The comparison of modified minimally invasive and open surgical approaches in the treatment of epithelial thymic tumours.

OBJECTIVES: Exploring the efficacy of a modified combined minimally invasive approach in patients with thymoma regardless of myasthenia gravis involvement in contrast to open surgery as the mainstay of treatment. BACKGROUND: Primary epithelial thymic tumours are rare malignancies of the anterior mediastinum, often present with myasthenia gravis, and with good prognosis when assuming complete surgical resection. We present a modified mini-invasive technique (MIT) that is unique in its extent. METHODS: Fifty-two patients were included in this retrospective study. Two groups of patients who had undergone different types of surgery were compared using the Mann-Whitney test (ordinal variables) and Fisher's exact test (binary variables). Changes after completing the surgical learning curve were observed. RESULTS: There was a statistical difference when comparing early Masaoka stages (I‒II) with later stages in favour of the mini-invasive method (p=0.013). The duration of surgery was longer in the mini­invasive group with a median value of 260 vs 133 min (p=0.001). The analysis of operation times revealed that after overcoming the learning curve period, the duration of surgery decreased (2008‒2012: 297 min; 2013‒2018: 199 min; p=0.005). The systemic complication rate was lower in the mini­invasive method (26.1 % vs 3.4 %; p=0.035). CONCLUSION: Our results showed the modified maximal minimally invasive thymectomy to be an effective and safe method, and after overcoming the learning curve, even superior to open surgery in cases with lower tumour stages in terms of its extent (Tab. 3, Fig. 1, Ref. 49).

Management of oesophageal anastomosis dehiscence after oesophagectomy for oesophageal cancer.

Oesophagectomy is being used in treatment of several oesophageal diseases, most commonly in treatment of oesophageal cancer. It is a major surgical procedure that may result in various complications. One of the most severe complications is anastomotic dehiscence between the gastric conduit and the oesophageal remnant. Anastomotic dehiscence after esophagectomy is directly linked to high morbidity and mortality. We propose a therapeutic algorithm of this complication based on published literature and our experience by retrospective evaluationof 164 patients who underwent oesophagectomy for oesophageal cancer. Anastomotic dehiscence was present in 29 cases.

“Maximal” minimally invasive thymectomy in patients with Nonthymomatous Myasthenia Gravis - short-term results over a 10year period - retrospective study.

INTRODUCTION: Thymectomy has always been considered an important treatment modality for patients with Myasthenia Gravis (MG). Because of the absence of randomized trials, its exact role was not clear and was even questioned by some. Indications for surgery were made on empirical basis. It was not until the results of the first randomized double- blinded multicentric study were published, where the combined surgical treatment of patients with nonthymomatous MG was proved superior to conservative treatment alone. In this study the technique of extensive thymectomy via longitudinal sternotomy was used as a mainstay of surgical treatment. In the advent of minimally invasive techniques a variety of options were presented for minimally invasive surgical treatment of thymic pathology. METHODS: The authors present a retrospective analysis of short term results using the slightly modified method of “Minimally Invasive Maximal Thymectomy” developed by Zielinski over a 10 year period (20082018). Besides the demographics, we assessed the peri- and postoperative results such as the length of surgery, blood loss, the need for conversion, learning curve impact, the lengths of drainage and hospital stay and the complication rate, both surgical and systemic. RESULTS: 48 patients underwent surgery using the above mentioned method for non-thymomatous MG. 81.25% (n=39) of patients were diagnosed with a seropositive generalized form of MG, 6 (12.5%) had seropositive ocular form and 3 patients (6.25%) had seronegative form of the disease. The sex ratio profoundly favored females (89.5%; n=43). The median value of the length of surgery was 186,5 minutes, the mean LOS and length of drainage were 4 and 3 days, respectively. CONCLUSION: According to our results and experience with Minimally Invasive Maximal Thymectomy, we found it to be an effective and safe method for MG patients after conquering the learning curve.

Complicated case of patient with cervical necrotising fasciitis and descending necrotizing mediastinitis case report.

Descending necrotizing mediastinitis is a severe, fulminant, life-threatening bacterial infection of the mediastinum. Even though improvements in diagnostics and treatment were achieved, the mortality rate remain shigh. Contrast-enhanced CT of chest and neck is the diagnostic gold standard. Radical debridement and drainage of the mediastinum should be considered the primary therapeutic target. The authors present a complicated case of a female patient with cervical necrotizing fasciitis and descending necrotizing mediastinitis. She was initially treated for a deep neck infection at the department of otorhinolaryngology. Surgical treatment, antibiotics, and intensive care became an integral part of the therapy after the transfer to the department of thoracic surgery. The authors had to face various complications with tracheostomy and extensively debrided soft tissues in the neck region. That is why the patient underwent repeated surgeries during several hospital stays, with an overall duration of treatment reaching 220 days.

Unexpected finding of an ablation catheter during thoracoscopic exploration for a spontaneous hemothorax - case report.

