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Treatment strategies for patients with pulmonary metastases of colorectal carcinoma are continuously evolving. This applies mostly to new systemic therapeutic approaches. For carefully selected patients surgical removal of pulmonary metastases remains an important interdisciplinary therapeutic option and is recommended as first treatment option by the guidelines. Five-year survival rates of up to 60 % are reported following pulmonary metastasectomy. Parenchyma sparing resection has been well established in this setting with low morbidity and mortality. Prognostic factors are, among others, complete resection, thoracic lymph node involvement, the number of metastases and the disease free interval. Although data result mostly from retrospective studies, these factors currently help in patient selection.

The benefits of surgical therapy of locally advanced non-small cell lung cancer (NSCLC) with infiltration of the superior vena cava (SVC) remains controversial. Here we describe our therapeutic approach and results of our intervention.A retrospective analysis of 22 patients with NSCLC who underwent SVC replacement (n = 17) or reconstruction (n = 5) between 1998 and 2013 was performed. Pneumonectomy was necessary in 16 patients, lobectomy in 8. Preoperative chemotherapy was administered to 3 patients, 16 received postoperative radiation treatment. The clinical course and survival were analyzed.Major postoperative morbidities were found in 13 patients. Graft thrombosis did not occur. Thirty-day mortality was 7 % in pneumonectomy patients and 0 % following lobectomy. Local recurrence was found in 4.5 %, distant metastases developed in 54.5 % of the patients (p = 0.0008). One- and five-year survival probabilities for all patients were 63.6 and 27.9 %. Five-year survival probability was 33 % for patients with SVC reconstruction and 25 % for patients with SVC replacement (p = 0.22). Five-year survival rates after pneumonectomy and lobectomy were 21.4 % and 37.5 %, respectively (p = 0.18).Radical resection involving the SVC in carefully selected patients with NSCLC results in excellent local tumor control. Due to the high rate of distant metastases, application of induction and adjuvant chemotherapy should be carefully assessed.

Chronic-thromboembolic pulmonary hypertension (CTEPH) is a serious complication of acute pulmonary embolism (PE). In untreated patients prognosis is poor. It depends on WHO-functional class. A delay from onset of symptoms and diagnosis can lead to a further worsening of prognosis. A pulmonary endarterectomy is the treatment of choice. We aimed to evaluate the time delay from onset of symptoms to diagnosis and the WHO-functional class at primary diagnosis in patients with CTEPH.Retrospective analysis of data from 70 monocentrically registered patients (48 women, 22 men, mean age 66,2 years ± 13,8 years) with confirmed CTEPH from the pulmonary hypertension expert center Missionsärztliche Klinik. Diagnostic work-up was performed according to the current guidelines.Mean delay from onset of symptoms to diagnosis of CTEPH was 18 ± 26 months. Time delay was only slightly shorter in patients with a history of PE (n = 56; 81 %) than in patients without a history of PE (n = 13; 19 %): 16,9 ± 23,8 vs. 23,5 ± 36,9 months. Time delay was higher in patients who received vasoactive medication before the first contact with a PH expert center and in patients who were classified as technically not suitable for a thrombendarterectomy. 38 patients with a history of acute PE did not have a period without symptoms. In 18 patients symptoms had transiently gone after PE. More than 70 % presented in WHO functional class III or IV.Time delay between onset of symptoms and diagnosis of CTEPH and referral to a PH expert center is long and the majority of patients presented in WHO-functional class III or IV. Prognosis is poor in untreated patients and getting worse with a higher WHO-functional class. For this reason, and because CTEPH can be cured by a pulmonary endarterectomy, each patient with suspected PH should be referred to a PH expert center to exclude CTEPH.

