Pneumonectomy with Carinal Sleeve Resection in Patients with Non-Small-Cell Lung Cancer

BACKGROUND

 Carinal sleeve resection with pneumonectomy is one of the rarest procedures in thoracic surgery, but for locally advanced central lung cancer with infiltration of the carina, it is an option to achieve complete resection. Additionally, it might be the method of choice for patients with stump insufficiency after pneumonectomy or in the cases with anastomosis dehiscence after sleeve lobectomy. The aim of this study was to evaluate the morbidity and long-term survival of patients with non-small-cell lung cancer (NSCLC) who underwent sleeve pneumonectomy, either for curative intent or as an option to treat postoperative complications.

METHODS

 All consecutive patients with NSCLC who underwent carinal sleeve pneumonectomy for the aforementioned indications in our department between December 2021 and September 2003 were included in this study. An analysis of demographic characteristics, perioperative variables, and long-term survival was carried out. Data were evaluated retrospectively.

RESULTS

 Fifty patients underwent pneumonectomy with carina sleeve resection. Thirty-one cases for curative treatment of NSCLC (primary sleeve pneumonectomy [pSP]) and 19 patients were treated because of postpneumonectomy bronchial stump insufficiency or bronchial anastomosis dehiscence (secondary sleeve pneumonectomy [sSP]). Complications occurred in 30 patients (60%) and the 90-day mortality was 18% (n = 9). Patients with pSP had an estimated overall survival of 39.6 months, compared to estimated overall survival for patients after sSP of 24.5 months (p = 0.01). The N status did not appear to affect outcomes.

CONCLUSION

 Carinal sleeve resection with pneumonectomy is a feasible procedure with limited morbidity and mortality. This procedure is a reasonable therapeutic option for patients with locally advanced central NSCLC after mandatory patient selection.

[Tracheobronchial Injuries]

Tracheobronchial injury is a rare, but potentially life-threatening condition. These injuries are associated with high morbidity and mortality, which is ascribed to underlying diseases and additional injuries. Lacerations of the airway are differentiated into iatrogenic and non-iatrogenic injuries, while the group of non-iatrogenic lesions are grouped into blunt and penetrating traumas.The exact incidence of tracheobronchial injury is unknown, because many iatrogenic injuries occur without symptoms and most patients after traumatic laceration die before inpatient treatment. All patients with suspicion of airway injury require fast and accurate management.Common signs and symptoms are dyspnoea, haemoptysis, stridor and subcutaneous emphysema.Bronchoscopy is the most important tool for diagnosis and in several cases also for initial treatment.Further management depends on the patient's clinical condition and findings of bronchoscopy and computed tomography. Surgery has been the cornerstone of therapy, but in selected patients bronchoscopic stent implantation or conservative management must be discussed.

[Prevention, Diagnosis, Therapy, and Follow-up of Lung Cancer - Interdisciplinary Guideline of the German Respiratory Society and the German Cancer Society - Abridged Version]

The current S3 Lung Cancer Guidelines are edited with fundamental changes to the previous edition based on the dynamic influx of information to this field:The recommendations include de novo a mandatory case presentation for all patients with lung cancer in a multidisciplinary tumor board before initiation of treatment, furthermore CT-Screening for asymptomatic patients at risk (after federal approval), recommendations for incidental lung nodule management , molecular testing of all NSCLC independent of subtypes, EGFR-mutations in resectable early stage lung cancer in relapsed or recurrent disease, adjuvant TKI-therapy in the presence of common EGFR-mutations, adjuvant consolidation treatment with checkpoint inhibitors in resected lung cancer with PD-L1 ≥ 50%, obligatory evaluation of PD-L1-status, consolidation treatment with checkpoint inhibition after radiochemotherapy in patients with PD-L1-pos. tumor, adjuvant consolidation treatment with checkpoint inhibition in patients withPD-L1 ≥ 50% stage IIIA and treatment options in PD-L1 ≥ 50% tumors independent of PD-L1status and targeted therapy and treatment option immune chemotherapy in first line SCLC patients.Based on the current dynamic status of information in this field and the turnaround time required to implement new options, a transformation to a "living guideline" was proposed.

Aspergillus niger pneumonia as superinfection in a patient with pulmonary tuberculosis

We report a patient with severe cavitary pulmonary tuberculosis and Aspergillus niger superinfection, whose only comorbidity was untreated diabetes mellitus. A. niger pneumonia was proven by PCR, sequencing and culture of pleural and respiratory secretions. The patient was successfully treated with a four-drug antituberculous regimen, liposomal amphotericin B (up to 5 mg/kg/d) and pleuro-pneumonectomy. Histology of the resected lung revealed destroyed lung tissue with inflammatory cells and fungal conidia. There were large deposits of polarising material, which was found to be calcium oxalate. There was also nodular caseating necrosis bordered by epitheloid cells and connective tissue. Thus, all diagnostic criteria for invasive A. niger infection were met. Several local risk factors, such as extensive lung damage and tissue acidification, may have favoured superinfection by A. niger. This case highlights the diagnostic value of calcium oxalate crystals in lung tissue and the need for combined antimicrobial and surgical treatment in extensive invasive aspergillosis caused by A. niger.

Atrial resection for T4 non-small cell lung cancer with left atrium involvement: a systematic review and meta-analysis of survival

PURPOSE

Extended resection for non-small cell lung cancer (NSCLC) with T4 left atrium involvement is controversial. We performed a systematic review and meta-analysis to evaluate the short- and long-term outcomes of this treatment strategy.

METHODS

We searched the PubMed database for studies on atrial resection in NSCLC patients. The primary investigated outcome was the effectiveness of the surgery represented by survival data and the secondary outcomes were postoperative morbidity, mortality, and recurrence.

RESULTS

Our search identified 18 eligible studies including a total of 483 patients. Eleven studies reported median overall survival and 17 studies reported overall survival rates. The estimated pooled 1, 3, 5-year overall survival rates were 69.1% (95% CI 61.7-76.0%), 21.5% (95% CI 12.3-32.3%), and 19.9% (95% CI 13.9-26.6%), respectively. The median overall survival was 24 months (95% CI 17.7-27 months). Most studies reported significant associations between better survival and N0/1 status, complete resection status, and neoadjuvant therapy.

