[Metachronous lung metastases of mammary carcinoma, or dual malignancy? a surgeons and oncologists point of view case report]. / Metachronní plicní metastázy mamárního karcinomu nebo duplexní malignita? Pohled chirurga a onkologa kazuistika.

Synchronous and metachronous metastases significantly diminish the possibility of remission from cancer. Therefore, therapy needs to be highly effective and strictly individualised. The authors present a case report of a female patient after radical mastectomy due to breast cancer with incidental detection of peripheral lung carcinoid. The aim of the case report is to inform about current trends in primary lung carcinoid therapy through a surgeons and oncologists point of view.

[Possibilities and results of surgical treatment of benign tracheoesophageal fistula]. / Moznosti a výsledky chirurgického riesenia benígnej tracheoezofageálnej fistuly.

AIM: Review of literature and a single-institution retrospective analysis of possibilities and results of various surgical techniques in treatment of benign tracheoesophageal fistula (TEF). MATERIAL AND METHODS: Between 1995 and 2010, 26 patients with benign tracheoesophageal fistula of various etiology underwent surgical treatment at the Department of Thoracic Surgery of Slovak Medical University and Faculty Hospital in Bratislava. The majority of patients had a postintubation TEF (21 cases), two fistulas were of traumatic origin, one iatrogenic, one congenital with adulthood manifestation and one tracheo-neoesophageal (TNEF) following an esophagectomy for carcinoma via extended cervical approach with lymphadenectomy and sternal retraction adpoted from transcervical extended mediastinal lymphadenectomy. We review the possible means of surgical treatment of TEF, of which we most frequently used segmental tracheal resection with end-to-end anastomosis and a non-overlying suture of the esophageal defect without muscle flap interposition (16 patients), transsection of the fistula with muscular flap interposition via cervical (2 patients) or transthoracic (1 patient) approach; or a T-tube insertion with (1 patient) or without (5 patients) discision and suture of the TEF. The only tracheo-neoesophageal fistula in our experience had been treated by neoesophagectomy, covering of tracheal defect by intercostal muscle flap and cervical esophagostomy. RESULTS: Short- and long-term results of TEF treatment in our institution have been favourable, with perioperative mortality of 3.8% (the patient with tracheo-neoesophageal fistula). Morbidity included 1 partial tracheal anastomotic dehiscence, 3 temporary left recurrent nerve palsies, temporary deglutition disorders (15 patients), tracheal anastomosis granulations in 1 patient and 2 wound infections. Out of 26 patients 15 (58%) are being followed-up on a regular basis, all with good (12 patients) or satisfactory (3 patients) functional results. CONCLUSION: In the paper we analyze the advantages and disadvantages of various techniques and their alternatives in the treatment of TEF. As the most reliable and suitable solution for patients with postintubation TEF, breathing spontaneously and with acceptable nutritional status, we favour segmental trachea resection with end-to-end anastomosis and esophageal suture without muscle interposition, regardless of presence of concomitant tracheal stenosis. Fistulae of other etiologies require diverse approaches, especially tailored with respect to their location. Management of tracheo-neoesophageal fistula following esophagectomy for carcinoma is extremely demanding. Therefore, it is crucial to adhere to basic rules of prevention of such benign but potentially fatal entities as TEF and TNEF.

[The management of restenosis following segmental resection for postintubation tracheal injury]. / Riesenie restenózy po segmentálnej resekcii pre postintubacné poranenie trachey.

AIM OF STUDY: In dealing with benign tracheal stenosis, segmental tracheal resection yields superior results in experienced hands when properly indicated, timed end executed. Several factors may contribute to early or delayed failure of resectional treatment. In our retrospective study we analyze the potential causes of tracheal restenosis in patients who underwent segmental tracheal resection for benign tracheal stenosis between 1995-2009 and propose an algorithm for prevention and treatment of such complication. PATIENTS AND METHODS: Between 1995-2009, of 249 patients with benign tracheal stenosis 169 underwent segmental tracheal resection with zero perioperative mortality. Of 9 serious anastomotic healing complications (5.3%) we experienced 2 partial and 1 complete anastomotic dehiscence, and 6 serious restenoses (3.6%). Another 2 patients with restenosis were referred from other hospitals. Four patients had a T-tube implanted, of these in 2 it was possible to restore airway continuity by means of a successful parastomic implantation of perforated rib cartilage and tracheoplasty. Two early and two delayed restenoses were dealt with by segmental re-resection. One of our patients with partial anastomotic dehiscence after first tracheal resection underwent a rib-cartilage tracheoplasty after initial T-tube insertion. Subsequently a slowly progressing restenosis had been treated by re-resection after 2 years of observation and worsening symptoms. RESULTS: In the patient with complicated history described above the long-term result of treatment continues to be uncertain. In the remaining 4 patients (80%) both anatomical and functional results of re-resection have been favourable even after a very long period of time (8-16 years). DISCUSSION: In the paper we analyze the causes of restenosis after segmental tracheal resection and propose an algorithm of restenosis treatment. We consider insufficient assessment of resected segment length and subsequent anastomosis construction in inflamed tracheal tissue to be the most important cause of early restenosis. The late restenoses in our experience were caused by excessive anastomotic tension and possibly by other factors, such as steroid medication. Indication and timing of re-resection depend also on identifying the cause of restenosis. Early restenoses possibly induced by technical error may be treated by reresection sooner than delayed restenoses, which usually require 6-12 months for inflammatory changes to subside. In both scenarios T-tube insertion represents a reliable temporary or even permanent solution.

