[Lung cancer: is surgery an option for persisting N2 after induction therapy?]. / Lungenkarzinom: Gibt es eine Indikation zur Resektion bei persistierendem N2 nach neoadjuvanter Chemotherapie?

BACKGROUND: Induction chemotherapy followed by surgical resection has been a treatment option for stage IIIA3 N2 non-small cell lung cancer since publication of some small randomised trials during the 1990s. Later on other studies suggested a poor prognosis in cases of persistent N2 disease, so surgical treatment for these patients was not recommended. This study analyses the outcome of patients with persisting N2 disease and tries to identify prognostic parameters within that group of patients. METHODS: We conducted a retrospective cohort study with 50 patients after induction therapy for stage IIIA N2 NSCLC. We analysed the influence of the postoperative lymph node involvement as well as the number of involved lymph nodes on the overall survival. RESULTS: 50 patients with potentially resectable stage IIIA N2 were included in the analysis. In 25 cases (50 %) a persisting N2 remained after induction therapy with cisplatin/gemcitabine, 11 patients had a mediastinal downstaging. 14 patients did not qualify for surgery because of disease progression or comorbidities. The resection consisted in 29 cases of a lobectomy or bilobectomy; two times pneumonectomy was necessary and 4 segmentectomies and one atypical resection were performed. The median survival of patients with persisting N2 (ypN2) was 14.6 months, if mediastinal downstaging was achieved (ypN0/1) it was 22.3 months (p = 0.172). The number of involved mediastinal lymph nodes was a significant prognostic factor. If less than 6 lymph nodes were involved the mean survival was 17.5 months, while it was 8.6 months in patients with more than 6 involved lymph nodes (p < 0.01). CONCLUSIONS: The median survival for patients with persisting N2 disease is less favourable compared to patients with mediastinal downstaging. However, the long-term survival for patients with less than 6 involved lymph nodes is 17.5 months. Therefore surgical resection for these patients seems to be justified. After induction therapy a rigorous restaging should be performed to rule out persisting multilevel N2 disease.

[Pulmonary metastasectomy: an analysis of technical and oncological outcomes in 301 patients with a focus on laser resection]. / Pulmonale Metastasektomie: Analyse technischer und onkologischer Ergebnisse bei 301 Patienten mit Fokus auf die Laserresektion.

BACKGROUND: Resection of lung metastasis is an important component in the therapy of patients with metastatic solid tumours. The aim of this analysis was to compare the technical and oncological outcomes of laser-assisted pulmonary metastasectomy with those of standard resection techniques such as electrocautery and stapling. PATIENTS/MATERIAL AND METHODS: We retrospectively analysed all patients who had undergone curative intended pulmonary metastasectomy in our department between January 2005 and June 2010. Follow-up was accomplished by visits in the outpatient department of our medical centre or by questionnaires of the primary physicians. RESULTS: 301 patients were identified. In 62 patients (20.6 %) the Nd-YAG laser was used for resection. Despite a significantly higher number of resected lesions in the laser-assisted resection group in comparison to the group with wedge and anatomic resections (median: 7.0 vs. 2.0; p < 0.01), there was no significant difference in surgical and overall morbidity except for a higher rate of pneumonia (11.3 vs. 2.9 %; p < 0.01). Follow-up was completed for 85.4 % of the patients. After a median follow-up of 27.2 months (range: 2.3 to 60.6 months) 42.5 % of the patients suffered from recurrence and 29.2 % had died. Mean disease-free interval was 12.9 months (range: 0 to 60.6 months). Although a higher number of metastases was resected in the laser group, we did not see a significant correlation between surgical technique and long-term survival (p < 0.8). Regression analysis confirmed the number of metastases to be a significant factor influencing survival (p < 0.02), but subgroup analysis of laser-assisted resections no longer showed significance in respect to the number of metastases. CONCLUSION: The number of metastases has an influence on prognosis but seems to be of secondary importance, particularly if complete technical resectability with the aid of the laser is given.

[Pulmonary metastasectomy: indication and technique]. / Lungenmetastasenchirurgie: Indikationen und Technik.