CONCLUSION

Extended lung resection, including the left atrium, for NSCLC is feasible with acceptable morbidity and mortality when complete resection is achieved. Lymph node N0/1 status coupled with the use of neoadjuvant therapies is associated with better outcomes.

Postoperative outcome after palliative treatment of malignant pleural effusion

BACKGROUND

The objective of this nationwide, registry-based study was to compare the two most frequently used procedures for the palliative treatment of a malignant pleural effusion (MPE) and to evaluate differentiated indications for these two procedures.

METHODS

This was a retrospective observational study based on data of the "PLEURATUMOR" registry of the German Society for Thoracic Surgery. Patients who were documented in the period from January 2015 to November 2021 and had video-assisted thoracic surgery (VATS) talc pleurodesis or implantation of an indwelling pleural catheter (IPC) were included.

RESULTS

A total of 543 patients were evaluated. The majority suffered from secondary pleural carcinomatosis (n = 402; 74%). VATS talc pleurodesis (n = 361; 66.5%) was performed about twice as often as IPC implantation (n = 182; 33.5%). The duration of surgery was significantly shorter in IPC-patients with 30 min compared to VATS talc pleurodesis (38 min; p = 0.000). Postoperative complication rate was 11.8% overall and slightly higher after VATS talc pleurodesis (n = 49; 13.6%) than after IPC implantation (n = 15; 8.2%). After VATS talc pleurodesis patients were hospitalized significantly longer compared to the IPC group (6 vs. 3.5 days; p = 0.000). There was no significant difference in postoperative wound infections between the groups (p = 0.10). The 30-day mortality was 7.9% (n = 41).

CONCLUSION

The implantation of an IPC can significantly shorten the duration of surgery and the hospital stay. For this reason, the procedure should be matched with the patient's expectations preoperatively and the use of an IPC should be considered not only in the case of a trapped lung.

[Mediastinal Staging]

Thorough mediastinal staging is pivotal for prognostic assessment and treatment planning in patients with non-small-cell lung cancer (NSCLC) without distant metastasis. It aims to answer the question of whether a technically and functionally feasible operation also makes sense from an oncological point of view. In case of a nodal-free mediastinum, primary surgical therapy can be considered. If the ipsilateral mediastinal lymph nodes are affected, multimodal therapy should be sought. Operating is usually no longer the first step, especially with extensive lymph node infestation. Surgery is recommended, if neoadjuvant (radio-)chemotherapy has achieved downstaging or major response. If the contralateral mediastinal lymph nodes are involved, curative surgery is no longer part of the therapeutic concept. The therapy of choice in this situation is definitive chemo-radiotherapy.Guidelines for mediastinal staging consistently require to combine radiological, nuclear medicine and minimally invasive methods. Imaging with CT and PET allows an initial assessment of the mediastinal status. In most cases it has to be complemented with tissue confirmation. Echoendoscopic assessment of the mediastinum with needle biopsy is the minimally invasive method of first choice ("needle first"). Surgical staging methods are reserved for situations, that cannot be satisfactorily clarified by echoendoscopy.Technique and outcome of the different methods are described and algorithms are presented for different oncological situations.

Primary Clear Cell Sarcoma of the Lung: a Case Report

Background:

Clear Cell Sarcoma of Soft Tissue (CCSST), or melanoma of the soft part, is a rare, aggressive tumor that originates in the aponeurosis and fasciae of the distal parts of the extremities. Reports from other sites of the body are rare.

Objective:

We are reporting an extremely rare tumor that presented as a central left-sided lung mass and found to be clear cell sarcoma of soft tissue.

Methods:

We report a 24-year-old male patient presented with recurrent attacks of left-sided chest pain associated with cough and dyspnea.

Results:

Imaging showed a central left-sided 8*5.5*5 cm lung mass. The age of the patient and the radiological characteristics of the lesion were suggestive of a benign pathology. After histopathological assessment of the lesion, suspicion of the malignant process was raised, mainly melanoma of soft part and PEComa. The patient underwent left-sided pneumonectomy. The postoperative histological examination, immunohistochemical findings including positive staining for S-100, HMB-45, and Melan-A, and positive FISH study for EWSR1 gene rearrangements supported the diagnosis of CCSST originating primarily in the major fissure of left the lung.

Conclusion:

The rarity of CCSST in general and tumors originating in the lung primarily raise the challenges in hypothesizing a differential diagnosis, choosing proper investigations and treatment methods. The histological examination, immunohistochemical, and cytogenetics of the tumor are mandatory to reach the final diagnosis.

Mediastinales Staging

Thorough mediastinal staging is pivotal for prognostic assessment and treatment planning in patients with non-small-cell lung cancer (NSCLC) without distant metastasis. It aims to answer the question of whether a technically and functionally feasible operation also makes sense from an oncological point of view. In case of a nodal-free mediastinum, primary surgical therapy can be considered. If the ipsilateral mediastinal lymph nodes are affected, multimodal therapy should be sought. Operating is usually no longer the first step, especially with extensive lymph node infestation. Surgery is recommended, if neoadjuvant (radio-)chemotherapy has achieved downstaging or major response. If the contralateral mediastinal lymph nodes are involved, curative surgery is no longer part of the therapeutic concept. The therapy of choice in this situation is definitive chemo-radiotherapy.Guidelines for mediastinal staging consistently require to combine radiological, nuclear medicine and minimally invasive methods. Imaging with CT and PET allows an initial assessment of the mediastinal status. In most cases it has to be complemented with tissue confirmation. Echoendoscopic assessment of the mediastinum with needle biopsy is the minimally invasive method of first choice ("needle first"). Surgical staging methods are reserved for situations, that cannot be satisfactorily clarified by echoendoscopy.Technique and outcome of the different methods are described and algorithms are presented for different oncological situations.

