulmonary disorders. CONCLUSION: Necrotizing pulmonary infections are infrequent but are life-threatening disease entities. Patients often present with severe comorbidity and chronic disorders causing immunodeficiency. If initial medical therapy fails surgery offers a reasonable therapeutic approach. Aim of surgical therapy is resection of all gangrenous lung parenchyma and effective drainage of pleural empyema. Then recovery is feasible in up to 80%.

The tale of spring water cysts: a historical outline of surgery for congenital pericardial diverticula and cysts.

Congenital pericardial diverticula and cysts are extremely uncommon lesions within the anterior mediastinum. Both lesions derive from the pericardial celom and represent different stages of a common embryogenesis. Initial reports date from the 19th century. Surgical pioneers were Otto Pickhardt, who removed a pericardial cyst at Lenox Hill Hospital in New York in 1931, and Richard Sweet, who accomplished the first resection of a pericardial diverticulum at Massachusetts General Hospital in Boston in 1943. These lesions were also called spring water cysts because they usually contain watery, crystal-clear fluid. This history outlines the milestones of evolving surgical management, from the first report in 1837 up to the present time.

Management of anastomotic leakage-induced tracheobronchial fistula following oesophagectomy: the role of endoscopic stent insertion.

OBJECTIVES: Tracheobronchial fistulas are rare but life-threatening complications after oesophagectomy. Leakage of the oesophagointestinal anastomosis with inflammatory involvement of the tracheobronchial tree is the predominant reason for postoperative fistulization between the airways and the oesophagus or the gastric tube. Successful management is challenging and still controversially discussed. After promising results in the treatment of intrathoracic anastomotic leaks, we adopted endoscopic stent implantation as the primary treatment option in patients with anastomotic leak-induced tracheobronchial fistula. The aim of this study was to investigate the feasibility, the limits and the results of this procedure. METHODS: Between January 2004 and December 2010, 222 consecutive patients underwent oesophageal resection mainly for oesophageal cancer. An anastomotic leak-induced tracheobronchial fistula was bronchoscopically verified in seven patients. Four patients received endoscopic implantation of either a self-expanding tracheal or oesophageal stent or both as primary treatment. Surgical re-exploration was mandatory in 2 patients because of necrosis of the pulled-up gastric tube or gangrene of the airways. One patient was conservatively managed. RESULTS: Endoscopic stent placement was successfully accomplished in all 4 patients. Two patients received an oesophageal stent, one patient a tracheal stent and one patient both an oesophageal and a tracheal stent. Closure of the fistula was achieved in all cases and 3 patients finally recovered while one died by reason of respiratory failure. In both surgical re-explored patients resection of the gastric tube was performed, and in one patient, because of subtotal gangrene of the right bronchial tree, emergency pneumectomy was also mandatory. Both patients died due to severe sepsis and respiratory failure. The one conservatively treated patient died from severe pneumonia. CONCLUSIONS: Treatment of anastomotic leak-induced tracheobronchial fistulas by means of oesophageal and tracheal stent implantation is feasible. If stent insertion is limited by gastric tube necrosis or bronchial gangrene, the prognosis is likely to be fatal.

Video-assisted thoracoscopic surgery for posttraumatic hemothorax in the very elderly.

OBJECTIVE: Thoracic injury is a life-threatening condition with advanced age being an independent risk factor for both higher morbidity and mortality. Furthermore, elderly patients often have severe comorbidity and in case of chest trauma with rib fractures and hemothorax, their clinical condition is likely to deteriorate fast. Aim of this study is to investigate the feasibility and results of video-assisted thoracoscopy for the treatment of posttraumatic hemothorax in very elderly patients of 80 years or more. METHODS: The outcomes of 60 consecutive patients who received video-assisted thoracoscopic surgery for posttraumatic hemothorax in a German tertiary referral hospital between 2006 and 2010 were reviewed in a retrospective case study. Patients older than 80 years were identified. RESULTS: There were 39 male and 21 female patients. The median age was 63.2 years. The in-hospital-mortality was 1.7% (1/60). Fifteen of the 60 patients were 80 years or older (80-91). Main reason for hemothorax was blunt chest trauma. Altogether 23 patients had fractures of three or more ribs including six octogenarians. Elderly patients suffered from preexisting cardiopulmonary disease and were often referred to the thoracic surgeon with considerable delay. Video-assisted thoracoscopic surgery was feasible and all octogenarian patients finally recovered well without in-hospital-mortality. CONCLUSIONS: Video-assisted thoracoscopic surgery for treatment of posttraumatic hemothorax shows excellent results in very elderly patients of 80 years or more. Despite severe comorbidity and often delayed surgery all patients recovered. We therefore conclude that advanced age is no contraindication for surgical management of posttraumatic hemothorax by means of video-assisted thoracoscopy.