Open Field Exercise Testing in Pediatric Congenital Heart Disease Patients: A Subsumption of Cardiovascular Parameters.

Heart failure is a common phenomenon in congenital heart disease patients. Cardiopulmonary exercise testing is used for a reliable assessment of heart failure but is still challenging, especially for young children. Implementing mobile cardiopulmonary exercise testing (CPET) can close that diagnostic gap. While average values for healthy children have already been published, this study aims to describe typical ranges of cardiovascular performance parameters of young children with congenital heart disease performing an 8-min running cardiopulmonary exercise test. Children aged 4-8 years with common congenital heart defects after corrective surgery (Tetralogy of Fallot; transposition of the great arteries and univentricular hearts after palliation) were included. The outdoor running protocol consisted of slow walking, slow jogging, fast jogging, and maximum speed running. Each exercise was performed for 2 min, except the last, in which children were instructed to keep up maximal speed as long as possible. A total of 78 children (45 male/33 female, mean age 6,24) with congenital heart disease participated in the study, of which 97% completed the CPET successfully. A detailed description of participating patients, including data on cardiac function and subjective fitness levels, is given to help physicians use this method to classify their patients. This study presents a typical range for cardiovascular performance parameters in a population of 4-8-year-old children with congenital heart disease tested in a newly developed outdoor running protocol for CPET.

Moxifloxacin is not anti-inflammatory in experimental pneumococcal pneumonia.

OBJECTIVES: Anti-inflammatory functions of antibiotics may counteract deleterious hyperinflammation in pneumonia. Moxifloxacin reportedly exhibits immunomodulatory properties, but experimental evidence in pneumonia is lacking. Therefore, we investigated moxifloxacin in comparison with ampicillin regarding pneumonia-associated pulmonary and systemic inflammation and lung injury. METHODS: Ex vivo infected human lung tissue and mice with pneumococcal pneumonia were examined regarding local inflammatory response and bacterial growth. In vivo, clinical course of the disease, leucocyte dynamics, pulmonary vascular permeability, lung pathology and systemic inflammation were investigated. In addition, transcellular electrical resistance of thrombin-stimulated endothelial cell monolayers was quantified. RESULTS: Moxifloxacin reduced cytokine production in TNF-α-stimulated, but not in pneumococci-infected, human lung tissue. In vivo, moxifloxacin treatment resulted in reduced bacterial load as compared with ampicillin, whereas inflammatory parameters and lung pathology were not different. Moxifloxacin-treated mice developed less pulmonary vascular permeability during pneumonia, but neither combination therapy with moxifloxacin and ampicillin in vivo nor examination of endothelial monolayer integrity in vitro supported direct barrier-stabilizing effects of moxifloxacin. CONCLUSIONS: The current experimental data do not support the hypothesis that moxifloxacin exhibits potent anti-inflammatory properties in pneumococcal pneumonia.

[Pneumothorax]. / Pneumothorax.

The presence of air between the visceral pleura and the parietal pleura with consecutive retraction of the lung from the chest wall is called pneumothorax. Regarding the genesis of the pneumothorax, a distinction is drawn between spontaneous and traumatic pneumothorax. The spontaneous pneumothorax is, depending on whether a congenital or an acquired pulmonary disease can be found, grouped into a primary spontaneous pneumothorax (PSP) without underlying lung disease and a secondary spontaneous pneumothorax (SSP) with the presence of a known lung disease. The traumatic pneumothorax is classified, depending on the cause, into penetrating and non-penetrating (blunt) traumatic events. A special form of the traumatic pneumothorax is the iatrogenic pneumothorax occurring as a result of diagnostic and/or therapeutic interventions. Clinically, a pneumothorax can range from an asymptomatic to an acute life-threatening situation. The required initial measures depend primarily on the patient's clinical condition. They vary from immediate insertion of a chest tube to wait and see with monitoring. The insertion of a chest tube is still the accepted therapeutic standard, but other procedures like aspiration of air through a needle or small catheter, particularly for small spontaneous pneumothoraces, represent alternative therapy options as well. The short-term goal is to treat possibly existing dyspnea and pain; in the long run a recurrence of the pneumothorax should be prevented. Until now, no uniform treatment algorithms or standardised therapy principles exist to achieve the therapeutic intentions of lung expansion and freedom from pain and late relapse.