Central airways stenoses management--a single institution experience.

Tracheal stenosis is a serious, life-threatening disease with an increasing tendency. The number of complicated tracheal lesions, where resection and anastomosis can not be performed, still increases and the situation requires solution by endoprosthesis. Consequent the management of such complicated obstructive tracheal lesions is individual and time-consuming. The main objective of this study is to review the single institution experience with central airways stenosis treatment and to define the role of endotracheal stenting in tracheal reconstruction surgery. This study presents the retrospective analysis of tracheal stenosis reconstruction by means of our own modification of Montgomery T-tube. (Tab. 3, Fig. 3, Ref. 12.)

[Surgical treatment of pulmonary metastases--long-term results]. / Chirurgická liecba plucnych metastáz--dlhodobé výsledky.

A group of 103 patients operated for lung metastases in the Surgical clinic of the FNsP of L. Dérer and in the II Surgical clinic of L. Pasteur is assessed in this work. Minor operations of atypical resection prevailed among the resections. The postoperative mortality in the whole group was 1.9%. The best long-term survival rates were reached in tumors primarily treated by chemotherapy and followed by the lung metastasectomy. All patients in this group suffered from testical tumors and their long-term survival rate was 69%. In tumor cases, where the metastasis was primarily removed by surgery, the long-term survival rate correlated with the literature data of 30%. When the prognostic factors were considered, the number of removed metachrone metastases being less than 3, appeared statistically significant from the point of view of the patient survival. Based on the evaluated results, it can be concluded that surgical treatment of the lung metastases performed within the interdisciplinary oncological concept, currently remains a generally accepted therapeutic procedure.

Complications of video-mediastinoscopy--successful management in four cases.

The authors describe complications of video-mediastinoscopy in a number of clinical cases and present case reports of four patients, where this complication occurred. The following types of complications were recorded: one case of esophageal perforation, one case of tracheal lesion and two cases of massive bleeding from central greater vessel. Possibilities of treatment methods of these complications, possible ways how to manage and decrease the incidence of life-threatening complication are being discussed in this paper. (Fig. 5, Ref. 9.).

Initial experience with lung transplantation in Slovakia--an example for successful bilateral cooperation between countries.

OBJECTIVE: To review initial experiences, results of single lung transplantation (SLT) and double lung transplantation (DLT) on the basis of bilateral cooperation between Slovakia and Austria. PATIENTS AND METHODS: During the period between July 1998 and January 2003 ten patients from Slovakia underwent lung transplantation in Vienna, Austria. There were 7 males and 3 females with an age range from 21 to 48 years. Eight patients underwent double lung transplantation, two patients had single lung transplantation. Indications were: pulmonary fibrosis in 2, cystic fibrosis in 2, emphysema in 2, primary pulmonary hypertension (PPH) in 4 cases. In the PPH patients (n = 4) and in the patients with cystic fibrosis (n = 2), bilateral lung transplantation under ECMO support was performed. One patient (n = 1) with postradiative pulmonary fibrosis and intracardial myxoma underwent bilateral lung transplantation under cardiopulmonary bypass. Only three patients (e.i. the two with emphysema and one with pulmonary fibrosis) underwent lung transplantation without any intraoperative circulatory support. RESULTS: No perioperative mortality was recorded. Two patients died in late postoperative period: one due to multiorgan failure on 93rd day after DLT, the other one--on a liver failure caused by cirrhosis after 2.5 years after LTX. All the remaining eight patients, but the two ones who underwent LTX several days ago, are with improved functional status in full work activity. The follow up period for all patients ranges between 10 days and 54 months. CONCLUSION: Both unilateral and bilateral lung transplantations are accepted treatment modalities in patients with end-stage pulmonary disease. Bilateral cooperation for such countries as Slovakia (with limited possibilities) offers a unique example of possible and successful way how to deal with such demanding procedures. (Tab. 3, Fig. 2, Ref. 19.).