Carinal sleeve resection: last exit for bronchial insufficiency-a 17-year, single-centre experience

OBJECTIVES

Bronchopleural fistula after pneumonectomy and dehiscence of an anastomosis after sleeve lobectomy are severe complications. Several established therapeutic options are available. Conservative treatment is recommended for a small fistula without pleural infection. In patients with a bronchopleural fistula and subsequent pleural empyema, surgical management is the mainstay. Overall, the associated morbidity and mortality are high. Carinal sleeve resection is the last resort for patients with a short stump after pneumonectomy or anastomotic dehiscence after sleeve resection near the carina.

METHODS

All patients with bronchopleural fistula after pneumonectomy or sleeve resection who underwent secondary carinal sleeve resection between 2003 and 2019 in our institution were evaluated retrospectively. Patients with anastomotic dehiscence after sleeve lobectomy underwent a completion pneumonectomy. The surgical approach was an anterolateral thoracotomy; the anastomosis was covered with muscle flap, pericardial fat or omentum majus. In case of empyema, povidone-iodine-soaked towels were introduced into the cavity and changed at least twice.

RESULTS

A total of 17 patients with an initial sleeve lobectomy in 12 patients and pneumonectomy in 5 patients were treated with carinal sleeve resection in our department. Morbidity was 64.7% and 30-day survival was 82.4% (n = 14). A total of 70.6% of the patients survived 90 days (n = 12). Median hospitalization was 17 days and the median stay in the intensive care unit was 12 days.

CONCLUSIONS

Carinal sleeve resection is a feasible option in patients with a post-pneumonectomy fistula or anastomotic insufficiency following sleeve lobectomy in the absence of alternative therapeutic strategies. Nevertheless, postoperative morbidity is high, including prolonged intensive care unit stay.

Rib Osteoblastoma as a Cause of Neurogenic Thoracic Outlet Syndrome: A Case Report

Patient: Female, 23-year-old

Final Diagnosis: Thoracic outlet syndrome

Symptoms: Cervical mass • pain • paresthesia

Medication: —

Clinical Procedure: CT scan • incisional biopsy • MRI • nerve conduction study • supraclavicular approach to the TOS

Specialty: Surgery

Rupture of pulmonary hydatid cyst in pediatrics: A cross-sectional study

Introduction

Pulmonary hydatid cyst is a parasitic disease causing an endemic and a health burden in many regions. Lung cysts are more common than liver cysts in children and patients may remain asymptomatic. Cyst rupturing is not uncommon, and it is considered the most feared complication. In this cohort study, we aimed to identify the risk factors related to cyst rupture in a Jordanian pediatric population.

Methods

We retrospectively evaluated all pediatric patients who underwent cystostomy and capitonnage for pulmonary hydatid cyst between 2003 and 2020 at King Abdullah University Hospital.

Results

We found 43 patients with a mean age of 13 ± 4 years who suffered from 61 pulmonary cysts. 55.6% of them were males. The most prevalent symptom was shortness of breath. The rupture rate for patients was 39.5%, and 29.5% for cysts. None of the patients with cyst rupture had an anaphylactic reaction. The left lower lobe was the most common location for both intact and ruptured cysts. 25.6% of the patients had giant cysts (>10 cm) with a mean of 7.4 cm for all cysts. Patients with intact cysts had higher-rates of cough (42.3% vs. 29.4%) and lower-rates of shortness of breath (34.6% vs. 52.9%) than patients with ruptured cysts, which were not statistically significant. Although statistically insignificant, patients with ruptured cysts tended to have multiple cysts in one lung (29.4% vs. 7.7%, p = 0.180), and more complication rates (29.4% vs 7.7%, p = 0.09). Both groups had almost identical IgG-ELISA positive results. We found no significant association between cyst rupture and age, gender, presenting symptoms, cyst size, cyst location, and rate of postoperative complications.

Conclusion

The rupture of pulmonary hydatid cyst has clinical consequences in pediatric patients, further studies on larger populations are needed to identify factors that make patients more prone to rupture and prioritize them for clinical monitoring and management.

•

Hydatid cyst rupture is a common serious complication in pediatrics with 39.5% of the diagnosed cases.

•

About 25% of pediatric patients tend to develop giant cysts but the cyst size was not significantly associated with rupture.

•

Pediatric patients with rupture pulmonary hydatid cyst have a low tendency to develop an anaphylactic reaction.

•

Larger sample size is needed to define the risk factors and predictors of pulmonary hydatid cyst rupture.

Thoracoscopic sleeve segmentectomy for bipulmonal non-small-cell lung cancer with curative approach

A patient with simultaneous bilateral non-small-cell lung cancer underwent a thoracoscopic sleeve segmentectomy on the right side to avoid lobectomy in curative approach. The patient also had a second, left-sided tumour requiring at least a left-sided sleeve upper lobectomy for complete resection. In anticipation of the second pulmonary resection in a patient whose lung function was already impaired by the first operation, we opted for a thoracoscopic approach with fast recovery. The left-sided operation was performed 60 days after the right-sided sleeve segmentectomy without any complications.

[Comprehensive Preoperative Evaluation of Patients with Lung Cancer]

Surgical resection continues to be a mainstay of curative treatment of patients with non-small cell lung cancers stages I - III and some small cell lung cancers. Reported rates of complications and mortality vary considerably. Therefore, a thorough and comprehensive preoperative evaluation of lung cancer patients is crucial in order to select appropriate surgical candidates and to determine their individual risk, including the extent of resection possible. Following available data and guidelines, such evaluation should include: ECOG-scoring, cardiac risk assessment, cerebrovascular assessment, pulmonary risk assessment, including split function analysis, and additional initiation or adjustment of treatment where appropriate; in patients aged ≥ 70 years: functional scoring (IADL). Risk stratification results in three groups: patients at low risk for complications and mortality, patients at increased risk, and patients who usually are not candidates for surgical resection. Finally, in order to support autonomous decisions of patients on optimal treatment based on defined risks, physicians must be familiar with values and preferences of patients as well as their familial and social situation.

