[The role of resection surgical techniques in complex treatment of multi-resistant pulmonary tuberculosis].

A total of 16 patients with pulmonary resections for MDR-TB are included in a retrospective study for a period of 7 years. They are 9 (63.4%) male and 7 (36.3%) female with an average age of 32.6 years. Unilateral cavitary lesions are visualized in all patients. Bilateral changes are found in 9 (55.5%) patients, but the contralateral lesions are predominantly nodules and fibrosis. Multi-drug resistance was observed to an average of 4.4 anti-TB medicines. The mean duration of the preoperative re-treatment regimens is 4.9 months. Despite the preoperative anti-TB treatment, 8 (50%) of our patients are positive at the time of surgery. The following operations are carried out: lobectomy (68.75%), lobectomy with S6 (6.25%) and pneumonectomy (25%). No intraoperative and 30-day postoperative deaths are observed in our cohort. Postoperative complications are found in 4 (25%) of the cases. The mean postoperative in-hospital stay is 10.2 days. The postoperative anti-TB regimens are administered for at least 18 months, but in most of the patients their duration is 24 months. Postoperative follow-up is possible in all patients for the mean period of 34 months. Relapse of the disease is found in 3 (18.75%) preoperatively positive patients. Late mortality is observed in 1 (6.2%) patient 9 months after pneumonectomy due to relapse and empyema development. Eight (50%) of the patients are under follow-up program without medication. The rest 5 (31.25%) patients are negative but still on anti-TB regimens. In conclusion, we feel that pulmonary resections are of a paramount importance as an adjunctive method in the complex treatment of MDR-TB with good postoperative results.

[Surgical treatment of pulmonary metastases--surgical methods, early and long-term results].

AIM: To retrospectively evaluate the postoperative results after surgery for lung metastases from extrapulmonary origin. METHODS: A total of 45 patients were operated on for lung metastases between Jan 1996 and Dec 2006. They were 22 (48.9%) male and 23 (51.1%) female with a mean age of 51.6 years. Unilateral operation was carried out in 34 (75.6%) of the patients and another 11 (24.4%) patients were operated on for bilateral metastases. In 8 of them a one-stage operation was performed via median sternotomy (6) and bilateral successive thoracotomies (2). Two-stage strategy was applied in 3 patients. Metastasectomy via sternotomy as a surgical procedure was performed in all cases with bilateral lesions. In one case with one-stage successive thoracotomies a lobectomy and metastasectomy were used. In the group of unilateral operation the following procedures were carried out: metastasectomy in 23 (51%), lobectomy in 7 (15.6%), extended lobectomy in 2 (4.4%), sleeve lobectomy in 1 (2.2%) and polysegmental resection in 1 (2.2%). VATS was applied in 6 (13.3%) patients. RESULTS: No 30-day postoperative mortality was faced. There were 3 (6.7%) minor postoperative complications. The mean number of resected metastases was 2.3 per patient. The primary tumor sites were as follow: colorectal carcinoma--15 (33.3%); renal carcinoma--5 (12.1%); breast carcinoma--6 (13.3%); soft tissue fibrosarcoma--6 (13.3%); osteosarcoma--4 (8.9%); melanoma--1 (2.2%); gastric carcinoma--1 (2.2%), thyreoid gland carcinoma--1 (2.2%); suprarenal carcinoma--1 (2.2%) and carcinoma of salivary gland type--1 (2.2%). Mediastinal lymph nodes dissection was carried out in all patients and in 5 (12.1%) was found a metastatic mediastinal lymph nodes involvement. Adequate control of primary site tumor was achieved in all patients. Until the end of the study 01.01.2008, 19 (42.2%) of the patients are alive. The median survival was 38 months with 95% Confidence Interval (33-43). The gender (p=0.194), metastases diameter (p=0.211), mediastinal lymphnode involvement (p=0.102), initial clinical symptoms (p=0.233) and the primary site stage (p=0.091) can not be considered as a prognostic factors. The prognosis was significantly influenced by histology (p=0.0275), but because of small number of cases in the groups result should be interpreted with caution. The disease free interval (p=0.0348) and metastases number > 3 (p=0.0456) are considered prognostic factors. CONCLUSION: Surgery is an integral part of multimodality treatment of lung metastases with low postoperative complication rate and good long-term results. Respectability, "disease free interval" and number of metastases are considered to be the main prognostic factors.

[Anatomical pulmonary resections via median sternotomy].

