An unexpected cause for cavitary pneumonia and empyema.

Tularemia is an emerging zoonotic disease mainly of the Northern Hemisphere caused by the Gram-negative coccobacillus Francisella tularensis. It is affecting a wide range of animals and causes human disease after insect and tick bites, skin contact, ingestion and inhalation. A 66-year-old man presented to our clinic with cavitary pneumonia and distinct pleural effusion. After failure of empiric antibiotic therapy, thoracoscopic assisted decortication and partial excision of the middle lobe were conducted. Conventional culture methods and broad-range bacterial PCR including RipSeqMixed analysis were performed from the excised biopsies. Culture results remained negative but broad-range PCR targeting the first half of the 16S rRNA gene revealed F. tularensis DNA. This result was confirmed by F. tularensis-specific PCR and by serology. The source of infection could not be explored. To conclude, we report the rare clinical picture of a community-acquired pneumonia followed by pleural effusion and empyema due to F. tularensis. Broad range bacterial PCR proved to be a powerful diagnostic tool to detect the etiologic organism.

Transcutaneous pleural biopsy with a retrograde forceps: a novel approach.

PURPOSE: Pleural biopsies are commonly performed to investigate the cause of exudative pleural effusion. Biopsy needles (e.g. Abrams needle, Cope needle) are traditionally used to perform the biopsy. However, certain complications such as pneumothorax and haemothorax have been described. We present a technique utilizing a novel retrograde forceps, which could improve the simplicity and lower the complication rate of performing closed pleural biopsies. DESCRIPTION: A retrograde forceps (Retroforceps, Karl Storz, Tuttlingen, Germany) was used to perform 20 transcutaneous pleural biopsies in a cadaver thorax under thoracoscopical control. Video documentation of the procedure from outside and inside the thorax was performed. The surgeon performing the biopsy was blinded to the thoracoscopical view. After the removal of the forceps, it was checked whether biopsy material was retrieved. The video material was retrospectively used to confirm whether the biopsy was taken from the pleura parietalis. EVALUATION: Biopsy material was retrieved in 19 out of 20 biopsy attempts. Video material confirmed that the biopsy was taken from the pleura parietalis in all cases. CONCLUSIONS: Using a retrograde biopsy forceps is a simple and practicable procedure suitable for clinical application. This technique could potentially reduce the incidence of pneumothorax.

Awake Uniportal VATS for the Evacuation of an Extensive, Superinfected Hemothorax in a Patient with Advanced Mediastinal SMARCA4-Deficient Tumor.

Background The so-called nonintubated or awake video-assisted thoracoscopic surgery (NIVATS) is performed on spontaneously breathing patients, which was shown to reduce postoperative complications and shorten hospital stay. Case Description Awake uniportal VATS was indicated for the evacuation of an extensive, superinfected hemothorax with symptomatic mediastinal shift in a patient with advanced mediastinal SMARCA4-deficient tumor and declined condition, who did not allow a general anesthetic procedure and was not a candidate for extensive surgery. Conclusion This short microinvasive intervention was a prerequisite to stabilize the threat to the patient's life and thus potentially enable any further tumor-specific therapy.

Rescue surgery in palliative indication as last therapeutic option for complicated advanced stage lung cancer.

OBJECTIVE: To evaluate the role of rescue surgery in complicated initially not operatively intended advanced stage lung cancer. MATERIALS AND METHODS: Retrospective analysis of 30 patients with advanced lung cancer who underwent rescue surgery for control of life-threatening, non-conservatively manageable tumor related complications like post-obstructive pneumonia, super-infected tumor necrosis or active bleeding. Study parameters included tumor stage, histology, type of resection, and patients' characteristics as well as postoperative outcomes. RESULTS: The study cohort consisted of 12 female and 18 male patients, among those 29 were diagnosed with Non-Small Cell Lung Cancer (NSCLC) and one with Small Cell Lung Cancer (SCLC). On initial tumor-diagnosis 20 patients had been classified as stage IV and 9 with stage III; 1 patient had not yet been completely staged at time of surgery for active tumor bleeding. In all patients, the indication for rescue surgery was not oncologic-therapeutic but to control non-conservatively manageable complications which either contradicted any tumor-specific systemic therapy or acutely threatened life. Types of resections included pneumonectomy, bi-lobectomy, lobectomy and segmentectomy. The mean overall survival was 13.3 (median 11.2) months, the 1-year-survival-probability of the cohort was 45,2%. The 30- and 90-day mortality was 13,3 and 30%, respectively. The reasons for early postoperative mortality were ARDS, multiorgan failure and bronchial-stump insufficiency. CONCLUSIONS: Rescue surgery for tumor- or therapy-induced life-threatening complications in patients with advanced stage lung cancer is associated with high morbidity and mortality. However, if all other treatment options have failed it nevertheless may be indicated as the last therapeutic chance and if surgery succeeds in controlling the acute event it may also set the condition for subsequent tumor-specific therapies. Future research should focus on elaborating effective criteria regarding patient selection and timing of surgery in order to restrict these high-risk-operations to only those patients, who most likely will benefit.

