Pulmonary metastasectomy for metastasized hepatocellular carcinoma after liver resection and liver transplantation: a single center experience.

BACKGROUND: The role of surgery in the treatment of metastasized hepatocellular carcinoma (HCC) remains uncertain. We here report our single centre experience with pulmonary metastasectomy (PM) for metachronous HCC metastases to the lung following curative liver resection (LR) and liver transplantation (LT), respectively. METHODS: Of 270 patients with HCC being treated by LR or LT at the University Hospital of Leipzig between January 1996 and July 2014, PM was performed in the follow up of 10 patients because of metachronous pulmonary HCC metastases. We retrospectively analyzed demographic and clinicopathological factors as well as the outcome after primary and secondary tumor treatment in these patients. RESULTS: Following LR/LT and metastasectomy, respectively, mean overall survival was 4.58 ± 0.84 years and 2.4 ±â€Š0.69 years. Postoperative morbidity after primary and secondary tumor treatment was 30 % and 20 %, respectively. Perioperative 30-day mortality was 0 %. Univariate analysis suggest tumor grading (p < 0.05), and a disease free-intervall > 1 year (p = 0.02) as significant prognostic parameters for survival in our collective. CONCLUSION: PM can be performed safely with a reasonable morbidity even in immunosuppressed patients after LT. Further studies are needed to evaluate whether PM can increase long-term survival in selected patients with resectable metastases and represents an alternative or additive treatment modality to the protein kinase inhibitor sorafenib.

[CT-guided marking of pulmonary nodules with a special lung marking wire before video-assisted thoracoscopic surgery - review of 184 cases]. / CT-gestützte Drahtmarkierung vor videoassistierter thorakoskopischer OP von pulmonalen Rundherden - eine Auswertung von 184 Fällen.

PURPOSE: Minimally invasive techniques like video-assisted thoracoscopic surgery (VATS) are currently the method of choice for the resection of small pulmonary nodules, when they are located in the periphery of the lungs. To guarantee quick and safe intraoperative identification of the nodule, preoperative marking is necessary and sensible. We report about our experiences in 184 markings with a special lung marking wire, which is placed in or around the pulmonary nodule using CT guidance. MATERIALS AND METHODS: In 184 patients (97 m, 87f, mean age: 58.1 ± 13.7 years) with pulmonary nodules, scheduled for resection with VATS, a special lung marking wire was placed preoperatively under CT guidance. We evaluated the technical success, safety, necessity of conversion to thoracotomy and histology in all patients. RESULTS: The marking wire could be positioned successfully in 181 cases (98.4 %). There was one major complication (uncontrollable pneumothorax). Minor adverse events like small pneumothorax (53.3 %) or a perifocal bleeding (30.4 %) did not necessitate treatment. Complete resection of the marked nodule was successful in 98.4 % of the patients. Conversion to thoracotomy was necessary in 29 patients (15.9 %) due to bleeding, adhesions, malignancy or wire dislocation. Histology revealed a benign nodule in 96 cases (54.4 %) and a malignant lesion in 78 cases (45.6 %), of which only 21 nodules (11.5 %) turned out to present a primary pulmonary carcinoma. CONCLUSION: CT-guided marking of pulmonary nodules using a special marking wire followed by thoracoscopic resection is an efficient and safe method for diagnosing suspicious nodules in the periphery of the lung.

[The preoperative multislice spiral CT in the surgical management of pulmonary metastases]. / Die präoperative Dünnschicht-Computertomografie im Management der Lungenmetastasenchirurgie.

INTRODUCTION: Inspection and palpation of the ventilated and exhausted lung reflect the guideline-compliant surgery of pulmonary metastases. Because a huge number of pulmonary nodules are missed on preoperative CT, metastases must be diagnosed by the surgeon's examination of the lung under exclusion of the video-assisted approach. The purpose of our study was to assess whether a special multislice (MS) spiral CT may close this diagnostic gap and change the management of pulmonary surgery. PATIENTS AND METHODS: We performed a prospective study to address this question. Operative and histological results of 60 patients with pulmonary nodules (7/2002 and 12/2004) were compared with the preoperative predictions of MS-CT. RESULTS: In 81 operations, 166 pulmonary metastases were confirmed histologically. The MS-CT predicted 229 suspicious metastases; 38% could not be confirmed histologically. However, in 14% of surgically confirmed metastases the radiological correlate was absent. 44% of these metastases were 4 mm; and were from the following primary entities: 48% hypernephroma, 30% sarcoma, 17% colorectal carcinoma and 4% breast cancer. The radiological prediction of 1 to 3 vs. 5 to 11 metastases implied 30% vs. 70% additional filiae, whereas radiologically non-described metastases were found in 12% of all operations. In contrast, the group with radiopaque material showed only 5% of metastases without a radiological correlate or 8% of non-described metastases. The overall sensitivity of MS-CT was 86%, whereas the group with radiopaque material had a sensitivity of 95%. CONCLUSION: The preoperative MS-CT does not resolve the problem of overlooked metastases and has no influence on the management of pulmonary surgery.