Delphi-Konsens der Deutschen Gesellschaft für Thoraxchirurgie über das perioperative Management bei onkologischen anatomischen Lungenresektionen

Einleitung Die anatomische Lungenresektion zur kurativen Behandlung einer malignen Grunderkrankung ist die am häufigsten durchgeführte elektive Operation in der onkologischen Thoraxchirurgie. Ziel dieses Projektes war die Erarbeitung eines Konsenses bez. der am häufigsten gestellten Fragen zum Thema perioperatives Management für elektive onkologische Lungenresektionen.

Methodik Die Arbeitsgruppe erarbeitete 2 elektronische Delphi-Fragerunden. Als Konsens wurde eine Übereinstimmung in ≥ 75% definiert. Nach der statistischen Auswertung der Ergebnisse der elektronischen Fragerunde erfolgte eine Expertenkonferenz, die in einer finalen Delphi-Abstimmung versucht hat, weiteren Konsens über strittige Themen zu erreichen.

Ergebnisse 14 Fragen bez. des perioperativen Managements für elektive onkologische Lungenresektionen konnten formuliert und abgestimmt werden. Konsens konnte für folgende Themen erreicht werden: präoperatives infektiologisches Screening, erweiterte lungenfunktionelle Diagnostik bei eingeschränkter Lungenfunktion, Verwendung eines validierten Cardiac-Risk-Assessment-Algorithmus, Überwachung des Patienten postoperativ, Thromboembolieprophylaxe, Kontrollbronchoskopie nach Bronchusmanschettenresektionen oder nach Pneumonektomie sowie Blutgasanalyse vor Entlassung. Für folgende Themen konnte kein Konsens erreicht werden: präoperative endobronchiale mikrobiologische Diagnostik, Spülung der Thoraxhöhle, standardisierte laborchemische Untersuchungen postoperativ.

Fazit Die vorliegende Arbeit fasste die Ergebnisse eines Delphi-Prozesses zusammen, der 2018/2019 mit Experten aus zertifizierten Kliniken oder hochvolumigen thoraxchirurgischen Einheiten geführt wurde. Insgesamt zeigte sich eine sehr hohe Konsensrate bez. des perioperativen Managements bei onkologischen anatomischen selektiven Lungenresektionen. Die präoperative mikrobiologische endobronchiale Diagnostik war der Hauptpunkt, wo ein Konsens nicht erreicht werden konnte.

[Application of artificial intelligence in thoracic surgery]

BACKGROUND

The application of artificial intelligence is a relatively new option to enable improved patient treatment in modern medicine and is therefore currently the focus of many research projects. In the clinical practice the application of artificial intelligence so far seems to be confined to the analysis of medical imaging.

OBJECTIVE

In which form is the use of artificial intelligence possible in routine daily work in thoracic surgery and is already being practiced?

MATERIAL AND METHODS

A search of the currently available literature was performed.

RESULTS

Under current conditions artificial intelligence can best be used as part of diagnostics and treatment planning; however, in order to enable a comprehensive use standardization and evaluation of the centralized data collection are necessary.

CONCLUSION

At the present time promising study results are available but the implementation into the surgical routine has so far been very difficult.

Does less surgical trauma result in better outcome in management of iatrogenic tracheobronchial laceration?

Background

Iatrogenic tracheobronchial injury is a rare, but severe complication of endotracheal intubation. Risk factors are emergency intubation, percutaneous dilatational tracheostomy and intubation with double lumen tube. Regarding these procedures, underlying patients often suffer from severe comorbidities. The aim of this study was to evaluate the results of a standardized treatment algorithm in a referral center with focus on the surgical approach.

Methods

Sixty-four patients with iatrogenic tracheal lesion were treated in our department by standardized management adopted to clinical findings between 2003 and 2019. Patients with superficial laceration were treated conservatively. In the case of transmural injury of the tracheal wall and necessity of mechanical ventilation, patients underwent surgery. We decided on a cervical surgical approach for lesions limited to the trachea. In case of involvement of a main bronchus we performed thoracotomy. Data were evaluated retrospectively.

Results

In 19 patients the tracheal lesion occurred in elective intubation and in 17 patients during emergency intubation. In 23 cases a tracheal tear occurred during percutaneous dilatational tracheostomy and in three patients at replacement of a tracheostomy tube. Two patients received laceration during bronchoscopy. Twenty-nine patients underwent surgery with cervical approach and 14 underwent thoracotomy. There was no difference in the mortality of these groups. Treatment of tracheal tear was successful in 62 individuals. Nine patients died of multi organ dysfunction syndrome (MODS), two of them during surgery.

Conclusions

Iatrogenic tracheal laceration is a life-threatening complication and the mortality after tracheal injury is high, even in a specialized thoracic unit. Conservative management in patients with superficial tracheal lesion is a feasible procedure. In case of complete laceration of tracheal wall, surgical therapy is recommendable, whereby several approaches of surgical management seem to be equivalent.

[Tracheal Surgery]

Surgery of the trachea is a specialised field in which many disciplines work jointly due to the variety of indications and the extended topography. Not only because of its particular functional importance, but also because of its complex morphology, anatomy and physiology, this organ represents a special therapeutic challenge. A variety of diseases require surgical procedures of the trachea; the therapeutic strategy is influenced both by the disease itself as well as patient-dependent parameters. Regardless of the nature of the underlying disorder, good results require a high level of expertise in airway management, a careful diagnosis and interventional planning as well as an experienced surgical team that masters extended operative techniques. An optimal treatment decision always requires a multidisciplinary assessment of the patient's individual situation by interventional pulmonologists, thoracic surgeons, visceral surgeons, ENT (ear, nose and throat) surgeons and anaesthesiologists.

[Comprehensive Preoperative Evaluation of Patients with Lung Cancer]

Surgical resection continues to be a mainstay of curative treatment of patients with non-small cell lung cancers stages I - III and some small cell lung cancers. Reported rates of complications and mortality vary considerably. Therefore, a thorough and comprehensive preoperative evaluation of lung cancer patients is crucial in order to select appropriate surgical candidates and to determine their individual risk, including the extent of resection possible. Following available data and guidelines, such evaluation should include: ECOG-scoring, cardiac risk assessment, cerebrovascular assessment, pulmonary risk assessment, including split function analysis, and additional initiation or adjustment of treatment where appropriate; in patients aged ≥ 70 years: functional scoring (IADL).Risk stratification results in three groups: patients at low risk for complications and mortality, patients at increased risk, and patients who usually are not candidates for surgical resection.Finally, in order to support autonomous decisions of patients on optimal treatment based on defined risks, physicians must be familiar with values and preferences of patients as well as their familial and social situation.