Varicose veins of lower extremities represent a common medical condition with minimally invasive percutaneous endovenous ablation techniques as a treatment of choice. A very rare complication is a catheter migration in the deep venous system. In the literature only 7 cases have been published so far, with only 2 cases with migration to the systemic circulation and heart involvement. In this paper we present an interesting case report from the perspective of a thoracic surgeon with the finding of a laser ablation catheter remnant in the left pleural cavity during thoracoscopic exploration for a spontaneous hemothorax in a 47-year old male patient after collapse. A similar complication affecting the pleural cavity has not been published before. In this paper we discuss possible routes of the cathether migration into the left pleural cavity, impending complications when a part of the catheter is left behind in the body and the means of prevention of these serious potentially fatal complications even after many years following the initial treatment.

[Short-term results of minimally invasive pectus excavatum repair in adult patients]. / Krátkodobé výsledky minimálne invazívnej korekcie pectus excavatum u dospelých pacientov.

INTRODUCTION: Pectus excavatum is the most common congenital chest wall deformity. Aproximatelly 1 out of 400 to 1000 newborns are affected by this diagnosis. Surgical correction is indicated in patients that fulfil the indication criteria. The highly modified Ravitch correction (HMRR) and minimally invasive pectus excavatum repair (MIRPE) are by far the most popular methods of correction. MIRPE has been established as the method of choice amongst children. Feasibility of the minimally invasive approach in the funnel chest correction in adult population still remains controversial. METHODS: The authors present a retrospective analysis of adult patients treated by MIRPE in their institution. Sixty adult patients with pectus excavatum underwent MIRPE from October 2010 to March 2015. Various parameters were evaluated retrospectively. The effectiveness and safety of both techniques were evaluated with the use of statistical software SPSS® version 21.0 (IBM, USA). Data were evaluated using Student´s t-test or Mann-Whitney U-test for normally and non-normally distributed data, respectively. The comparison of categorical variables between the groups was evaluated by Pearson´s chi-square test. A p value of less than 0.05 was considered statistically significant. RESULTS: 45 men and 15 women underwent MIRPE during the period. Median age in the group was 23 years without any statistically significant difference between males and females (p=0.386). Median Haller index was 3.93 and was slightly higher in women (p= 0.285). Asymmetric deformities were present in 20 patients (33.3%) without any statistically significant difference between the sexes (p=0.206). Median duration of the surgical correction was 73 minutes and was longer in males (p=0.312). Two bars were implanted in 27 patients with no significant difference between the sexes (p=0.454). Complication rate was 25% (15/60) without any significant difference based on the number of implanted bars (p=0.178), sex (p=0.863) or the presence of an asymmetric deformity (p=0.527). Wound seromas with 10% (6/60) were the most common complication. Median postoperative length of stay was 5 days without any significant difference between males and females (p=0.653) and patients with different number of bars implanted (p=0.600). The need for rehospitalisation and reoperation was indicated in 5 patients (8.3%). Allergy to chromium led to bar extraction in 1 patient and 4 patients were treated by V.A.C.® therapy (KCI, USA) because of wound abscess (1) and seroma (3). CONCLUSION: Minimally invasive pectus excavatum repair is an effective surgical technique for the treatment of pectus excavatum in adult patients. This technique can be learned and performed safely even without any former experience with this correction in children. KEY WORDS: adult patients - MIRPE pectus excavatum.

[Surgical repair of recurrent pectus excavatum in adults and adolescents]. / Moznosti korekcie recidívy pectus excavatum u dospelých pacientov a adolescentov.

INTRODUCTION: Recurrent pectus excavatum is the most serious late complication after primary repair. Redo open repair (Highly Modified Ravitch Repair, HMRR) or minimally invasive repair of pectus excavatum (MIRPE) are usually performed in indicated cases. This paper focuses on the evaluation of available redo surgical techniques in adult and adolescent patients with recurrent pectus excavatum. METHODS: 126 operative corrections, predominantly in adult patients, were performed by the authors between June 2006 and October 2014. HMRR was the method of choice in 51 cases, and MIRPE in 75 cases. Recurrent pectus excavatum was the indication in 12 repair procedures (9.5%) in 11 patients. Prior repairs included HMRR in 10 patients and MIRPE in one case. Both HMRR and MIRPE were indicated as redo procedure in six cases. The median age in the redo group was 23.5 (1744) years and the median interval between the primary correction and the redo procedure was 9.5 (231) years. The male to female ratio was 3:1. RESULTS: The use of MIRPE resulted in shorter operation time (120 vs. 172 min). There was no difference in the length of postoperative hospitalisation. Three complications (50%) were recorded in the HMRR group (wound seroma, intrapericardial bar migration with hemopericardium, displaced rectus abdominis muscle) and one (16.7%) occurred in the MIRPE group (symptomatic fluidothorax). CONCLUSION: Despite our limited experience with both techniques in the treatment of recurrent pectus excavatum we believe that MIRPE should be regarded as a safe and effective technique for the redo repair in adolescent and adult patients.Key words: HMRR - MIRPE recurrent pectus excavatum.