Sleeve lobectomy is an established surgical procedure in patients with lung cancer. Usually the only surgical alternative would be a pneumonectomy. This article describes the perioperative risks and functional results in patients after sleeve lobectomy compared to pneumonectomy and typical lobectomy.There were only minor differences with respect to postoperative morbidity comparing the different procedures but the mortality rate was higher following pneumonectomy. Bronchopleural fistula rates were also similar comparing lobectomy and sleeve lobectomy but elevated following pneumonectomy. Bronchovascular fistulas after sleeve lobectomy are potentially life-threatening. Postoperative pulmonary function tests showed similar values for lobectomy and sleeve lobectomy patients and were considerably better than following pneumonectomy.Whenever possible sleeve lobectomy should take preference over pneumonectomy.

Zielsetzung: Induktive Chemotherapie mit anschließender Resektion bleibt bei der Behandlung des nicht kleinzelligen Bronchialkarzinoms im Stadium III umstritten. Unser Vorgehen sowohl bei lokal fortgeschrittenem Tumorstadium (T4) als auch bei N2-Situation, ist entweder die primäre Operation[for full text, please go to the a.m. URL], Gemeinsame Jahrestagung der Deutschen, Österreichischen und Schweizerischen Gesellschaft für Thoraxchirurgie

Hintergrund: Die Bronchusstumpfinsuffizienz stellt eine gravierende Komplikation dar und bringt den Patienten in Lebensgefahr. Die Behandlungsstrategie mit einem thorakomyoplastischen Verfahren zum Verschluß der Insuffizienz und einer Vakuumversiegelung der Resthöhle zur Wundkonditionierung[for full text, please go to the a.m. URL], Gemeinsame Jahrestagung der Deutschen, Österreichischen und Schweizer Gesellschaft für Thoraxchirurgie

Hintergrund: Die Lymphknotenentfernung in der Metastasenchirurgie ist vielerorts noch kein akzeptiertes Routineverfahren. Selbst für die Indikation zur Metastasenchirurgie bestehen kaum Richtlinien. Auf der Suche nach abteilungsinternen Standards und zur Qualitätssicherung haben wir unsere[for full text, please go to the a.m. URL], Gemeinsame Jahrestagung der Deutschen, Österreichischen und Schweizer Gesellschaft für Thoraxchirurgie

Zielsetzung: Die plastische Deckung einer Brustwandresektion kann schwierig sein. Demonstriert wird der Einfluss der CT-gestützte 3-D-Rekonstruktion auf die Planung und Durchführung erweiterter Lungenresektionen. Methodik: In einer retrospektiven Studie wurden 90 Patienten mit kombinierten[for full text, please go to the a.m. URL], 16. Jahrestagung der Deutschen Gesellschaft für Thoraxchirurgie

Zielsetzung: Die Diagnose „solitärer fibröser Pleuratumor“ bezeichnet kein einheitliches Tumorleiden. Anhand von drei Kasuistiken zeigen wir Unterschiede in Bildgebung, Histologie, operativem Befund und Verlauf. Methode: Fall 1: Eine 76 jährige Frau mit dem Zufallsbefund[for full text, please go to the a.m. URL], 18. Jahrestagung der Deutschen Gesellschaft für Thoraxchirurgie

Die Standardtherapieverfahren beim Pleuraempyem sind Stadienabhängig. Zum Einsatz kommen die Empyemdrainage, videoassistierte Frühdecortication bzw. die offene Decortication. Grundvoraussetzung dieser Verfahren ist, dass die Lunge den Hemithorax ausfüllt. Ist dieses mit konventionellen[for full text, please go to the a.m. URL], 18. Jahrestagung der Deutschen Gesellschaft für Thoraxchirurgie

Die einem Pleuraempyem als Infektion des Brustfells zu Grunde liegende Ursache und der Allgemeinzustand des Patienten bestimmen die Therapie. Die in den letzten 5 Jahren unserer thoraxchirurgischen Klinik an einem Pleuraempyem erkrankten 404 Patienten wurden ausgewertet. Zügige Diagnostik,[for full text, please go to the a.m. URL], 18. Jahrestagung der Deutschen Gesellschaft für Thoraxchirurgie

We present the case of a 52-year-old male who underwent thoracotomy for resection of a suspected bronchogenic cyst in the right posterior mediastinum. The size of the tumor had increased over years, according to repeated X-rays, and the cyst became symptomatic with obstruction of the right subclavian and jugular veins. To our surprise, histopathology revealed a hydatid cyst.