[Thymectomy in myasthenia and/or thymoma]. / Thymektomie bei Myasthenie und/oder Thymom.

Thymectomy, the surgical removal of the thymic gland, is essential in cases of thymoma. The majority of cases of a myasthenia gravis (MG) represent a relative indication for thymectomy which requires cooperation with specialized neurologists. Patients with MG may present with a tumor of the thymic gland. In case of suspicious thymoma, the resectability of the tumor has to be evaluated in the preoperative diagnostic. The clinical condition of patients with MG has to be stabilized preoperatively. The aim of thymectomy is the radical removal of thymoma and/or maximal improvement of MG symptoms. This requires the complete extirpation of the thymic gland including all ectopic thymic tissue in the anterior mediastinum. There is a variety of surgical techniques for performing a complete thymectomy. In addition to the conventional techniques with sternotomy, the significance of minimally-invasive approaches is increasing rapidly. Despite the ongoing scarcity of data of higher evidence concerning the procedure of thymectomy an increasing number of equivalent results with minimally-invasive operation techniques for MG and for thymoma are available. The successful surgical performance of a thymectomy is part of an interdisciplinary cooperation in the perioperative treatment of MG as well as the postoperative long-term care for patients with MG and/or thymoma.

[Application of the da Vinci robotic system in thoracic surgery]. / Anwendung des daVinci-Robotersystems in der Thoraxchirurgie.

INTRODUCTION: The latest technical developments of minimally invasive thoracic surgery are characterized by robotic-assisted operative procedures. Robotic-assisted thymectomy is the most advanced method in this field. METHODS: A systematic literature search (PubMed, Medline) was carried out and the databank system of Intuitive Surgical (Sunnyvale, CA) was analysed. Target criteria were the analysis of the quantitative data over time, technical advantages and limiting factors of robotic-assisted thoracic surgery. RESULTS: The da Vinci robotic system has been used in thoracic surgery since 2001, and up to 2012 a total of 10,895 robotic-assisted lobotomies have been carried out worldwide. A total of 12 ectopic parathyroid glands in the mediastinum were resected and published. Furthermore, more than 3,500 cases of robotic-assisted thymectomy were performed. A rapid increase in the number of operations has occurred particularly for thymectomy and lung resections. DISCUSSION: Acceptance of robotic-assisted thymectomy for myasthenia and/or thymoma and mediastinal tumors is growing rapidly. For anatomic lung resection in lung cancer, robotic-assisted hilar and lymph node dissection due to this new quality are also comparable to open surgical techniques. The principles form the intrinsic technical advantages of the da Vinci robotic system.

Bilateral pneumothorax following a blunt trachea trauma.

A-13 year old boy had an accident with his bike with a blunt thorax trauma and presented shortly after with facial swelling. Due to respiratory insufficiency, intubation was done during the transport to the clinic. First, a chest radiograph was performed, which showed a unilateral pneumothorax. Later a CT scan revealed bilateral pneumothorax and pneumomediastinum. Bilateral chest tube insertions improved the respiratory situation. Bronchoscopy showed a tracheal lesion two cm posterior to the main carina. After good wound healing, the patient was dismissed after 21 days in good health. Conservative treatment can be recommended in selected patients with a tracheal lesion when having a stable respiratory situation. If the patient does not improve after 48 h or if the clinical condition worsens, surgical management should be considered.

Selective neurogenic blockade and perioperative immune reactivity in patients undergoing lung resection.