During a 10-year period a total of 5 anatomical pulmonary resections (2 lobectomies, 2 pneumonectomies with mediastinal tumor extirpation and 1 polysegmental resection-S1-3) were carried out in 4 patients via median sternotomy. They were operated on for bilateral complicated pulmonary hydatidosis (2), mediastinal teratocarcinoma with right lung invasion and mediastinal Hodgkin's disease after chemotherapy failure. The mean operative time was 161 minutes, and the mean in-hospital stay was 12.75 days. The postoperative period was complicated in 1 patient by pulmonary edema, successfully treated by medication. Teratocarcinoma patient died on the 73th postoperative day with disease progression. The long-term postoperative results in the rest 3 cases (follow-up between 5 and 8 years) are considered very good. In conclusion, median sternotomy is acceptable approach for unilateral or bilateral pulmonary resections in carefully selected patients.

[Indications for the surgical treatment in bronchiectasis and postoperative results]. / Indikatsii za khirurgichno lechenie pri bronkhiektazii i sledoperativni rezultati.

During Jan. 1990 and Dec. 2002 a total of 14 patients with bronchiectasis were operated on. They were 5 female and 9 male with mean age of 35.7 years. In two of them (14.3%) the disease was with bilateral localization. Patients were typically presented with cough and purulent sputum production 12(85.7%), recurrent pulmonary infections 8(57.1%), halitosis 6(42.9%) and hemoptysis 4(28.6%). The mean duration of clinical manifestations was 8.4 years. The indications for surgery were failure of medical treatment in 10(71.4%) patients, hemoptysis in 2(14.3%) and lung abscesus, as a complication in 2(14.3%) patients. The operative methods included 9(64.3%) lobectomies, 1(7.1%) pleuropneumonectomy, 1(7.1%) pneumonectomy, 1(7.1%) bilobectomy with broncho-esophageal fistula resection, 1(7.1%) middle lobectomy with polysegmental resection S7-10 and 1(7.1%) polysegmental resection S7-10. No 30-day postoperative death was faced. Major complications, followed by rethoracotomy, were found in 2(14.3%) of the cases. The postoperative results were excellent in 8(57.1%) of the patient, very good in 5(35.75) of them and in only 1 patient there was no clinical improvement. In conclusion, surgery for bronchiectasis is followed by acceptable postoperative complications and better long-term result after radical operation.

[Surgical treatment of chronic pleural empyema--seven years' experience]. / Khirurgichno lechenie na khronichniia plevralen empiem--sedemgodishern opit.

During a 7 years period a total of 112 patients with chronic pleural empyema were operated on. There were 92 male and 20 female with mean age of 48.4 years. The mean duration of empyema clinical manifestation up to the operation was 59 days. Pleurectomy and decortication were carried out in 99 patients and in the other 5 cases they were associated with pulmonary resection. Additional thoracoplasty was necessary in only 7 patients. Rethoracotomy for hemostasis was performed in 5 (5.6%) patients. The overall postoperative mortality was 5.6%. The mean hospital stay after pleurectomy and decortication was 13 days and after the thoracoplasty it was 19 days. The follow-up period was 6 months for 84 (75%) and 12 months for 70 (62%) of the patients. No disease relapse was observed. Pulmonary function was improved after 3 to 6 months in the majority (89%) of the patients. Fully recovered working capacity was found in 44% of the patients.

Primary pulmonary sarcomas and carcinosarcomas--postoperative results and comparative survival analysis.