Lung Cancer still is the major cause of death in malignant diseases. For several years the German Society for Thoracic Surgery attempted to establish an external quality management for the surgical treatment of lung cancer. Despite positive expert opinions and several negotiations no governmental support could be achieved. Therefore a pilot trial was started with financial support from the German Society for Thoracic Surgery and from the Association for Quality Management of Pneumology and Thoracic Surgery. During 2001 data of patients operated for lung cancer were prospectively recorded. Six high volume centres were prepared to participate. Mortality and morbidity rate as well as rate of sleeve resections and mediastinoscopies were selected as quality criteria. For the evaluation percentage and appropriate confidence intervals were used. 1494 interventions in 1099 patients were recorded. The type of resection was lobectomy in 565 (38%) cases, pneumonectomy in 148 (10%) cases and other interventions in 781 (52%) cases. Complications occurred in 31% of lobectomies and pneumonectomies with variations between the hospitals between 20% and 44%. Hospital mortality was 2.8% (1.5-3.5%) for the whole group. For lobectomies the hospital mortality was 2.6%, for pneumonectomies 8.1% (4-33%). The rate of mediastinoscopies in the hospitals varied between 20% and 80%. On the basis of the selected indicator and the quality criteria it could be shown that a quality management is possible. Das Bronchialkarzinom ist nach wie vor die häufigste Todesursache bei malignen Erkrankungen in Deutschland. Seit vielen Jahren versucht die Deutsche Gesellschaft für Thoraxchirurgie eine externe Qualitätssicherungsmaßnahme für die operative Therapie des Bronchialkarzinoms zu initiieren. Trotz vieler Verhandlungen und positiver Begutachtungsergebnisse des Projektes war von den Verantwortlichen im Gesundheitswesen keine öffentliche Förderung zu erhalten. Es wurde daher mit Geldern der Deutschen Gesellschaft für Thoraxchirurgie und des Vereins für Qualitätsmanagement in der Pneumologie und Thoraxchirurgie eine Pilotstudie gestartet. Es wurden Daten von Patienten, die aufgrund eines Bronchialkarzinoms im Jahre 2001 operiert wurden, prospektiv erhoben. Sechs große thoraxchirurgische Kliniken bzw. Abteilungen waren freiwillig bereit teilzunehmen. Qualitätskriterien waren die Letalitäts- und Komplikationsraten sowie die Anzahl der Manschettenresektionen und die Anzahl der Mediastinoskopien pro Haupteingriff. Die Auswertungen erfolgten als Prozentzahlen mit den zugehörigen Konfidenzintervallen. Es wurden 1494 Eingriffe bei 1099 Patienten dokumentiert. Die Eingriffsart war in 565 (38%) Fällen eine Lobektomie, in 148 (10%) Fällen eine Pneumonektomie und in 781 (52%) Fällen andere Eingriffe. Komplikationen traten bei großen Eingriffen bei 31% der Patienten auf. Innerhalb der Kliniken kam es zu Schwankungen zwischen 20% und 44%. Die Krankenhausletalität der gesamten Gruppe betrug 2,8%. Die geringste Letalität betrug 1,5%, die höchste 3,5%. Betrachtet man nur die Patienten, die lobektomiert wurden, so betrug die Letalität der gesamten Gruppe 2,6%. Bei den Pneumonektomien betrug die Letalität 8,1%. Sie schwankte zwischen 4% und 33%. Die Rate der Mediastinoskopien in Bezug auf die kurativen Eingriffe schwankte zwischen 20% und 80%. Anhand des vorgegebenen Indikatorproblems (Bronchialkarzinom) und der Qualitätskriterien konnte in der Studie gezeigt werden, dass eine sinnvolle und aussagekräftige externe Qualitätssicherung in der operativen Thoraxchirurgie mit den erhobenen Daten möglich ist.