OBJECTIVE: This double-blind, prospective, randomized, controlled trial examined the effects of thoracic epidural block and intravenous clonidine and opioid treatment on the postoperative Th1/Th2 cytokine ratio after lung surgery. The primary endpoint was the interferon γ (IFN-γ; Th1 cytokine)/interleukin 4 (IL-4; Th2 cytokine) ratio. Secondary endpoints were reductions in pain and incidence of pneumonia. METHODS: Sixty patients were randomized into three groups to receive remifentanil intravenously (remifentanil group, n=20), remifentanil and clonidine intravenously (clonidine group, n=20), or ropivacaine epidurally (ropivacaine group, n=20). Pain was assessed using a numerical rating scale (NRS). Cytokines were measured using a cytometric bead array. RESULTS: Patients in the ropivacaine group (thoracic epidural block) had a significantly lower IFN-γ/IL-4 ratio at the end of surgery than those in the remifentanil group and clonidine group. There were no significant between-group differences in the IFN-γ/IL-4 ratio at other time-points. There were no differences in NRS scores at any time-point. No patient developed pneumonia. CONCLUSION: Intraoperative thoracic epidural block decreased the IFN-γ/IL-4 ratio immediately after lung surgery, indicating less inflammatory stimulation during surgery.

Support of a patient-specific therapeutical acoustic stimulation in tinnitus by numerical modeling.

The pathogenesis of tinnitus involves multiple hierarchical levels of auditory processing and appraisal of sensory saliency. Early tinnitus onset is most likely attributed to homeostatic plasticity in the periphery, while the chronification and decompensation are tightly linked to brain areas for the allocation of attentional resources, such as e.g., the thalamocortical feedback loops and the limbic system. Increased spontaneous firing after sensory deafferentation might be sufficient to generate a phantom perception, yet the question why not every peripheral hearing loss automatically elicits a tinnitus sensation is still to be addressed. Utilizing quantitative modeling of multiple hierarchical levels in the auditory pathway, we demonstrate the effects of lateral inhibition on increased spontaneous firing and the resulting elevation of firing regularity and synchronization of neural activity. The presented therapeutical approach is based on the idea of disrupting the heightened regularity of the neural population response in the tinnitus frequency range. This neural activity regularity depends on lateral dispersion of common noise and thus is susceptible for edge effects and might be influenced by a change in neural activity in bordering frequency ranges by fitted acoustical stimulation. We propose the use of patient specifically adapted tailor-made notched acoustic stimulation, utilizing modeling results for the optimal adjustment of the stimulation frequencies to archive a therapeutical edge-effect.

Resection of ectopic mediastinal parathyroid glands with the da Vinci robotic system.

BACKGROUND: Mediastinal ectopic parathyroid adenoma is a frequent cause of persistent or recurrent hyperparathyroidism, traditionally treated by open surgery. Thoracoscopic access is associated with reduced morbidity in mediastinal surgery. The aim of this study was to evaluate the feasibility and effectiveness of robot-assisted dissection for mediastinal ectopic parathyroid glands. METHODS: Two patients with recurrent secondary hyperparathyroidism and three with complicated primary hyperparathyroidism were operated on between July 2004 and August 2008 for ectopic mediastinal parathyroid glands. Fusion of single-photon emission computed tomography and computed tomography led to an exact identification of the culprit glands. Surgery was performed thoracoscopically with the da Vinci robotic system using a three-trocar approach. RESULTS: All procedures were completed successfully with the robotic system. No perioperative morbidity or mortality was noted. Median operating time was 58 (range 42-125) min. Intraoperative parathyroid hormone reduction indicated complete resection. Median hospital stay was 3 (range 2-4) days. CONCLUSION: Robot-assisted dissection is a promising approach for resection of ectopic parathyroid glands in remote narrow anatomical locations such as the mediastinum.