[Lobectomy of Right Lower Lobe Eight Years after Foreign Body Aspiration]

A young man presented with haemoptysis, eight years after foreign body aspiration. The initial evaluation took place in the emergency department of a general hospital. However, neither chest x-ray nor bronchoscopy were performed. Bronchoscopy performed in our hospital revealed a foreign body in right lower lobe bronchus. Extraction failed because it was embedded in granulation tissue. The chronic atelectasis of right lower lobe and recurrent bronchopulmonary infections during the last years were the indication for lobectomy.

[Failure of Endo-VAC or Stenting Therapy after Oesophageal Anastomotic Insufficiency - How to Avoid Oesophagectomy]

INTRODUCTION

Oesophageal anastomotic leak after oesophagectomy is a severe complication and associated with a high mortality rate. Initial treatment is conservative and includes stent implantation or endo-VAC therapy. This study describes a combined treatment strategy of endoscopic and surgical management after failure of conservative management.

MATERIALS AND METHODS

All patients were included who had been treated after oesophagectomy with gastric conduit reconstruction in our department of thoracic surgery between May 2008 and December 2016. Clinical data was evaluated from a prospectively acquired database. We surgically managed these patients with a combination of oesophageal stent implantation, transmural stent fixation with absorbable suture, stent coverage with muscle flap, radical debridement of mediastinal and pleural empyema and discontinuous pleural space irrigation, when conservative management failed. We evaluated the factors influencing mortality rate after surgical treatment of anastomotic insufficiency repair.

RESULTS

18 patients were introduced to our department after external failure of conservative therapy. 15 patients were introduced < 20 days after conservative therapy and three cases after > 20 days of conservative therapy. All patients presented with right sided pleural empyema, pneumonia, mediastinitis and sepsis. Three cases were accompanied by bilateral pleural empyema. Definitive successful surgical reconstruction occurred in 100%. The 90-day mortality rate was 20% (three patients), who died because of multi-organ failure.

CONCLUSION

Oesophageal anastomotic leak after oesophagectomy can be managed successfully by the combined treatment strategy of endoscopic and surgical procedures following failure of conservative treatment. The only factor influencing mortality seems to be a prolonged conservative therapy of more than 20 days.

Video-Assisted Thoracoscopic Surgery of Parapneumonic Empyema - a 10-year Single-Centre Experience

OBJECTIVES

 Evaluation of a standardised management for the treatment of patients with parapneumonic empyema.

METHODS

 A retrospective 10-year single-centre analysis of all patients with parapneumonic empyema undergoing a standardised thoracoscopic treatment approach. We describe referral and age patterns, microbiological results, overall and stage-dependent success rates, conversion rates, 30-day and in-hospital mortality.

RESULTS

 From May 2003 to April 2013, 248 patients with parapneumonic empyemas were treated in our centre. Most patients were referred at weekends, and younger patients had advanced stages. The cure rate in stage I was 97.6 % and reached 80.3 % in stage II and 63.1 % in stage III. 6 patients (2.4 %) (all stage III) needed conversion to an open procedure. A revision was required in 19.7 % of cases in stage II and 27.7 % in stage III. 30-day mortality was 4.8 %, in-hospital mortality was 8.1 %.

CONCLUSION

 A standardised approach, including VATS, is associated with a high cure, low revision and moderate conversion rates. In view of a still considerable mortality, a higher index of suspicion and detection of advanced stages, especially in younger patients, is required to improve outcomes.

[Tracheal Surgery]

Surgery of the trachea is a specialised field in which many disciplines work jointly due to the variety of indications and the extended topography. Not only because of its particular functional importance, but also because of its complex morphology, anatomy and physiology, this organ represents a special therapeutic challenge. A variety of diseases require surgical procedures of the trachea; the therapeutic strategy is influenced both by the disease itself as well as patient-dependent parameters. Regardless of the nature of the underlying disorder, good results require a high level of expertise in airway management, a careful diagnosis and interventional planning as well as an experienced surgical team that masters extended operative techniques. An optimal treatment decision always requires a multidisciplinary assessment of the patient's individual situation by interventional pulmonologists, thoracic surgeons, visceral surgeons, ENT (ear, nose and throat) surgeons and anaesthesiologists.

Olfactory Receptors Modulate Physiological Processes in Human Airway Smooth Muscle Cells

Pathophysiological mechanisms in human airway smooth muscle cells (HASMCs) significantly contribute to the progression of chronic inflammatory airway diseases with limited therapeutic options, such as severe asthma and COPD. These abnormalities include the contractility and hyperproduction of inflammatory proteins. To develop therapeutic strategies, key pathological mechanisms, and putative clinical targets need to be identified. In the present study, we demonstrated that the human olfactory receptors (ORs) OR1D2 and OR2AG1 are expressed at the RNA and protein levels in HASMCs. Using fluorometric calcium imaging, specific agonists for OR2AG1 and OR1D2 were identified to trigger transient Ca²⁺ increases in HASMCs via a cAMP-dependent signal transduction cascade. Furthermore, the activation of OR2AG1 via amyl butyrate inhibited the histamine-induced contraction of HASMCs, whereas the stimulation of OR1D2 with bourgeonal led to an increase in cell contractility. In addition, OR1D2 activation induced the secretion of IL-8 and GM-CSF. Both effects were inhibited by the specific OR1D2 antagonist undecanal. We herein provide the first evidence to show that ORs are functionally expressed in HASMCs and regulate pathophysiological processes. Therefore, ORs might be new therapeutic targets for these diseases, and blocking ORs could be an auspicious strategy for the treatment of early-stage chronic inflammatory lung diseases.