OBJECTIVE: To evaluate the early and long-term results after surgery for primary pulmonary sarcomas (PPS) and to compare them with those of patients with pulmonary carcinosarcomas (PCaSa). METHODS: During a 20-year period, 48 patients with PPS and 15 patients with PCaSa underwent surgery. There were 40 males and 23 females with a mean age of 52.1 years (range 13-78). The histologic diagnoses in PPS group were fibrosarcoma (15), fibroleiomyosarcoma (10), leiomyosarcoma (6), rhabdomyosarcoma (6), hemangiopericytoma (3), epitheloid hemangioendothelioma (3), malignant schwannoma (1), liposarcoma (1) and undifferentiated sarcoma (3). The following curative resections were carried out: lobectomy (36), including two sleeve lobectomies (in PPS group), pneumonectomy (15) and polysegmental resections (4). In four PPS cases, these procedures were extended to the thoracic wall, diaphragm or pericardium. An atypical resection was applied in one PPS patient (the tumor was falsely classified as benign on frozen section examination). Exploratory thoracotomy was performed in five of PPS patients (11%) and in two of those with PCaSa (13%). The majority of PPS patients were with low stages I and II (76%). The PCaSa patients were predominantly with stage IIIA (39%). RESULTS: No postoperative death was registered. Major complications included two localized empyemas (4.2%) in PPS and one reoperation for bronchial stump fistula (6.7%) in PCaSa groups. Local recurrences were operated on in one patient per group (2.1 and 6.7%, respectively). Follow-up was available on 57 patients and ranged from 4 to 148 months. The overall cumulative 5-year survival was 48.81% for PPS and 49.38% for PCaSa patients (P=0.9035). It was better in low vs. higher stage cases, statistically significant in PPS group (P=0.0005) and without significant difference in PCaSa cohort (P=0.11). CONCLUSIONS: Complete resection of PPS and PCaSa favors an acceptable survival, especially in low stages. There is no significant difference in the survival rates between PPS and PCaSa patients, despite the greater number of cases with higher stages in PCaSa group.

[Surgical treatment of post-traumatic intrapulmonary haematomas]. / Khirurgichno lechenie na posttravmatichni intrapulmonalni khematomi.

In a 14-year period 18 patients with post-traumatic intrapulmonary haematomas (PIH) were diagnosed and treated in our departments. There were 14 men and 4 woman with mean age 42.1 year. The mean diameter of PIH was 7.5 cm and they were localized mainly in the left lower lobe. Three of the patients were successfully treated with conservative antibiotic and mucolytic therapy. The remaining 15 patients (83%) were operated on: lobectomy (7), segmental resection (2), extirpation with partial resection of the fibrous capsule and capitonnage (4) and total extirpation with fibrous capsule removal (2). Indications for surgery were as follows: infection, haemoptysis and suspicions of malignant lesion. The early and late results are excellent. We recommend the surgical approach to PIH as a safe and effective treatment.

[Major respiratory tract traumas]. / Travmi na magistralnite vuzdukhonosni putishta.

Between 1988 and 2000 a total of 33 patients with traumatic tracheobronchial lesions were diagnosed and treated. The trauma was penetrating in 7 (stab and gun-shot), blunt in 10 (car accidents, compression and falling from heights) and iatrogenic in 16 of them (postintubational--15, after foreign body extraction--1). The main clinical and radiological features were subcutaneous emphysema, hemoptysis, respiratory insufficiency, pneumomediastinum and pneumothorax. The diagnosis was confirmed in all patients by early fiberoptic bronchoscopy. "Watch and see" tactics with massive antibiotics therapy was followed in 4 (12%) patients. A surgical treatment was carried out in 29 (88%) patients as follows: simple repair--19 (58%), left pneumonectomy--2 (6%), tracheal resection and anastomosis "end to end"--2 (6%), tracheostomy--1 (3%), thoracocenthesis and drainage--3 (9%) and cervical mediastinotomy--2 (6%). The operative mortality was 9%. The cause of death in these 3 patients were associated brain and spinal cord injuries. In the rest of patients the early and long-term postoperative results were considered very good.

Surgical treatment of bilateral hydatid disease of the lung.

OBJECTIVE: To evaluate the various tactics and approaches in the surgical treatment of bilateral pulmonary hydatidosis (BPH). MATERIALS AND METHODS: Between 1969 and 2000, a total of 127 BPH patients underwent surgery. The operative techniques of choice were parenchyma-preserved methods. Up to 1988, two-stage operations via thoracotomies were performed on 30 patients. One-stage operations with successive thoracotomies were carried out on two patients. Since 1988, only four patients underwent two-stage operations. One-stage surgery was carried out on 91 patients: 82 via median sternotomy (MS), one via clamshell incision, four through successive thoracotomies and three through video-assisted thoracic surgery (VATS) and mini-thoracotomies. One-stage bilateral lower lobectomies via MS were performed on one patient. In 11 cases, the concomitant dome localized liver cysts were extirpated via right phrenotomy during MS. Sterno-laparotomy was performed on 11 patients: for associated hepatic (seven), and hepatic and spleen cystectomies (four). In eight cases, abdominal echinococcosis was operated on a second stage, and in one case, a complicated hepatic cyst was extirpated on a first stage. RESULTS: No intraoperative deaths occurred. The postoperative mortality rate was 0.78%; one patient died of pulmonary embolism. No fatal complications have appeared in eight cases (skin suppuration, residual pleural cavity and atelectasis). Adult respiratory distress syndrome was successfully treated in one case after MS. The long-term postoperative results are considered very good, with no recurrences observed. CONCLUSIONS: One-stage surgery is superior to a classic two-stage approach as it decreases the morbidity, hospital stay and costs. MS is an excellent approach, but in some cases, VATS mini-thoracotomies could be indicated.