Surgical treatment of proximal aortic disease traditionally consists of composite replacement of valve and aorta. Recent reconstructive procedures on the aortic root allow for treatment of aortic dilatation and concomitant aortic valve regurgitation without the associated disadvantages of mechanical heart valves. From 10/95 to 09/99 we treated 84 patients for regurgitation of the aortic valve and dilatation of the aortic root. Valve preserving replacement of the root consisted of root remodeling (n = 68) or reimplantation of the aortic valve (n = 16). Operative mortality in valve-preserving surgery was not elevated compared to overall results of proximal aortic replacement (3.6% vs 5.6%); this applied to elective procedures (1.8% vs 2.3%) as well as emergency operations (9.3% vs 16.3%). Initial aortic valve function was adequate in all cases. Actuarial freedom from regurgitation grade II or higher was 98% after root remodeling and 92% after valve reimplantation. Freedom from reoperation at two years was 96% in remodeling and 100% in valve reimplantation. Hemodynamic function of the reconstructed valve was investigated in 17 patients under conditions of rest and exercise. These were compared to 9 patients with a mechanical composite valve. Patients with reconstructed valves had almost physiologic gradients during rest and exercise. These gradients were thus significantly lower than the increased gradients of patients after composite replacement. Application of reconstructive procedures to the aortic root allows for restoration of aortic valve function in the majority of patients. Disadvantages of heart valve prostheses can be avoided, and the hemodynamic performance of the reconstructed valve appears almost physiologic.

Intramural hematoma is a spontaneous, localized bleeding in the wall of the thoracic aorta without evidence of intimal tear. Clinically, intramural hematoma manifests itself as an acute thoracical pain in patients with hypertension and therefore shows parallels with the classical aortic dissection. In the literature there is controversial discussion whether intramural hematoma can be regarded as its own aortic pathology or a precursor in the development of classical aortic dissection. We present the case of a 66 year old male who showed an intramural hematoma of the descending aorta which rapidly progressed to classical dissection within 3 months. This finding was secondarily accompanied by a dilatation of the descending aorta which leads to operative treatment with replacement of the proximal aorta descendens. This case supports the hypothesis that intramural hematoma is a potential early manifestation of aortic dissection and at the same time stresses the necessity for frequent follow-up investigations and, if necessary, early operative therapy.

Reconstruction of a regurgitant bicuspid aortic valve is a new alternative to aortic valve replacement. With concomitant aortic root dilatation adequate reconstruction is feasible by valve-sparing aortic replacement. Between 10/95 and 02/00, 30 patients underwent reconstruction of a regurgitant bicuspid aortic valve. Additional aortic replacement was performed in 23 cases. Valve reconstruction was performed by plication of the prolapsing leaflet. No patient died peri- or postoperatively. Freedom from aortic valve regurgitationor = II as well as freedom from reoperation were 100% after 48 months. Reconstruction of a regurgitant bicuspid aortic valve is feasible with encouraging mid-term results. With concomitant dilatation of the ascending aorta, a combination of aortic replacement and valve reconstruction can achieve stable results even in bicuspid valve anatomy.