Severe Complications of Ultrasound Guided Transbronchial Needle Aspiration--A Case Series and Review of the Literature

Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) has become essential for the workup of patients with lung cancer and other pulmonary diseases. The emphasis of currently available literature is related to the diagnostic yield of EBUS-TBNA which was found to be high. Complications seem to be rare but such data are scant. We report three cases of complications including mediastinitis, pneumothorax and bleeding and provide a review on the existing literature.

Initial management of primary spontaneous pneumothorax with video-assisted thoracoscopic surgery: a 10-year experience

OBJECTIVES

First-line conservative treatment of primary spontaneous pneumothorax (PSP) may be challenged by recurrence rates and complications associated with different treatment options. The aim of this study was to evaluate the use of a standardized surgical treatment as 'first-line' treatment.

METHODS

In a 10-year period, 185 patients with PSP were treated with a standardized video-assisted thoracic surgery (VATS) approach including wedge resection and parietal pleurectomy. Data were evaluated retrospectively. All patients with a first event of PSP were included in the study. In addition, follow-up was done by a questionnaire.

RESULTS

Mean follow-up period was 70.8 months (±33.5 months). Sub-pleural emphysematous changes were found in every histopathological specimen. In addition, 70.8% had fibrosis of visceral pleura. Recurrence occurred in 4 patients (2.2%). Ten-year freedom from recurrence was 96.2%. Procedure-related morbidity rate was 7.6%. Approximately 85.7% of patients were satisfied with the procedure and the cosmetic result. Three patients died during follow-up (1.6%).

CONCLUSIONS

Treatment of first episode of PSP by VATS is a safe procedure, with a very low rate of recurrence and a high patient satisfaction. This management of first episode of PSP is based on the underlying pathology. We recommend the use of VATS as the treatment of first choice for patients with PSP.

Zur Chemie des Phorbols, XII

Dehydration of phorbol-20-monoacetate or phorbol-20-tritylether with phosphoroxychloride/pyridin yields phorbobutanon-20-monoacetate or -20-tritylether (1) respectively. From 1 phorbobutanon (2) is prepared. 2 is one of the products obtained from the reaction of phorbol with 0,02 N sulfuric acid (Flaschenträger reaction). From NMR- and CD-measurements of 2 and its derivatives and from mechanistic considerations of the pinacol rearrangement involving the α- [hydroxy-cyclopropyl]-carbinol group the structure and stereochemistry of phorbobutanon is derived. 2 is a 4,9,20-trihydroxy-14 (13 → 12) abeo-tigliadien- (1,6) -dion- (3,13).

Zur Chemie des Phorbols, VI

Oxidation of the secondary hydroxyl in phorbol-13,20-diacetate with chromium-trioxide/pyridine yields the diketone phorbol-12-on-13,20-diacetate. The newly introduced carbonyl group is sterically hindered thus allowing for selective reduction of the α„β-unsaturated ketone to give neophorbol-13,20-diacetate, a positional isomer of phorbol-13,20-diacetate in respect to the carbonyl group. By addition of the circular dichroismus of phorbol-13,20-diacetate and neophorbol-13,20-diacetate the dichroism of phorbol-12-on-13,20-diacetate was calculated, indicating that the electronic system of the two carbonyl functions in the latter do not interact. This excludes the existence of the structural unit of an 1,2-diketone in phorbol-12-on-13,20-diacetate. UV-absorption and circular dichroic spectra of derivatives of phorbol esterified or etherified in the 4-position suggest strongly the presence of a tertiary 1,2-ketol group in phorbol. By investigations of the UV-absorption below 200 nm of tetrahydro-phorbol derivatives, the cyclopropane component in phorbol is confirmed. Circular dichroism and UV-absorption of certain derivatives of phorbol-12-on suggest the presence of an β-cyclopropyl ketone group.

Structure-Activity Relationships of Polyfunctional Diterpenes of the Tigliane Type, V / Preparation and Irritant Activities of Amino Acid and Peptide Esters of Phorbol

Tho synthesis of a series of 12-O-amino acyl- and 12-O-peptidyl-13-acetate and -13,20- diacetate esters of the tetracyclic diterpene alcohol phorbol is described. These esters, which include amino acid moieties with both N-protected and free amino functions, were all tested for irritant activity on mouse ear. The highest activities were observed for esters with N-9-fluorenylmethyloxycarbonyl-protected leucine and 11-aminoundecanoic acid.

Phorbol

The preparation of phorbol C20H28O6 from croton oil and of some functional derivatives is described. The six oxygen functions of phorbol are identified as five hydroxyl groups and one carbonyl group. Two C=C double bonds are part of primary allylalcoholic and α,β-unsaturated carbonyl groupings. The carbon skeleton contains four rings and the parent hydrocarbon is most probably of diterpene nature.

Zur mathematischen Behandlung multiplikativerVerteilungsverfahren

Die Fortführung der in früheren Mitteilungen angegebenen Behandlungsweise multiplikativer Verteilungsverfahren läßt die Trennfunktion der Watanabe-Morikawa- Verteilung ableiten. Sie steht in der erwarteten einfachen Beziehung zur Trennfunktion der O'Keeffe - Verteilung.

On the Chemistry of Ingenol, III [1] Synthesis of 3-Deoxy-3-oxoingenol, Some 5-Esters and of Ethers and Acetals of Ingenol

3-Deoxy-3-oxoingenol (3) was prepared from ingenol-5,20-acetonide (25) by oxidation and subsequent removal of the acetonide. 3 was acylated to give homologous 5,20-diacylates 5-9. From these the 5-monoacylates 14, 15 and 17 were obtained in only moderate yields. Therefore the 20-silyl ether 10 (prepared from 3) was acylated. After smooth removal of the silyl ether the homologous 5-acylates 16. 18 and 19 resulted in good yield. The 5,20-dibutyrate 6 and all 5-acylates prepared (14-19) showed no irritant activity on the mouse ear. The 3-oxo-5-acylates 14-19 could not be reduced to give ingenol-5-acylates (24). Therefore various ingenol derivatives, 29-32, with suitable protected hydroxyl functions as well as the corresponding 5-clecanoates 35-38 were synthesized. The protecting groups of the derivatives 35-38 could however not be cleaved off to yield ingenol-5- decanoate (24)

Die radikalische Hydroxylierung von Tetralol-(6) mit Fenton's Reagenz

Die radikalische Hydroxylierung von Tetralol- (6) (I) mit Fentons Reagenz und die Bildung folgender einfacher Hydroxylierungs-Produkte wird untersucht und nachgewiesen.