[Operative procedure for treatment of large and oversize cysts with interlobar location in pulmonary hydatid disease]. / Operativen metod za lechenie na golemi i ogromni kisti s interlobarna lokalizatsiia pri belodrobnata ekhinokokoza.

A procedure for treating large and oversize cysts with interlobar location, consisting in supplementary post-echinococcotomy draining of the respective interlobar groove using No. 18-20 catheter, is developed. It allows for maximal unfolding of the adjoining parenchyma, adherence of the fibrous capsule walls without any risk of a residual cavity formation. The procedure is successfully used in thirteen patients at average postoperative hospitalization 13.4 days. Both the early and long-term results are estimated as very good.

[Omentoplasty in surgical management of postpulmonectomy pleural empyema]. / Omentoplastika v khirurgichnoto lechenie na postpulmonektomichniia plevralen empiem.

A method of treating postpulmonectomy pleural empyema, practically implemented in this country for the first time, is described. Three patients are subjected to operation. Right pulmonectomy for lung cancer and chronic inflammatory process is done twice, and left pleuropulmonectomy for tuberculosis--once. Postpulmonectomy empyema persists in all three cases regardless of the adequate continuous suction drainage and intrapleural antiseptic management. Anaerobic and gram-negative flora is isolated. The size and location of the intrapleural cavity being cured are assayed by CT, thoracic ultrasonography and fistulography. In none of the patients is clinical and FBS evidence of bronchopleural fistula established. The operative procedure consists in resection of a 4 cm segment from the underlying rib in the drainage zone, and further cavity treatment under thorascopic control. Minor median laparotomy and skeletization of the greater omentum are performed preserving a major nutrient vessel depending on the location of the cavity. The omentum is drived into the pleural cavity through a parietal opening of the diaphragm, measuring 3-4 fingerbreadths. Pleural cavity drainage is carried out according to Redon. Two patients run an uneventful postoperative course. One female patient develops pylorospasm successfully cured by spasmolytic therapy and H2 blockers. CT and thoracic echography do not show presence of residual cavities. The patients are free of any complaints over periods ranging from 6 to 16 months postoperatively. The inference is reached that omentoplasty is a new method promoting successful elimination of both postpulmonectomy empyema, and other residual pleural cavities as well, with or without bronchopleural fistula.

[Plastic and reconstructive surgery of the bronchial tree]. / Plastichni i rekonstruktivni operatsii na bronkhialnoto durvo.

Bronchoplastic and reconstructive operations (BPRO) are a major issue in the broad methodological spectrum of thoracic surgery. It is the aim of the study to analyze the indications, operative technique and results of such operations on the basis of experience gained in the Clinic of Thoracic Surgery over a 5-year period. A total of 19 patients (14 men and 5 women) at mean age 50.7 y (range 16 to 70 y) are operated. By histological variant of the tumor operated on, the patients are distributed as follows: carcinoid--4 cases, fibromas--1, squamous cell carcinoma--10, adenocarcinoma--1, bronchoalveolar carcinoma--1, small-cell carcinoma--1 and leiomyosarcoma--one. The reconstructive operations performed include: isolated bronchus resection--2, right upper lobectomy with cuff resection--7, right upper bilobectomy with cuff resection--2, left upper lobectomy with cuff resection--7 (in two instances in conjunction with angioplasty), and left lower lobectomy with cuff resection and angioplasty--one. No intraoperative and perioperative lethality (within 30 days) is recorded. An overweight female patient with diabetes hardly lending itself to compensation develops severe suppuration. In two instances serious concurrent complications necessitate reoperation. Overall postoperative hospital stay--20 days; without the 3 severe complications--12.8 days. One patient dies of brain metastases within 6 months of the intervention. The survivorship term in the remainder varies from 1 year to 4 years 9 months, averaging 31 months. There are no stenoses or granulations of the anastomoses requiring endoscopic treatment. Presumably, BPRO are an adequate therapeutic approach to patients presenting centrally located malignant and benign tumors. The results of their application in the series being examined are estimated as very good.