Distant metastases of solid tumours are most frequently located in the lung. Most patients with lung metastases suffer from multiple pulmonary lesions or metastases in other organs, which makes these patients unsuitable for surgical treatment. However, several studies suggest a survival benefit if complete resection of all pulmonary metastases is possible. In some patients pulmonary metastasectomy may even be the only curative treatment option. If pulmonary metastases are suspected contrast-enhanced computed tomography is the diagnostic procedure of first choice. Generally accepted rules for intended curative pulmonary metastasectomy are control of the primary tumour, technically completely resectable metastases, the exclusion of extrapulmonary metastases except for potentially completely resectable hepatic metastases and a functional operability. The most important prognostic factors are complete resection, the exact entity of the tumour, disease-free interval and, to a limited extent, also the number of metastases. In bilateral disease sternotomy and sequentially staged or one-stage thoracotomy are the standard surgical approaches to be considered, whereby thoracotomy is more advantageous in cases of centrally located lesions and left lower lobe metastases. In unilateral disease, video-assisted resection may be considered under certain circumstances. Primary aim must be R0 resection. Tissue-sparing pulmonary dissection techniques are proposed besides anatomic resections. In particular in cases of centrally located or multiple lesions an extensive expertise in thoracic surgery is necessary to preserve as much functional lung parenchyma as possible. Secondary mediastinal lymph node involvement is associated with an adverse prognosis and should therefore be ruled out preoperatively.

[Malignant pleural mesothelioma]. / Das maligne Mesotheliom der Pleura.

Malignant pleural mesothelioma (MMP) is a highly aggressive tumor arising of the pleural mesothelium. Asbestos exposure is the main factor involved in the pathogenesis of MMP and according to the late ban of this agent in 2005 the peak incidence in Europe is expected in the next twenty years. The highly aggressive behaviour of this tumor results in a poor prognosis with a mean overall survival between 7 and 9 months. Despite the progress made in diagnosis and therapy of this entity the optimal treatment remains a subject of debate. In this article we review the current state of treatment and diagnosis.

Outcome of incidental thyroid carcinoma in patients undergoing surgery for Graves' disease.

UNLABELLED: Thyroid malignancy detected incidentally in patients who are operated for Graves'disease (GD) has been reported at different rates. The aim of this study was to investigate the rate and outcome of incidental thyroid carcinoma in thyrotoxic GD patients managed by surgery in our institution. METHODS: A retrospective study was performed on a consecutive series of 92 patients with GD operated between January 2000 and December 2006 in the Department of Surgery of the Philipps University, Marburg. All patients were identified via the central electronic patient registry. Incidence and outcome of thyroid carcinoma incidentally discovered in patients undergoing surgery for GD were analysed. RESULTS: 82.6% were females and 17.4 were males. Mean age at time of surgery was 41.6 years (range: 12-72). Mean hospital stay was 5 days (range: 1-21). Two (2.2%) of all patients had a papillary thyroid microcarcinoma. Tumour size was 3 mm and 5 mm. Multifocality and lymph node involvement were not detected. Following thyroidectomy, the two patients are well and disease free with a follow-up of 6, respectively 3 years. CONCLUSION: The incidence of incidentally thyroid microcarcinoma was not higher in patients with GD compared to other benign thyroid disorders described in the literature. Differentiated thyroid cancer found incidentally at surgery for hyperthyroidism seems to have a good prognosis.

The impact of parathyroid gland autotransplantation during bilateral thyroid surgery for Graves' disease on postoperative hypocalcaemia.

OBJECTIVE: The aim of this study was to compare the rate of hypocalcaemia after bilateral thyroid resection for Graves' Disease in patients with and without parathyroid gland autotransplantation (PTAT). PATIENTS AND METHODS: A total of 153 patients following thyroid surgery for Graves' disease were studied. Patients were divided into three groups. Subgroup I comprised of 129 patients without PTAT, Subgroup II comprised of 19 patients with PTAT of one parathyroid gland and Subgroup III comprised of 6 patients with PTAT of two parathyroid glands. Association between PTAT and postoperative hypocalcaemia (PH) after thyroidectomy was investigated. RESULTS: There were 27/128 (21.1%) patients with transient and 10/128 (7.8%) patients with permanent hypocalcemia within Subgroup I. Among Subgroup II 4/19 (21.1%) patients developed transient and no patient developed permanent hypocalcaemia, while in Subgroup III 2/6 (33.3 %) patients developed transient hypocalcaemia which became persistent. Thus, the frequency of permanent postthyroidectomy hypocalcaemia (PH) was significantly higher in the Subgroup III with PTAT of two parathyroid glands when compared to the Subgroup I without PTAT (p=0.032) and Subgroup II with PTAT of only one parathyroid glands (p=0.012). CONCLUSION: PTAT of one parathyroid gland is an effective procedure to reduce the incidence of permanent hypoparathyroidism after bilateral surgery for Graves disease. Transient hypoparathyroidism was not influenced by PTAT.