1. Tetralin-p-chinol (II), durch Überführung in [2.4-Dinitrobenzol-] <1-azo-6>-tetralin und IR-spektroskopischen Vergleich dieser Verbindung mit authentischer Substanz.

2. 6.7-Dihydroxy-tetralin (III), durch papierchromatographischen und UV-spektroskopischen Vergleich mit der authentischen Substanz.

Auf Grund der Abhängigkeit der Reaktion von der Anwesenheit von Fluoridionen bzw. Sauerstoff wird ein möglicher Mechanismus der radikalischen Hydroxylierung von Tetralol- (6) formuliert und in Beziehung gesetzt zur enzymatischen Hydroxylierung der Östrogene in Rattenleber durch die mikrosomale, mischfunktionelle Oxygenase.

Zur Chemie des Ingenols, II [1] Ester des Ingenols und des ⊿7.8 -Isoingenols / On the Chemistry of Ingenol, II [1] Esters of Ingenol and ⊿7.8 -Isoingenol

Preparation and purification of 3-acylates of ingenol (1a) structurally related to naturally occuring, irritant and cocarcinogenic principles are described. It is shown that 3-acylates partly rearrange to corresponding 5-acylates when they are chromatographecl. From the 3-acylates or from ingenol (1a) a mixed and a symmetric ingenol-3,20-diacylate is synthesized respectively. Ingenol-5,20-acetonide (2a) is rearranged to its ⊿7.8-isomer 3b. Starting with 3b ⊿7.8-isoingenol (3a) and the 3-tetradecanoate of ⊿7.8-isoingenol (3d) are prepared. Most of the ingenol derivatives prepared are tested for their irritant activity on the mouse ear.

Struktur-Wirkungsbeziehungen polyfunktioneller Diterpene des Tigliantyps, IV [1-3]. Derivate des Tiglians mit fehlendem oder geöffnetem Cyclopropanring und ihre irritierende und tumorpromovierende Wirkung / Structure-Activity Relationships of Polyfunctional Diterpenes of the Tigliane Type, IV [1-3]. Derivatives of Tigliane without or with Opened Cyclopropane Ring and their Irritant and Promoting Activity

The synthesis of the esters 6d-8d, 9 c and 10 c is described. These compounds are closely structurally related to the irritant and tumorpromoting 12-O-tetradecanoylphorbol-13-acetate (TPA, 2 a) and to phorbol-12,13-didecanoate (PDD, 2 c) except that they possess no cyclopropane ring. Biological tests show that opening or complete removal of the cyclopropane ring leads to nearly total loss of irritant or tumorpromoting (tested in the case of 9 c and 10 c) activity.

Polybenzoate und -acetate des Phorbols und Phorbol-3-ols und funktionelle Derivate der Allylgruppierung des Phorbols

Base catalysed transesterification of phorbol-12,13,20-tribenzoate yields phorbol-12,13-dibenzoate. By base catalysed transesterification of phorbol-pentaacetate phorbol-9,12,13-triacetate is obtained. This can be re-acetylated to give phorbol-9,12,13,20-tetraacetate which is also obtained by treatment of phorbol-12,13,20-triacetate with acetic anhydride/p-toluene-sulfonic acid.

Reduction of phorbol-12,13,20-triacetate with LiAlH4 yields phorbol-3-ol which reduces Fehling's and Tollen's reagent. Reduction of the 3-keto group alone can be accomplished with sodium borohydride. From all phorbol-esters investigated only in phorbol-pentaacetate an acetyl migration is observed during the sodium borohydride reduction leading to phorbol-3-ol-3,9,12,13,20-pentaacetate. By these findings those two tertiary hydroxyl groups of phorbol which are not acetylated with acetic anhydride/pyridine at room temperature were further characterized.

Oxidation of phorbol-12,13-diacetate with activated manganese dioxide yields phorbol-20-al-12,13-diacetate. By evaluation of nmr-spectra of this aldehyde and of some of its derivatives as well as of the epoxide of phorbol-12,13-diacetate and of 6-oxo-7-hydroxy- and 6,7-diacetoxy-20-nor-phorbol-12,13-diacetate the sequence of C-atoms around the allylic alcohol group of phorbol is further characterized.

Zur Chemie des Phorbols, VIII

Oxidation of phorbol with one mole of lead tetraacetate yields bisdehydrophorbol, tiglophorbol and small amounts of phorbolacton-semiacetal. By chemical and spectroscopic investigations of bisdehydrophorbol and its derivatives its complete structure 16 is derived based upon the partial structures and structural elements of phorbol (1 - 3) which have been deduced in preceding communications. By consideration of the mechanism of the oxidative scission of the cyclopropanol unit in phorbol the structure 15 of this new tetracyclic diterpene is obtained. 15 has a pentamethyl-tetradecahydro-1H-cyclopropabenzazulene skeleton (tiglian) carrying as functional groups a tertiary hydroxyl group, an α,β-unsaturated tertiary 1.2-ketol group, a primary allyl alcohol group and a α- [hydroxycyclopropyl] -carbinol group. Phorbol is 4.9.12β.13.20-pentahydroxy-tigliadien- (1.6) -on- (3) (15) , bisdehydrophorbol 4.9.12β.20-tetrahydroxy-13.15-seco-tigliatrien- (1.6.15) -dion- (3.13) (16) the conformations of which have been determined. The structure of phorbolacton-semiacetal is determined in the following communication of this series. Based upon the structure of phorbol and additional chemical and spectroscopic evidence the structure of tiglophorbol (17) is also derived. With the data provided the relative configuration and the conformation of six out of the eight asymmetric centers of phorbol is determined.