[Tracheobronchial ruptures: classification and management]. / Tracheobronchiale Verletzungen Klassifikation und Therapiestrategie.

BACKGROUND: Tracheobronchial ruptures are rare surgical emergencies with significant mortality. We present management and outcome of such ruptures treated at the University of Leipzig in Germany and propose a novel therapeutic algorithm-a new classification system for stratifying treatment of patients with tracheobronchial ruptures. METHODS: We retrospectively studied 24 patients 19 to 88 years old who were treated in our institution for tracheobronchial injury. RESULTS: Eighty-seven percent of the injuries were caused iatrogenically. Fifty-four percent were type I injuries (isolated tracheal lesions), 38% type II (involvement of carina or main stem bronchi), and 8% type III (distal lesions of lobar or segmental bronchi). Seventy-five percent of the patients were operated via right-sided dorsolateral thoracotomy. In four (22%), insufficiency of the tracheal closure occurred, with mediastinitis possibly being a significant risk factor for this event (P<0.001). In surgically treated patients, rupture-related and overall mortality were 5.5% and 28%, respectively, whereas in medically treated patients, mortality was 33%. CONCLUSION: The proposed classification of tracheobronchial injuries enables stratifying the treatment of patients with tracheobronchial ruptures. Type I lesions can be surgically closed either by a right-sided thoracotomy or transcervical-transtracheal approach. In contrast, surgical management of type II and III injuries always requires thoracotomy.

Does tumor heterogeneity limit the use of the Weiss criteria in the evaluation of adrenocortical tumors?

Adrenal incidentalomas are detected more frequently with high-resolution imaging modalities. It is difficult to distinguish between benign and malignant lesions despite the so-called histologic Weiss criteria, imaging features, and molecular studies. We here present a 52 yr-old man who was found to have an adrenal incidentaloma during an annual check-up at his urologist. An 8 cm large adrenal lesion was detected on ultrasound, computed tomography, and magnetic resonance imaging with imaging features suggestive of malignancy. The lesion was hormonally inactive. A left-sided adrenalectomy was performed and histologic grading revealed a Weiss score of 2, suggesting a benign tumor. However, on further follow-up, the patient developed a local recurrence and pulmonary metastases diagnosed 6 yr after initial presentation. After repeat surgery in the left adrenal bed adrenocortical tumor tissue had a Weiss score of 8, clearly suggesting histologic malignancy. The patient received adjuvant mitotane therapy. Under this therapy, he developed a right-sided adrenal mass (contralateral from the primary tumor) of 2 cm size which disappeared during the following 9 months, whereas the pulmonary metastases remained unchanged, suggesting tumor clones with a variable response to treatment or spontaneous apoptosis. This case suggests that adrenal incidentalomas larger than 6 cm with imaging features such as intratumoral necrosis suggestive of malignancy, should be managed as potential cancers independent of the so-called Weiss criteria. In such patients, close follow-up examinations including high-resolution imaging (preferably 3 monthly) are needed and should be carried out by a physician familiar/specialized in endocrine oncology.

[Intraoperative electrophysiological monitoring of the recurrent laryngeal nerve in thyroid gland surgery--a prospective study]. / Anwendung des Neuromonitoring des N. laryngeus recurrens in der Schilddrüsenchirurgie - eine prospektive Studie.

