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.

VATS lobectomy, history, indication, contraindication and general techniques.

VATS lobectomy is a respected modality of anatomic lung resections nowadays. Video-assisted lobectomies without rib extractor fulfil all current requirements for minimally invasive lung resections. This type of an anatomic pulmonary resection with a targeted treatment of hilar structures doesn't traumatize the intercostal space by using rib retractor. Videothoracoscope serves to visualize the surgical field on the screen. Assisted VATS (aVATS) lobectomy is a procedure using 3-5 cm working incision. Fully endoscopic resection (VTS) or complete VATS lobectomy (cVATS) are operations performed only through ports, without working incision. The authors supplement the article with a videorecord of VATS lobectomy general technique (Fig. 4, Ref. 11).

[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.

[Possibilities and results of surgical treatment of benign tracheoesophageal fistula]. / Moznosti a výsledky chirurgického riesenia benígnej tracheoezofageálnej fistuly.

AIM: Review of literature and a single-institution retrospective analysis of possibilities and results of various surgical techniques in treatment of benign tracheoesophageal fistula (TEF). MATERIAL AND METHODS: Between 1995 and 2010, 26 patients with benign tracheoesophageal fistula of various etiology underwent surgical treatment at the Department of Thoracic Surgery of Slovak Medical University and Faculty Hospital in Bratislava. The majority of patients had a postintubation TEF (21 cases), two fistulas were of traumatic origin, one iatrogenic, one congenital with adulthood manifestation and one tracheo-neoesophageal (TNEF) following an esophagectomy for carcinoma via extended cervical approach with lymphadenectomy and sternal retraction adpoted from transcervical extended mediastinal lymphadenectomy. We review the possible means of surgical treatment of TEF, of which we most frequently used segmental tracheal resection with end-to-end anastomosis and a non-overlying suture of the esophageal defect without muscle flap interposition (16 patients), transsection of the fistula with muscular flap interposition via cervical (2 patients) or transthoracic (1 patient) approach; or a T-tube insertion with (1 patient) or without (5 patients) discision and suture of the TEF. The only tracheo-neoesophageal fistula in our experience had been treated by neoesophagectomy, covering of tracheal defect by intercostal muscle flap and cervical esophagostomy. RESULTS: Short- and long-term results of TEF treatment in our institution have been favourable, with perioperative mortality of 3.8% (the patient with tracheo-neoesophageal fistula). Morbidity included 1 partial tracheal anastomotic dehiscence, 3 temporary left recurrent nerve palsies, temporary deglutition disorders (15 patients), tracheal anastomosis granulations in 1 patient and 2 wound infections. Out of 26 patients 15 (58%) are being followed-up on a regular basis, all with good (12 patients) or satisfactory (3 patients) functional results. CONCLUSION: In the paper we analyze the advantages and disadvantages of various techniques and their alternatives in the treatment of TEF. As the most reliable and suitable solution for patients with postintubation TEF, breathing spontaneously and with acceptable nutritional status, we favour segmental trachea resection with end-to-end anastomosis and esophageal suture without muscle interposition, regardless of presence of concomitant tracheal stenosis. Fistulae of other etiologies require diverse approaches, especially tailored with respect to their location. Management of tracheo-neoesophageal fistula following esophagectomy for carcinoma is extremely demanding. Therefore, it is crucial to adhere to basic rules of prevention of such benign but potentially fatal entities as TEF and TNEF.

[The management of restenosis following segmental resection for postintubation tracheal injury]. / Riesenie restenózy po segmentálnej resekcii pre postintubacné poranenie trachey.