Complete arterial coronary artery bypass grafting seems to be an alternative surgical approach in the treatment of coronary artery disease. Complications in the long-term follow-up due to degeneration of venous grafts may be reduced using arterial conduits. Prolonged operating times and increased trauma due to harvesting of multiple arterial grafts have been arguments for the conventional operative approach. We present our experience using new operative techniques, such as skeletonization of arterial grafts and the T-graft configuration.Between 3/96 and 7/99, 405 patients with multiple coronary artery disease underwent complete arterial revascularization at our institution. The operations were performed using only two skeletonized grafts, both internal thoracic arteries in 105 patients (25.9%), internal thoracic artery and radial artery in 299 patients (73.8%) and 1 radial artery in 1 patient (0.3%).In 346 patients (85.4%) a T-graft configuration was used. A mean of 4.1 +/- 0.9 coronary anastomoses were performed per patient. In hospital mortality was 2%. Sternal dehiscence or infection occurred in 0.8% of patients. Harvesting of the radial artery was performable with a low morbidity. One week postoperatively, coronary angiography showed 96.7% of coronary anastomoses free of stenosis50%.Complete arterial coronary revascularization using skeletonized grafts and the T-graft approach is a safe technique in the treatment of multiple coronary artery disease. Low perioperative morbidity and mortality make its usage on a routine basis possible.

The present study investigates the effects of dopexamine on the splanchnic perfusion and the general circulation in patients undergoing coronary artery bypass grafting.34 Patients undergoing elective coronary artery bypass grafting were randomized to receive either dopexamine (1 microg/kg/min) or placebo (0,9% NaCl. ) Cardiac output was measured by thermodilution using a pulmonary artery catheter. Splanchnic blood flow was determined by constant infusion technique of indocyanine green dye (ICG) using a hepatic vein catheter.Under steady state conditions before surgery, dopexamine increased systemic oxygen supply and cardiac output by an increase in heart rate and stroke volume, with no increase in systemic oxygen demand. Before surgery dopexamine increased splanchnic blood flow together with an increase in cardiac output. After cardiopulmonary bypass dopexamine increased splanchnic perfusion without a concomittant rise in cardiac output.These results provide evidence that dopexamine improves splanchnic blood flow in patients with coronary artery disease before and after pulmonary bypass without impairment of general hemodynamics.

Procalcitonin (PCT) is an inflammatory peptide of still unknown origin. In this study we investigated a potential source for circulating PCT in patients undergoing coronary artery bypass grafting.To determine PCT concentrations, arterial, liver-venous and mixed-venous blood samples were collected time matched perioperatively in 20 patients scheduled for cardiac surgery using cardiopulmonary bypass (CPB).PCT concentrations significantly increased 4 hours postoperatively compared to baseline values (0.74 +/- 0.45 vs. 0.16 +/- 0.04 ng/ml). The highest concentrations were measured 18 hours postoperatively (1.44 +/- 1.01 ng/ml). PCT concentrations in liver venous samples were significantly higher (1.67 +/- 1.29 ng/ml) than in time matched collected arterial samples (1.44 +/- 1.01 ng/ml).These results provide evidence, that hepatosplanchnicus is a source for PCT synthesis in patients following CPB. The mechanism of PCT induction remains unclear. A loss of gut mucosal barrier function with translocation of endotoxins and the inflammatory response with release of cytokines following cardiopulmonary bypass has to be discussed.

The standard surgical repair of disease of the aortic valve and the ascending aorta has been combined replacement, which includes the disadvantage of inserting a mechanical valve. We have investigated an individualized approach which preserves the native valve.Between October 1995 and October 1997, a consecutive total of 101 patients (72 men, 29 women, aged 21-83 years) underwent operations for disease of the ascending aorta: aortic dissection type A in 34 patients, aneurysmal dilatation in 67. Dilatation of the aortic arch was associated with aortic regurgitation in 58 patients. There were 11 patients with aortic valve stenosis or previously implanted aortic valve prosthesis among a total of 46 whose aortic valve was replaced (group II). Supracommissural aortic replacement with a Dacron tube was performed in 16 patients (group I) with normal valve cusps and an aortic root diameter3.5 cm. In 28 patients with an aortic root diameter of 3.5-5.0 cm the aortic root was remodelled (group III). Resuspension of the native aortic valve was undertaken in 11 patients with aortic root dilatation of5.0 cm (group IV).Operative intervention was electively performed in 72 patients, without any death. Of 29 patients operated as an emergency for acute type A dissection four died (14%). In 55 of the 58 patients with aortic regurgitation in proved possible to preserve native aortic valve (95%). In the early postoperative phase and after an average follow-up time of 11.8 months, transthoracic echocardiography demonstrated good aortic valve function, except in one patient each of groups III and IV who developed aortic regurgitation grades I or II.The described individualized approach makes it possible to preserve the native aortic valve in most patients with aortic regurgitation, at a low risk. Follow-up observations so far indicate good results of the reconstruction.