The impact of self-belief on laparoscopic performance of novices and experienced surgeons.

BACKGROUND: In many professions, nontechnical aspects such as motivation or coping with stress are known to influence performance, success, and outcome. These qualities are assessed and trained in novices for quality and safety reasons. This study explored the impact of self-belief of surgeons on laparoscopic performance using a virtual reality simulator (LapSim). METHODS: Eighteen inexperienced surgical residents (with less than ten laparoscopic procedures performed) and 22 advanced residents (with more than 50 laparoscopic procedures performed) filled out a ten-item questionnaire used for the assessment of the individual sense of general self-efficacy (GSE). Afterward the participants were asked to perform three defined tasks on the LapSim, each at two different levels of difficulty. The tasks consisted of coordination, dissection, and application of clips. To assess laparoscopic performance, the total time to complete the tasks, economy of motion, and damage parameters were analyzed and correlated with the GSE score by means of Bravis-Pearson correlation analysis. RESULTS: In novices, high GSE scores correlated with more errors and poor economy of motion, while in advanced residents, laparoscopic performance was independent of the level of assessed self-efficacy. CONCLUSION: In a small sample, high self-belief does not predict success. In novices it negatively correlates with laparoscopic skills, while in advanced residents it is independent of laparoscopic performance. Thus, training aspects seem to be of greater importance for laparoscopic skills. Nevertheless, nontechnical aspects like self-belief, motivation, stress-coping strategies, judgment, decision-making, and leadership should be included in the surgical curriculum.

[Simulation of endoscopic procedures--an innovation to improve laparoscopic technical skills]. / Simulation d'operations endoscopiques--innovation dans le développement de la dextérité manuelle en chirurgie laparoscopique.

BACKGROUND: Laparoscopic surgery is a technically more demanding procedure compared to open surgery. Safe realistic training and unbiased quantitative assessment of technical skills are required for laparoscopic surgery. Virtual reality (VR) simulators may be useful tools for training and assessing basic and advanced surgical skills and procedures. AIM: to assess the acquisition of laparoscopic skills using virtual reality simulators. METHODS: systematic review of the literature. RESULTS: (1) The simulator can be used to objectively assess the laparoscopic skills of surgeons and distinguish between novices and experienced laparoscopic surgeons. (Evidence level III-B) (2) The target group as well as the benefit of a three-day practical course for laparoscopic surgery can be determined by the simulator. (Evidence level III-C) (3) Novices in laparoscopic surgery seem to benefit mostly from simulation training. (Evidence level III-B) (4) Steepness and plateau of a learning curve may be more dependent on the level of performance required by the particular training session rather than the number of repetitions during a training session. (Evidence level III-B) (5) Clinical background and understanding of the clinical value of a training program lead to faster acquisition and improvement of laparoscopic skills as performed on the laparoscopy simulator. (Evidence level III-B) (6) Non technical skills such as visual-spatial perception and stress coping positively correlates with virtual laparoscopic skills. (Evidence level III-B). CONCLUSION: To date, the best method for teaching laparoscopic surgery has not been defined. However, the use of virtual simulators for laparoscopy training is useful when learning basic techniques allow the surgeon to improve hand dexterity and coordination in laparoscopic surgery.

[High-grade intimal sarcoma in an aneurysm of the infrarenal aorta]. / Hochmalignes Intimasarkom in einem Aneurysma der infrarenalen Bauchaorta.

Primary intimal sarcomas of the aorta are extremely rare and aggressive tumors metastasizing into bones and visceral organs including liver, kidneys, adrenal glands, and lung. The first symptoms are often nonspecific and often caused by arterial embolism. We report a case with an incidental finding of primary intimal sarcoma in an aneurysm of a patient with claudication due to tumor embolization.