On the Chemistry of Resiniferonol. I. Preparation of Resiniferonol, Synthesis of Homologous Aliphatic Resiniferonol-9,13,14-orthoesters and Some of their Bioactivities

The preparation of the daphnane prototype polyfunctional diterpene resiniferonol from resiniferatoxin (1) contained in latex from Euphorbia unispina or E. poisonii was modified to convert in an `early’ fraction of the acetone extract the extremely irritant 1 to the much less irritant 9,13,14-ortho(phenylacetate) 2 by transesterification. 2 was obtained in good yields and can be handled conveniently to prepare resiniferonol as reported previously. By esterification of resiniferonol with homologous straight chain aliphatic acids from C2 to C18 resiniferonol-14,20-diacylates were prepared. Treatment of the diacylates with perchloric acid/methanol yielded by intramolecular formation of the orthoester function the corresponding 9,13,14-orthoester-20-acylates. They were cleaved selectively by base catalysed transesterification to obtain the resiniferonol-9,13,14-orthoacetate (3), -hexanoate (4), -decanoate (5), -tetradecanoate (6) and -octadecanoate (7). On the mouse ear, unexpectedly they exhibit only weak irritant activity and on the mouse back skin practically no tumor promoting activity.

Partialsynthese von Wirkstoffen des Crotonöls

Partial syntheses of mixed functional phorbol- (12,13) -diesters with acetic acid and long-chain fatty acids at the α-glycol group of phorbol are described. Six of the phorbol diesters synthesized are identical with the irritant and tumorpromoting acetyl-phorbol-acylates A1 — A4, B4 and B7 isolated from croton oil. The isomeric phorbol- (12,13) -diesters A2 and B7 as well as A3 and B4 are pairs of positional isomers regarding the fatty acid residues. It may be generalized for all the eleven phorbol· (12,13) -diesters isolated so far from croton oil that compounds of the A group carry the long-chain fatty acid residue at C-13 and the short chain fatty acid residue at C-12. Compounds of the B group show inverse positions of these fatty acid residues. Isomeric phorbol-diesters of the types A and B may be differentiated by their Rf values in thin layer chromatography, their IR and mass spectra as well as the melting points of their 20- [4'-nitrophenylazobenzoic acid- (4)] - esters. Via the synthetic routes described phorbol- (12,13) -diesters with defined chemical structure are now easily accessible.

Eine einfache Trennfunktion zur Gegenstromverteilung und ihre Bedeutung für die Praxis

Die Theorie der Gegenstromverteilung wird vervollständigt durch Ableitung einer Trennfunktion, die mit einem Minimum an Experimenten den günstigsten Weg und den zu erwartenden Erfolg einer Gegenstromverteilung vorausberechnen läßt. Für die Auswahl der Lösungsmittelsysteme und des günstigsten Volumenverhältnisses ergeben sich daraus wichtige Hinweise. Durch die Trennfunktion wird ein quantitativer Vergleich des Trenneffektes der Gegenstromverteilung mit dem anderer Trennverfahren möglich.

On the Chemistry of Ingenol, IV [1]

A simple and fast procedure was worked out to prepare from the commercially available seeds of Euphorbia lathyris L. substantial amounts of the polyfunctional tetracyclic diterpene ingenol (la). Ingenol-3,4:5,20-diacetonide (1d) was treated with five different bases at two different temperatures to achieve epimerization to 8-epiingenol. In any case unchanged 1 d was obtained. By reduction of ingenol-3,4: 5,20-diacetonide (1d) with sodium in ether/2-propanol (9 R)-9-deoxo-9-hydroxyingenol-3,4:5,20-diacetonide (2b) was obtained and converted to the corresponding 5,20-monoacetonide 2e. Reduction of ingenol-5,20-acetonide (le) with LiAlH4 in tetrahydrofuran furnished the epimeric (9 S)-9-deoxo-9-hydroxyingenol-5,20-acetonide (3c).The (9 R)-monoacetonide 2e was used to prepare the 3-tetradecanoate 2c of (9 R)-9-deoxo-9-hydroxyingenol (2a). From the (9 S)-monoacetonide 3 c four 3-esters [butyrate (3d), tetradecanoate (3e), eicosanoate (3f), benzoate (3g)] of (9S)-9-deoxo-9-hydroxyingenol (3 a) were synthesized. The 3,4 : 5,20-diacetonides of 2a and 3a, i.e. 2b/3b were used to provide the 9-hexadecanoates 2 f and 3j. The irritant activities of the 3-esters of the (9 S)-series depend strongly on the nature of the acyl group, thus furnishing, e. g. the moderately irritant tetradecanoate 3e [compared to corresponding 3-esters lb of ingenol (la)] as well as the highly active benzoate 3g of 3 a. The (9 R)-3-tetradecanoate 2c exhibits comparable activity as its (9 S)-analogue 3e. Thus, the spatial orientation (R or S) of the 9-hydroxy function plays a significant but not a crucial role for irritant activity. Both epimeric (9 R)/(9 S)-hexadecanoates 2f/3j were non-irritant.

Zur mathematischen Behandlung der Gegenstromverteilung

Die Theorie der einfachen Gegenstromverteilung ist bekannt. Für die komplizierteren Arbeitsweisen, die sich bisher der Berechnung entzogen haben, werden Formeln abgeleitet und für den praktischen Gebrauch in eine Form gebracht, die eine leichte Berechnung der theoretischen Verteilungskurven ermöglicht. Die Anwendungsgebiete der verschiedenen Methoden werden diskutiert und mit experimentellen Ergebnissen verglichen.

Über die Wirkstoffe des Crotonöls, III

Ein toxisch, entzündlich und cocarcinogen hochaktiver Wirkstoff Al wird aus Crotonöl durch Anwendung multiplikativer Verteilungsverfahren erstmals rein dargestellt. Es handelt sich um einen bisher unbekannten Diester C36H56O8 von Essig- und Myristinsäure mit einem polyfunktionellen diterpenoiden Grundalkohol der Bruttozusammensetzung C20H28O6. Die Dosis, die eine deutliche Entzündung am Mäuseohr hervorruft, ist kleiner als die wirksame Dosis mancher Hormone.