Video-assisted thoracoscopic surgery (VATS) lower lobe bisegmentectomy (S7/8) for a central pulmonary metastasis.

Surgery for pulmonary metastasis is performed heterogeneously with regard to surgical approach [open vs. video-assisted thoracoscopic surgery (VATS)] and resection techniques (e.g., laser enucleation, electro-cautery resection, stapling). Complete tumor resection and preservation of lung parenchyma are of upmost importance. This is technically challenging, especially for central lesions close to vascular and bronchial segmental structures. Thus, simple thoracoscopic wedge resections are often not feasible. A VATS lower lobe bisegmentectomy (S7/8) was performed on a 62-year-old patient with a suspicious pulmonary nodule and a history of hemicolectomy for colorectal carcinoma. Different VATS techniques of vessel dissection and parenchymal control were applied. VATS anatomic segmental resections represent a helpful tool in surgical therapy of central pulmonary metastasis.

Twenty years of cardiac surgery in patients aged 80 years and older: risks and benefits.

BACKGROUND: Patients aged 80 years and older who require cardiac surgical procedures are an increasing population and usually present with considerable comorbidity. Detailed operative risk stratification versus long-term survival and quality of life after surgery is mandatory. METHODS: A retrospective analysis was performed on 1,003 patients aged 82.3 years (range, 80 to 94 years) who underwent aortic valve replacement (n = 303), coronary artery bypass grafting (n = 403), or aortic valve replacement with coronary artery bypass grafting (n = 297) between 1987 and 2006. Preoperative data, operative outcome, long-term survival, and predictors for early and late mortality were analyzed. Furthermore, the Short Form 36 Health Status questionnaire was used to evaluate the quality of life. RESULTS: Overall in-hospital mortality was 7.1%. Overall actuarial survival at 1, 5, and 10 years was 81.6% ± 1.2%, 60.4% ± 1.9%, and 23.3% ± 2.6% (mean survival time, 6.25 ± 0.2 years) and showed no significant difference compared with an age- and sex-matched general population. Multivariate analysis showed that preoperative creatinine concentration greater than 1.3 mg/dL (p < 0.001), preoperative atrial fibrillation (p < 0.005), and postoperative prolonged ventilation (p < 0.001) were independent predictors for poor long-term survival. The physical health summarized score of the Short Form 36 Health Status questionnaire was significantly increased in the study population compared with a German standard population aged 80 years and older (p < 0.05). CONCLUSIONS: Despite an increased operative mortality, octogenarians showed a considerable quality of life and an excellent long-term survival. To further improve surgical outcome in octogenarians, patient selection should be done with consideration of the identified independent preoperative risk factors.

Cardiac reoperation in patients aged 80 years and older.

BACKGROUND: The benefit of cardiac surgery in octogenarians is well described. Today, nearly every second patient who undergoes cardiac surgery is older than 70 years. The time between primary cardiac surgery and reoperation is 7 to 13 years. Therefore, in the future we can expect to see an increasing number of reoperations in octogenarians. METHODS: We studied 71 patients (41 male) with a mean age of 83 +/- 2.8 years, who underwent cardiac reoperation between 1994 and 2006. These patients were compared with 71 octogenarians who underwent primary cardiac operation. Patients were matched for age, sex, year of operation, and surgical procedure. Demographic profiles, operative data, long-term survival, and quality of life by the Short-Form 36-Item Health Survey questionnaire were analyzed. RESULTS: Average time between previous operation and reoperation was 10.8 +/- 5.6 years (range: 1.7 to 30.6). The 30-day mortality rate was 14.7% in the reoperation group and 8.5% (p = 0.43) in the control group. Actuarial survival at 1, 3, and 6 years was 71% +/- 5.5%, 60.5% +/- 6.1%, and 30% +/- 8.1% for patients who underwent cardiac reoperation; and 77.2% +/- 5%, 58.3% +/- 6.3%, and 36.3% +/- 7.8% for matched octogenarians who underwent primary cardiac surgery (p = 0.68). No significant differences were found between groups regarding the physical health summarized score (40.7 +/- 9.4 versus 39.1 +/- 10; p = 0.55) and the mental health summarized score (51.9 +/- 10.9 versus 48 +/- 12.9; p = 0.24) of the Short-Form 36-Item Health Survey questionnaire. CONCLUSIONS: Octogenarians exhibit a similar long-term survival and quality of life after primary and redo cardiac surgery. Therefore, cardiac reoperation should not be a contraindication per se in octogenarians.