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Background: Pulmonary metastasectomy is widely accepted for different malignant diseases. The role of mediastinal lymph node (LN) dissection in these procedures is discussed controversially. We evaluated our results of LN removal at the time of pulmonary metastasectomy with respect to the frequency of unexpected LN disease., Methods: This was a retrospective analysis of 313 resections performed in 209 patients. Operations were performed in curative intention. Patients with known thoracic LN involvement and those without lymphadenectomy (n = 43) were excluded. Patients were analyzed according the type of LN dissection. Subgroups of different primary cancers were evaluated separately., Results: Sublobar resections were performed in 256 procedures with lymphadenectomy, and 14 patients underwent lobectomy. Patients underwent radical lymphadenectomy (n = 158) or LN sampling (n = 112). The overall incidence of unexpected tumor in LN was 17% (radical lymphadenectomy, 15.8%; sampling, 18.8%). Unexpected LN involvement was found in 17 patients (35.5%) with breast cancer, in 120 (9.2%) with colorectal cancer, and in 53 (20.8%) with renal cell carcinoma. The 5-year survival was 30.2% if LN were tumor negative and 25% if positive (p = 0.19). LN sampling vs radical removal had no significant effect on 5-year survival (23.6% vs 30.9%; p = 0.29)., Conclusions: Dissection of mediastinal LN in resection of lung metastases will reveal unexpected LN involvement in a relevant proportion of patients, in particular in breast and renal cancer. Routine LN dissection appears necessary and may become important for further therapeutic decisions. On the basis of our data, LN sampling seems to be sufficient., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Pneumonectomy has traditionally been the treatment of choice for central lung tumors. Bronchial sleeve resections are increasingly considered as a reasonable alternative. For tumor involvement of both central airways and pulmonary artery, bronchovascular sleeve resections are possible, but considered to be technically demanding and associated with a higher perioperative risk. In addition, their role as adequate oncologic treatment for lung cancer is unclear. We have compared the early and long-term results of bronchovascular sleeve resection with those of bronchial sleeve resection and pneumonectomy., Methods: We retrospectively analyzed all patients who underwent bronchial sleeve resection (group I, n = 104), bronchovascular sleeve resection (group II, n = 67), and pneumonectomy (group III, n = 63) for central lung cancer in our institution., Results: The groups were comparable regarding demographics and tumor, node, and metastasis (TNM) stage. Early mortality was 1.9% in group I, 1.5% in group II, and 6.3% in group III (p = 0.19). The rate of bronchial complications was 0.96% in group I, 0% in group II, and 7.9% in group III (p = 0.006). Five-year survival was 46.1% in group I, 42.9% in group II, and 30.4% in group III (p = 0.16). Freedom from local recurrence of disease (5 years) was 83.8% in group I, 84.2% in group II, and 88.7% in group III (p = 0.56)., Conclusions: Bronchovascular sleeve resections are as safe as bronchial sleeve resections for the treatment of central lung cancer. Both procedures have comparable early and long-term results, which are similar to those of pneumonectomy. It appears reasonable to apply bronchovascular sleeve resections more liberally.

Background: In patients with bronchogenic carcinoma, mediastinal lymph node staging is essential for determining treatment options. In this retrospective analysis we compared the results of positron emission tomography (PET) using F-18 fluorodeoxyglucose with those of mediastinoscopy in nodal staging for suspected bronchogenic carcinoma., Methods: From March 1997 to June 2001, 102 patients (86 male,16 female, age 62 +/- 9 years) underwent both PET and mediastinoscopy for radiologically suspected mediastinal lymph node disease in bronchogenic carcinoma. Total body emission scans were acquired 90 to 150 minutes after injection of 230 MBq of F-18 fluorodeoxyglucose. Mediastinoscopic evaluation of lymph node stations was performed according to the method of Mountain and Dresler (1R, 1L, 2L, 2R, 4L, 4R,7). Patients were eligible if surgical staging was performed within 6 weeks after the PET scan. RESULTS. Of the 102 patients, benign lesions were diagnosed in 15. In 87 patients malignant disease was proven by histology, and bronchogenic carcinoma was found in 82. Of 469 nodal stations analyzed, malignancy was documented by histology in 84. In PET analysis 79 true-positive and 304 true-negative samples were found. Five lymph node stations were false negative, and 81 samples were false positive. False-positive findings in PET frequently were seen in inflammatory lung disease. The sensitivity of PET was 94.1%, specificity was 79% with a diagnostic accuracy of 81.6%. The positive predictive value of PET was 49.3%, and the negative predictive value was 98.4%., Conclusions: In patients with positive PET scan results histologic verification appears necessary for exact lymph node staging. In view of the negative predictive value mediastinoscopy can be omitted in patients with bronchogenic carcinoma whose PET scan results were negative.