Prostacyclins in pulmonary hypertension treatment.

Pulmonary hypertension is a rare, treacherous disease affecting the lungs and heart. Elevated pulmonary artery pressure (above 2.67 kPa) and pathologically high pulmonary vascular resistance are characteristic for this disease. This disease is insidiously progressive and often leads to sudden death mainly in middle and younger middle ages. Exhausting the traditional conservative means of treatment, lung/heart-lung transplantation offers the only possibility to improve the quality of patient's life. Nowadays more and more reports about the successful application of intravenous prostacyclin for treatment of this disease appear in specialized literature. Epoprostenol (prostacyclin PGI2) represents a new, potent drug for the treatment of pulmonary hypertension. The objective of this paper is to introduce prostacyclin PGI2 to experts and demonstrate new possibilities, procedures, trends in treatment of pulmonary hypertension. (Tab. 1, Ref. 30.).

Extracorporeal membrane oxygenation in lung transplantation.

Lung transplantation has become an accepted surgical modality. As the primary pulmonary graft failure accounts for almost one third of early deaths, new possibilities to positively influence this life-threatening complication had been searched for. extracorporeal membrane oxygenation (ECMO) offers an unique advantage of overcome the demanding peri- and postoperative period. The authors present the advantage of ECMO use, introduce a review of experience with its application in lung transplantation. (Fig. 2, Ref. 36.)

[The complications of pulmonary resection treatment of lung cancer]. / The complications of pulmonary resection treatment of lung cancer.

This article discusses the complications of the pulmonary resection treatment in lung cancer. A significant decrease in incidence of cardiovascular and respiratory complications has already been achieved during the last decades. However, infectious complications, mainly pneumonias and postpneumonectomy empyemas still remain and belong among treacherous complications which are often associated with significant mortality. This article devotes special attention to the possibilities of influencing and decreasing the incidence of these complications.

[Management of malignant pleural diseases]. / Management of malignant pleural diseases.

Pleural effusions are the oldest indication of the thoracoscopic treatment. They represent the terminal state of malignancy and the aim of the treatment is palliative. The most effective is the thoracoscopic procedure in general anaesthesia with one lung ventilation and application of talc powder. We have been using videothoracoscopy in such cases since 1993 and we have treated more than 700 patients. The thoracoscopic procedure was successful in 70% of cases.

Lung transplantation today.

Lung transplantation has become an accepted surgical modality, and it is indicated in patients with a long-term benign pulmonary disease in stage when all the other therapeutic possibilities failed. Nowadays it presents a real possibility to significantly improve the quality of life. Success, (mainly in the last decade), establishing international professional centers, national coordinations, shifts transplantation towards the standard treatment procedures. The objective of the paper is to offer an overview of the international activities, trends and results in the area of lung transplantation. Authors present a review of the current situation based on their own experiences gained from the bilateral cooperation with Vienna Transplant Group. (Tab. 4, Fig. 4, Ref. 19.)

Circumstances of bronchiolitis obliterans development after lung transplantation: analysis of risk factors.

Bronchiolitis obliterans after lung transplantation is the major factor which limits the long term survival. It affects 35-68% of those patients who survive longer than 3 months. Nowadays, the results of treatment and evaluation of bronchiolitis obliterans risk factors are not very encouraging. Although several risk factors of the development of bronchiolitis obliterans have already been identified, their role and importance have not been clearly defined yet. The objective of this article is to give an overview of the current international knowledge in treatment strategies and analyse to international trends in the research of risk factors of the development of this complication together with available results. Special attention is given to donor and recipient risk factors. (Tab. 2, Fig. 1, Ref. 32.)

Laryngeal hamartoma: surgical management.

A newborn female infant with severe inspiratory stridor was found to have a laryngeal non-encapsulated hamartoma in the supraglottic area, medial to the hyoid bone and extending into the petiole of the epiglottis. Histologic examination revealed an extremely uncommon glandular hamartoma. Surgical management in the newborn period consisted of conservative endoscopic excision combined with open laryngofissure. The hamartoma was removed in the newborn period to avoid tracheostomy, because decanulation after tracheostomy in infants can be difficult.