AIM OF STUDY: In dealing with benign tracheal stenosis, segmental tracheal resection yields superior results in experienced hands when properly indicated, timed end executed. Several factors may contribute to early or delayed failure of resectional treatment. In our retrospective study we analyze the potential causes of tracheal restenosis in patients who underwent segmental tracheal resection for benign tracheal stenosis between 1995-2009 and propose an algorithm for prevention and treatment of such complication. PATIENTS AND METHODS: Between 1995-2009, of 249 patients with benign tracheal stenosis 169 underwent segmental tracheal resection with zero perioperative mortality. Of 9 serious anastomotic healing complications (5.3%) we experienced 2 partial and 1 complete anastomotic dehiscence, and 6 serious restenoses (3.6%). Another 2 patients with restenosis were referred from other hospitals. Four patients had a T-tube implanted, of these in 2 it was possible to restore airway continuity by means of a successful parastomic implantation of perforated rib cartilage and tracheoplasty. Two early and two delayed restenoses were dealt with by segmental re-resection. One of our patients with partial anastomotic dehiscence after first tracheal resection underwent a rib-cartilage tracheoplasty after initial T-tube insertion. Subsequently a slowly progressing restenosis had been treated by re-resection after 2 years of observation and worsening symptoms. RESULTS: In the patient with complicated history described above the long-term result of treatment continues to be uncertain. In the remaining 4 patients (80%) both anatomical and functional results of re-resection have been favourable even after a very long period of time (8-16 years). DISCUSSION: In the paper we analyze the causes of restenosis after segmental tracheal resection and propose an algorithm of restenosis treatment. We consider insufficient assessment of resected segment length and subsequent anastomosis construction in inflamed tracheal tissue to be the most important cause of early restenosis. The late restenoses in our experience were caused by excessive anastomotic tension and possibly by other factors, such as steroid medication. Indication and timing of re-resection depend also on identifying the cause of restenosis. Early restenoses possibly induced by technical error may be treated by reresection sooner than delayed restenoses, which usually require 6-12 months for inflammatory changes to subside. In both scenarios T-tube insertion represents a reliable temporary or even permanent solution.

Central airways stenoses management--a single institution experience.

Tracheal stenosis is a serious, life-threatening disease with an increasing tendency. The number of complicated tracheal lesions, where resection and anastomosis can not be performed, still increases and the situation requires solution by endoprosthesis. Consequent the management of such complicated obstructive tracheal lesions is individual and time-consuming. The main objective of this study is to review the single institution experience with central airways stenosis treatment and to define the role of endotracheal stenting in tracheal reconstruction surgery. This study presents the retrospective analysis of tracheal stenosis reconstruction by means of our own modification of Montgomery T-tube. (Tab. 3, Fig. 3, Ref. 12.)

[The complications of pulmonary resection treatment of lung cancer]. / The complications of pulmonary resection treatment of lung cancer.

This article discusses the complications of the pulmonary resection treatment in lung cancer. A significant decrease in incidence of cardiovascular and respiratory complications has already been achieved during the last decades. However, infectious complications, mainly pneumonias and postpneumonectomy empyemas still remain and belong among treacherous complications which are often associated with significant mortality. This article devotes special attention to the possibilities of influencing and decreasing the incidence of these complications.

[Management of malignant pleural diseases]. / Management of malignant pleural diseases.

Pleural effusions are the oldest indication of the thoracoscopic treatment. They represent the terminal state of malignancy and the aim of the treatment is palliative. The most effective is the thoracoscopic procedure in general anaesthesia with one lung ventilation and application of talc powder. We have been using videothoracoscopy in such cases since 1993 and we have treated more than 700 patients. The thoracoscopic procedure was successful in 70% of cases.

[Tracheal stenosis and its treatment]. / Stenóza trachey a jej liecba.

A group of 89 patients suffering from tracheostenosis was studied in the period from January 1990 to January 1999. Surgical procedure on trachea was performed in 63 patients with postintubation (posttracheostomic) stenosis, in 6 patients with direct tracheal trauma, in 9 with tracheoesophageal fistula, in 7 with malignant stenosis, in 3 with postinflammatory subglottic stenosis. In the treatment of tracheal stenosis a set of methods was used ranging from laser and tracheal endoproteses, through cartilage implantation and plastic reconstruction of tracheal defects to extensive segmental resections. In a group of 50 patients with segmental resection in 43 (%) of them the result was good, in 2 (4%) of them satisfying, in 4 (8%) of them temporary brace (on T-cannule) persists, 1 patient died in postoperative period (2%). In a group of 39 patients with combined conservative treatment in 18 patients good results were reached (43.8%), in 6 satisfying (15.4%), in 13 of them temporary brace (on T-cannule) persists (33.3%) and 2 died in postoperative period (5.1%). In conclusion the results of this work suggest that the most frequent indication for surgical treatment is postintubation (postracheostomy) stenosis and that segmental trachea resection has priority in the treatment of tracheal stenoses. (Tab. 2, Ref. 18.)

[Surgical complications of tracheal intubation--tracheal rupture]. / Chirurgická komplikácia tracheálnej intubácie--ruptúra trachey.

Authors present case report of 47-year-old woman with a rupture of trachea in its lower part after an intubation with a double-lumen tube without any problems. Tracheal lesion was discovered at the end of operation after an extirpation of mediastinal tumor and wedge resection of lung during the examination of hermeticity of lung mechanical suture. Rupture was cured by suture resorbable monofilamental material. Development after operation wasn't any different than a common lung resection. In the lecture authors discuss the possible causes of tracheal rupture, different kinds of therapy, and complications.