After cardiac surgery, transient renal dysfunction often occurs. The main reasons for impairment of renal function are intraoperative hypotension, ischemia/reperfusion injury and inflammatory response to cardiopulmonary bypass (CPB). Pentoxifylline is known to have anti-inflammatory properties. Gamma-hydroxybutyrate (GHB), an endogenous regulator of energy metabolism, showed beneficial effects on experimental intestinal ischemia/reperfusion injury and liver graft function. Both drugs may be of practical interest in diminishing renal damage during and after cardiac surgery. After approval by the ethics committee and informed consent, 45 patients for elective coronary artery bypass grafting with no clinical and laboratory impairment of renal function were randomized into 3 groups (15 patients each): group 1 received saline as control, group 2 received pentoxifylline intraoperatively (1 mg/kg/h after a priming dose of 1 mg/kg) and group 3 received GHB intraoperatively (25 mg/kg/h after a priming dose of 25 mg/kg) in a double-blinded fashion. During 3 periods (before CPB, from the beginning of CPB until the end of surgery, 24 hours postoperatively), glomerular (creatinine clearance, CCr) and tubular markers of renal function (beta-NAG, alpha 1-microglobulin) were detected in addition to clinical routine standards (creatinine, urea, fractional excretion of sodium). Changes in glomerular and in tubular function were comparable in all groups without characteristic effects of either GHB or pentoxifylline. With CPB, CCr decreased significantly until the end of operation, but showed a rise to preoperative levels on the first day after operation. Tubular function markers (beta-NAG, alpha 1-microglobulin, related to simultaneous excretion of creatinine) showed a remarkable rise after the beginning of CPB up to the postoperative period. The results of the present pilot study suggest the detection of tubular proteins and enzymes a useful addition to present routine clinical standards for recognizing early intraoperative changes in renal function. In the patients studied, there were no clinical signs of renal dysfunction. Neither GHB nor pentoxifylline--in the doses applied--was able to show a therapeutic benefit despite the theoretical advantages.

A giant Solitary Fibrous Tumor (SFT) arising in the pericardium is described. A 53 year old woman was suspected to have a lung tumor and thoracotomy was performed. Intraoperatively the child-head sized mass was found to be localized in the pericardial sac. The histopathological interpretation of a small wedge-biopsy was 'endothelioma of uncertain malignancy' and heart-transplantation was performed two months later. The patient died of postoperative infection. Post mortem examination could exclude tumor rest or metastasis. The explanted heart revealed a large bulk of 2800 grams arising from the epicardium of the left chamber and enveloping the heart without invading the underlying myocardium. The histopathological pattern varied between cell-rich and -poor fibromatous areas and well capillarized endothelioma-like zones. Immunohistochemistry revealed positive reactions with monoclonal antibodies against Vimentin and CD 34 and no reactions against Cytokeratins and Faktor VIII. This pattern was confirmed in 7 SFT's of the pleura from our archives. A second control group of 7 mesotheliomas was positive for cytokeratins and vimentin but not for CD 34 and Faktor VIII. Diagnosis of SFT might be difficult because of its variability in histopathology, sometimes mimicking a hemangiopericytoma or endothelioma. Recent reports of tumor localizations devoiding serosal surfaces illustrate the diagnostic and histogenetic dilemma of this tumor. The differentiation of SFT from mesothelioma and endothelioma can be achieved by immunophenotyping including CD 34.

von Karl Graeter In Fraktur Progr.-Nr. 151