INTRODUCTION: In the last few years the use of intraoperative electrophysiological monitoring of the recurrent laryngeal nerve (RLN) in thyroid gland surgery has become more and more important. PATIENTS AND METHOD: In a prospective study 223 nerves at risk in 116 patients were monitored with the Neurosign(R)100 (Fa. Magstim Ltd., UK). We used intramuscular needle electrodes inserted into the vocal muscle through the conic ligament. Practicability, complications, acceptance and predictive value of the method were documented. Recurrent nerve palsy rate and complications were compared with a control group operated upon without monitoring. RESULTS: The intraoperative delay using this method was on average 8.9 minutes. There were problems with monitoring equipment avoiding use in 6.4 %. In 2 cases (1.7 %) an accidental lesion of endotracheal tube cuff was found related to malpositioning of the needle and in 7.7 % a hematoma of the vocal cords was observed. 73.3 % of the surgeons accepted the method to identify and control the nerve integrity. False-positive and false-negative signals may occur. In cases of a final real stimulus response a regular vocal cord motility was found in 95 %. If a nerve conduction block was noted an immobility of ipsilateral vocal cord was diagnosed postoperatively in 50 %. There was no decrease in transient recurrent palsy rate using monitoring (10.7 % vs. 9.6 % without monitoring) but in permanent paralysis (1.8 % vs. 3.0 %). CONCLUSIONS: It may be concluded that intraoperative electrophysiological monitoring of the RLN is a simple and accepted method with low complications reducing the incidence of permanent RLN palsy rate. We found the monitoring especially useful for operations of recurrent goiter and carcinomas of the thyroid gland as well as for learning thyroid gland surgery.

[CT-guided marking of lung lesions before minimally invasive operation]. / CT-gesteuerte Lungenherdmarkierung vor minimal-invasiver Operation.

Video-assisted thoracoscopic surgery (VATS) is an established method for resection of suspicious pulmonary lesions. However, there are problems to detect small subpleural lesions. A procedure for localization of such lesions will be demonstrated. Since may 2000 our experience includes 5 patients (4m, 1f) suffering from solitary pulmonary lesions. In preparation of VATS a CT-guided marking was carried out using both a lasermarker system as well as a special marker system for lung lesions. All 5 procedures were successful. With the laser system the pulmonary nodule was exactly marked and the special wire was placed without any complications. Consequently, the pulmonary nodule was fixed. During video-assisted wedge resection the nodule can be tracted outside. Operating time was reduced in comparison to time consuming search of unmarked lesions. The combined application of CT-guided marking, transthoracic fixation of pulmonary nodule and VATS is recommended preoperatively. It should apply in lesions, which are located subpleural and thoracoscopically not visible.

Evaluation of ultracision in lung metastatic surgery.

BACKGROUND: There are very few studies on the histological outcome of lung metastatic surgery using the Ultracision particularly in deeper areas of the lung. METHODS: In a prospective study, we resected 24 lung metastases from 18 patients using the Ultrasonic scalpel (Ethicon Endo-Surgery, Norderstedt, Germany). We analyzed the risk of bleeding and air leakage as well as the histopathological features of the resection area. RESULTS: There was no intraoperative bleeding and, in 72%, no intraoperative air leakage. The resection surface was closed with a suture. In 8 cases, the metastases were located deeply, near the hilus of the lobe which did not necessitate a lobectomy. Histologically, occluded blood vessels as well as occluded small bronchioli under 0.1 cm were observed. There was no evidence of deep tissue destruction. No postoperative complications occurred. CONCLUSIONS: Ultracision in metastatic lung surgery is an appropriate method of treatment with minimum risk of bleeding or air leakage. This procedural approach allows for adequate resection of lung metastases while sparing a generous amount of healthy lung tissue.

[Recurrent laryngeal nerve paralysis as intubation injury?]. / Die Recurrensparese als Intubationsschaden?

INTRODUCTION: Vocal cord paralysis is a important complication in thyroid gland surgery. A prospective study was conducted ascertain the frequency of laryngeal nerve palsy not caused by surgical trauma. PATIENTS AND METHODS: Two hundred and ten patients were investigated laryngoscopically pre- and postoperatively after short-term intubation in the course of operations far removed from thorax or neck region. We noted the inner diameter of the tube, intubation problems, the qualification of the anaesthesiologist and the positioning of the patient. RESULTS: Preoperatively we found previously unknown unilateral laryngeal nerve palsy in 1.9% of cases. Postoperatively there were pathological findings of vocal cords in 13 patients (6.2%). In 10 patients a direct lesion (oedema, rubor, haematoma, granuloma) was established. Three patients (1.4%) were found to have a movement disorder caused by a neural lesion without morphological findings, leading to restitutio ad integrum in two of three cases after 6 months. CONCLUSION: The frequency of intubation-related recurrent nerve palsy is 1.4% transiently and 0.5% permanently. The reasons are discussed. Preoperative laryngoscopic investigation of vocal cords should be carried out before intubation.