We describe the case of a 58-year-old female patient who underwent redo mitral valve replacement and remained in heart failure. The diagnosis of a left ventricular-right atrial fistula was made. The fistula was closed surgically with a patch of autologous pericardium. The patient improved immediately after the operation and has been asymptomatic since.

Background: The standard treatment in patients with acute aortic dissection type A (AADA) and aortic regurgitation is either supracommissural aortic or composite replacement of ascending aorta and valve. Valve-preserving surgical procedures provide a promising alternative. We retrospectively analyzed midterm results after these different approaches., Methods: From October 1995 to December 1999, 52 patients (35 men, 17 women) underwent repair of AADA. Patient ages ranged from 30 to 83 years. Composite replacement was chosen for degenerated aortic valves or prior valve replacement (group A; n = 8). With normal root diameter, supracommissural replacement of the ascending aorta was performed (group B; n = 22). For preexisting root dilatation the aortic root was either remodeled (root diameter 30 to 50 mm, group C; n = 17) or the valve reimplanted within a vascular graft (root diameter more than 50 mm, group D; n = 5)., Results: All patients underwent either proximal (n = 46) or total (n = 6) arch replacement under circulatory arrest. Eight patients (15.4%) died (group A: n = 3; group B: n = 3; group C: n = 2). Freedom from aortic regurgitation of grade 2 or more at 2 years was 100% in groups A and D, 90.9% in group C, and 75% following supracommissural replacement. At 2 years freedom from proximal reoperation was 100% in groups A, C, and D and 84.5% in group B., Conclusions: In AADA valve-preserving root replacement leads to improved stability of aortic valve function without an increased operative risk. Midterm results are promising and may show further superiority over supracommissural aortic replacement in the future.

Background: To improve postoperative pulmonary reserve, we have employed parenchyma-sparing resections for central lung tumors irrespective of pulmonary function. The results of lobectomy, pneumonectomy, and sleeve resection were analyzed retrospectively., Methods: From October 1995 to June 1999, 422 typical lung resections were performed for lung cancer. Of these, 301 were lobectomies (group I), 81 were sleeve resections (group II), and 40 were pneumonectomies (group III)., Results: Operative mortality was 2% in group I, 1.2% in group II, and 7.5% in group III (group I and II vs. group III, p<0.03). Mean time of intubation was 1.0+/-4.1 days in group I, 0.9+/-1.3 days in group II, and 3.6+/-11.2 days in group III (groups I and II vs. group III, p<0.01). The incidence of bronchial complications was 1.3% in group I, none in group II, and 7.5% in group III (group I and II vs group III, p<0.001). After 2 years, survival was 64% in group I, 61.9% in group II, and 56.1% in group III (p = NS). Freedom from local disease recurrence was 92.1% in group I, 95.7% in group II, and 90.9% in group III after 2 years (p = NS)., Conclusions: Sleeve resection is a useful surgical option for the treatment of central lung tumors, thus avoiding pneumonectomy with its associated risks. Morbidity, early mortality, long-term survival, and recurrence of disease after sleeve resection are similar to those seen after lobectomy.

Background: Currently, isolated reconstruction of a regurgitant bicuspid aortic valve can be performed with adequate early results. Dilatation of the proximal aorta is known to be associated with this valve anomaly and may be partially responsible for the development of primary regurgitation or secondary failure of valve repair. We have used repair of the bicuspid valve with remodeling of the aortic root as an alternative to insertion of a composite graft., Methods: Between October 1995 and May 1999, 16 patients (12 men, 4 women, aged 35 to 73 years) were seen with a regurgitant bicuspid aortic valve and dilatation of the proximal aorta of more than 50 mm. All patients underwent repair of the valve using either coapting sutures alone (n = 12) or in combination with triangular resection of a median raphe (n = 4). Using a Dacron graft, the aortic root was remodeled and the ascending aorta (n = 16) and proximal arch (n = 4) replaced., Results: No patient died. The postoperative degree of aortic regurgitation was less than grade II in all patients. Valve function has remained stable in all patients between 2 and 43 months postoperatively., Conclusions: Reconstruction of the regurgitant bicuspid valve in the presence of proximal aortic dilatation is feasible with good results by combining the root remodeling technique with valve repair.