[Tracheal stenosis and its treatment]. / Stenóza trachey a jej liecba.

A group of 89 patients suffering from tracheostenosis was studied in the period from January 1990 to January 1999. Surgical procedure on trachea was performed in 63 patients with postintubation (posttracheostomic) stenosis, in 6 patients with direct tracheal trauma, in 9 with tracheoesophageal fistula, in 7 with malignant stenosis, in 3 with postinflammatory subglottic stenosis. In the treatment of tracheal stenosis a set of methods was used ranging from laser and tracheal endoproteses, through cartilage implantation and plastic reconstruction of tracheal defects to extensive segmental resections. In a group of 50 patients with segmental resection in 43 (%) of them the result was good, in 2 (4%) of them satisfying, in 4 (8%) of them temporary brace (on T-cannule) persists, 1 patient died in postoperative period (2%). In a group of 39 patients with combined conservative treatment in 18 patients good results were reached (43.8%), in 6 satisfying (15.4%), in 13 of them temporary brace (on T-cannule) persists (33.3%) and 2 died in postoperative period (5.1%). In conclusion the results of this work suggest that the most frequent indication for surgical treatment is postintubation (postracheostomy) stenosis and that segmental trachea resection has priority in the treatment of tracheal stenoses. (Tab. 2, Ref. 18.)

High frequency jet ventilation in trachea reconstructions--its advantages in our experience.

Maintaining sufficient airflow in the distal airways during tracheal resection remains to be a challenging task. Disadvantages of cross-field intubation are well known. Experiences with using two models (CHIRAJET NCA and PARAVENT PAT) of ventilators for High Frequency Jet Ventilation (HFJV) during 82 resection of trachea (94 applications) are reported. Postintubation or post-tracheostomy stenosis required surgery in 76% of the cases. 11% of the cases required surgery for tumour stenosis. In 4/82 cases trauma necessitated the trachea surgery. Six tracheo-esophageal fistulas were operated on using this technique. No perioperative technique related complications was encountered. No perioperative and early postoperative mortality was noted. The usage of HFJV is method of first choice in our experience, especially in lesions of upper part of the trachea. It proved to be safe, effective and easy to use ventilation technique.

[Surgical complications of tracheal intubation--tracheal rupture]. / Chirurgická komplikácia tracheálnej intubácie--ruptúra trachey.

Authors present case report of 47-year-old woman with a rupture of trachea in its lower part after an intubation with a double-lumen tube without any problems. Tracheal lesion was discovered at the end of operation after an extirpation of mediastinal tumor and wedge resection of lung during the examination of hermeticity of lung mechanical suture. Rupture was cured by suture resorbable monofilamental material. Development after operation wasn't any different than a common lung resection. In the lecture authors discuss the possible causes of tracheal rupture, different kinds of therapy, and complications.

[Therapy of tracheal stenoses]. / Liecebné moznosti tracheálnej stenózy.

BACKGROUND: Tracheal stenosis is a serious disease of the upper airways. With advances in resuscitation its incidence is steadily increasing. Despite modern therapeutic procedures and the use of perfect materials tracheal stenosis is still a serious therapeutic problem. METHODS AND RESULTS: The authors present a group of 48 patients with tracheal stenosis treated during the period between January 1990 and September 1995. Thirty-eight patient with postintubation stenosis were subjected to surgery. 4 with direct tracheal injury, 5 with a tracheoesophageal fistula and one with a malignant stenosis of the trachea. For treatment of tracheal stenosis a wide range of therapeutic procedures was used: from laser destruction to long-term stenting on a T cannula and plastic reconstruction of tracheal defects to extensive segmental resections of the trachea. In the group of patients with segmental resection of the trachea (21 patients) in 17 good results were achieved (81%), in three satisfactory results (14%) and one patient died during the postoperative period. In the group with combined treatment (27 patients) in 13 good results were recorded (48%), in three satisfactory results (11%), in nine patients treatment still proceeds (33%) their prognosis in uncertain. During the postoperative period two patients died. CONCLUSIONS: From the results of the work the authors conclude that segmental resection of the trachea holds a priority position in the treatment of tracheal stenoses. It gives the best immediate and late therapeutic results. It is important to emphasize prevention of tracheal stenoses during prolonged controlled ventilation. Because the most difficult tracheal reconstructions are those after unsuccessful primary reconstructions, it is essential to concentrate serious tracheal lesions in departments which have adequate staff and technical equipment and ample experience.