[Therapeutic management of postoperatively diagnosed bilateral recurrent laryngeal nerve paralysis]. / Therapeutisches Management bei postoperativ diagnostizierter doppelseitiger Recurrensparese.

UNLABELLED: Bilateral vocal cord paralysis is a rare but potentially dangerous postoperative complication in thyroid gland surgery. There is a controversial discussion about therapeutic management of postoperative bilateral vocal cord paralysis. METHODS: We analysed the frequency of bilateral nerve palsy in 985 operations. The disease of thyroid gland, the operative procedure, the exposure of laryngeal nerve, the mobility of vocal cord detected by an otolaryngologist, clinical symptoms and therapy of patients with bilateral paralysis were analysed. All patients were examined immediately postoperatively and 5 days, 14 days, 6 and 12 months after resection. RESULTS: The overall transient bilateral palsy rate was 0.7%, the permanent 0.3%. The palsy rate depended on the disease of thyroid gland. After resection of simple goitre we found a 0.2% transient injury rate (0.1% permanent), after operation of thyroid cancer 2.0% transient (1.0% permanent) and in cases of recurrent goitre 5.9% transient (1.9% permanent) palsies. The immediate postoperative symptoms are also very different. There are patients suffering from stridor and dyspnoea, patients with dysphonia without dyspnoea and those without any symptoms. These different clinical symptoms are due to the different grade of laryngeal nerve damage and the resulting position of vocal cords. The bilateral paralysis was completely temporary in 4 cases. 12 months later 4 patients suffered from dysphonia. Only in 3 patients with thyroid cancer and a preoperative unilateral vocal cord paralysis tracheostomy was necessary after operation. The vocal cord mobility did not recover in these 3 cases after 12 months and the patients are not decannulated. DISCUSSION: Bilateral paralysis is only relevant in thyroid cancer and recurrent goitre. The symptoms varies and no patient should leave the hospital without examination of the vocal cords by an otolaryngologist. Because vocal cord paralysis is temporary in most cases an emergency tracheostomy is seldom indicated.

[Demand for and use of blood supply for elective surgical procedures]. / Anforderung und Verbrauch von Blutkonserven für chirurgische Wahleingriffe.

UNLABELLED: In elective surgical operations on thyroid gland and breast gland, in cholecystectomy, axillary or inguinal dissections and hernioplasties blood units are usually ordered for the operation. The aim of the study was to analyse the real requirement of transfusions during several years and to show that in the above-mentioned operations only in exceptional cases blood units must stand by. METHODS: At the Surgical Hospital I of the University Leipzig, a retrospective analysis of the anaesthetic records and patient documentations from 1994 to 1997 was performed with regard to intraoperative blood transfusions. RESULTS: There were 1122 operations on the thyroid gland (119 of it as total thyroidectomy), 465 operations on the breast gland, 413 cholecystectomies, 70 axillary and 60 inguinal dissections and 445 hernioplasties. Intraoperative transfusions were necessary in nine operations on the thyroid gland (0.8%), in six operations on the breast gland 1.3%), twice in cholecystectomy (0.5%) and only once in an axillary dissection (1.4%). The analysis of the patients' records showed in almost all of these cases special risk factors such as disorders of blood coagulation or thyroidal function, anaemia, serious other diseases or a necessary extension of the operation. CONCLUSION: It is justified to perform the above-mentioned operations without a routine order of blood units. This would lead to enormous financial savings. Because the optimal care for the patients has priority, it is necessary to estimate the individual risk of a required transfusion preoperatively and to keep low the blood loss by the surgeon during the operation.

[Inflammatory pseudotumor of the lung in hilus lymph node histoplasmosis]. / Inflammatorischer Pseudotumor der Lunge bei Hiluslymphknotenhistoplasmose.

The article deals with the case of an inflammatory pseudotumour of the lung in conjunction with histoplasmosis of the hilar lymph glands in a 35-year-old immunocompetent woman in a non-endemic area. She had been suffering from headaches and painful swelling of the lower legs, reddening and hyperthermia for 1.5 years. In addition to the above-mentioned symptoms she also complained of a typical flush syndrome which had begun a year later. The main paraclinical finding was a round mass in the right lung in chest radiography. After considering various differential diagnostic possibilities, thoracotomy and resection of the upper lobe of the right lung were performed. The histological diagnosis of the material removed was that of an inflammatory pseudotumour of the lung, combined with histoplasmosis of the hilar lymph glands. Following a postoperative period without complications, antimycotic treatment was performed. The discussion includes whether the simultaneous occurrence of these two diseases is coincidental or whether there is a causal relation between the two. The authors also discuss various treatments with reference to the relevant literature.

[Idiopathic pulmonary ossification]. / Untersuchungen zur idiopathischen pulmonalen Ossifikation.

OBJECTIVE: Linear and round shadows are very often revealed on chest radiographs. A rare entity most commonly appearing as branching linear shadows of calcific density involving a limited area of the lung is the so-called disseminated pulmonary ossification (DPO). Only 141 cases have been reported worldwide up to now since the first description. MATERIAL AND METHODS: A study on 490 autopsies was performed to find out the frequency of DPO. In case of DPO we compared the structures with the chest radiographs and CT of the patients. Further, we evaluate clinical communities of patients with DPO. RESULTS: From a total of 490 lungs eight were identified with DPO (1.6%). The mean age of patients with DPO was 80.2 years, the male/female ratio seven to one (mean age of all patients: 64.6 years, male/female ratio one to one). All cases were associated with hypertension followed by extreme arteriosclerosis. In 5 cases there was a proven extrapulmonary carcinoma and a renal insufficiency. In 4 cases we found diabetes mellitus. At postmortem radiographs and CT, a collection of small rounded calcific nodules and further linear shadows arranged in a branching or net-like configuration was identified. This was compared with the chest radiographs of the patients. There were no dysfunctions of lungs due to DPO. CONCLUSIONS: In chest radiographs of elderly men the differential diagnosis "DPO" should be given more importance.

[Value of intraoperative cytology in thoracic surgery]. / Stellenwert der intraoperativen Zytologie in der Thoraxchirurgie.

Cytological investigations are established in thoracic surgery beside intraoperative histological examinations. We use these intraoperative cytological investigations as an additional diagnostic option for surgical decisions at our hospital for more than 15 years. 1008 intraoperative cytological findings were compared with the final histological results in a retrospective study to investigate the security of these cytological findings. The diagnostical sensitivity for the detection of any malignancy was 97.7%. A correlation of cytological and histological results was found for benign tumors in 96.2% and for inflammatory diseases in 89.2%. The cytological and histological diagnoses regarding the real histological type of malignant tumors corresponded in only 667 of 834 cases. Due to these findings we conclude that intraoperative cytology is very useful to diagnose malignancy. However, additional diagnostic and clinical parameters have to be used for making final intraoperative decisions.

Technique and results of regional hyperthermic cytostatic arm perfusion for malignant melanoma.

Isolated hyperthermic cytostatic limb perfusion has been established as an efficient procedure for the treatment of malignant melanoma of the limbs. However, perfusions of the upper extremities are generally carried out much less frequently than would be expected given the distribution pattern of malignant melanoma and sarcoma. Thus, isolated descriptions of treatment results for perfusion of the upper extremities are not available. Between 1991 and 1994, arm perfusions using melphalan 1.0 mg/kg body weight were given to 14 patients with malignant melanoma, using the standardized method of perfusion described herein. Within an average observation period of 34.9 months (range, 12-65 months), 11 (78.7%) of the 14 patients who had M.D. Anderson stage II-IV melanoma remained free of local recurrence. In fact, 10 (71.6%) of the patients were still alive at the end of the observation period. None of the 14 patients showed any systemic adverse effects, although 1 patient developed a lymphedema 32 months after perfusion and 2 patients showed a postoperative temporary neurologic deficit. These results demonstrate that isolated perfusion of the upper limb with heat and melphalan under standardized conditions remains the treatment of choice for melanoma of the arm, as for melanoma of the leg, without a higher rate of complications.

[Postoperative alkaline reflux after total gastrectomy for stomach cancer]. / Der postoperative alkalische Reflux nach totaler Gastrektomie wegen Magenkarzinom.

After presentation of postgastrectomy syndromes the methods for demonstrating the quantity of alkaline reflux are described. In 81 patients with gastrectomy the authors compare the reconstruction methods--named after Siewert/Peiper, Hunt/Lawrence, Schreiber and Schloffer--according to their reflux characteristics. The Y-Roux anastomosis shows better results than the Schloffer method.