["Fast-track" rehabilitation in thoracic surgery. First experiences with a multimodal, interdisciplinary, and proven perioperative treatment course]. / "Fast-track-Rehabilitation" in der Thoraxchirurgie. Erste Erfahrungen mit einem interdisziplinären, multimodalen, beweisbegründeten und perioperativen Behandlungspfad.

OBJECTIVES: "Fast-track" rehabilitation is a multimodal perioperative treatment concept for accelerating postoperative recovery which has been already used successfully in visceral surgery. Of its use in thoracic surgery however, almost no data exist and the relevance of this concept for pulmonary operations is unknown. PATIENTS AND METHODS: In this prospective study we examined a new perioperative fast-track treatment concept for thoracic surgery and evaluated the results. This program employs detailed information of patients, intensive perioperative respiratory therapy, thoracic peridural analgesia, forced mobilization, and an early start of postoperative normal food intake. RESULTS: Fifty consecutive patients with benign or malignant diseases of the lung aged an average of 64 years (range 22-78) were operated on thoracoscopically (n=15) or with thoracotomy (n=35) and treated perioperatively using the fast-track program. All patients were mobilized beginning 4 h postoperatively and had normal food. The incidence of general postoperative complications was 0% in this study. Postoperative stay lasted 4.5 days (range 1.5-28.5). There was no increase in surgical complications, and 6% of the patients were readmitted. The patients' acceptance of this concept was high. CONCLUSION: Fast-track rehabilitation resulted in a decreased rate of general complications and accelerated rehabilitation in thoracic surgery.

[Minimally invasive thymus surgery]. / Minimal-invasive Chirurgie des Thymus.

There are absolute and relative indications for complete removal of the thymus gland. In the complex therapy of autoimmune-related myasthenia gravis, thymectomy plays a central role and is performed with relative indication. In case of thymoma with or without myasthenia, thymectomy is absolutely indicated. Thymus resection is further necessary for cases of hyperparathyroidism with ectopic intrathymic parathyroids or with certain forms of multiple endocrine neoplasia. The transcervical operation technique traditionally reflected the well-founded desire for minimal invasiveness for thymectomy. Due to the requirement of radicality however, most of these operations were performed using sternotomy. With the evolution of therapeutic thoracoscopy in thoracic surgery, several pure or extended minimally invasive operation techniques for thymectomy have been developed. At present uni- or bilateral, subxiphoid, and modified transcervical single or combination thoracoscopic techniques are in use. Recently a very precise new level of thoracoscopic operation technique was developed using robotic-assisted surgery. There are special advantages of this technique for thymectomy. An overview of the development and experiences with minimally invasive thymectomy is presented, including data from the largest series published so far.

[First line application of a modified dilatational tracheostomy in the intensive care]. / Die modifizierte Dilatationstracheotomie als Wahleingriff in der Intensivtherapie.

BACKGROUND: Despite the growing clinical use of the percutaneous dilatational tracheostomy data concerning their first line application are still lacking. METHODS: Retrospective analysis of the intra- and postinterventional morbidity of a modified dilatational tracheostomy in a surgical intensive care unit of a German university hospital over a 2-year period. RESULTS: A total of 107 elective dilatational tracheostomies were performed in 105 patients. There were no intraoperative complications. 2 accidental decannulations occurred in the postoperative period. One conventional tracheostomy had to be performed secondary. Stoma side bleeding or clinical relevant infection had not been observed. After definite decannulation wound closure was spontaneous in all patients. CONCLUSIONS: The first line application of the dilatational tracheostomy has a low morbidity.

Matched-pair comparison of three different approaches for thymectomy in myasthenia gravis.

BACKGROUND: Because of the lack of evidence-based data comparing different techniques for thymectomy (Thx), a matched-pair study was conducted to evaluate the role of thoracoscopic Thx (tThx) more objectively. METHODS: Of 182 patients who underwent Thx, 3 groups according to the operation technique were matched for myasthenia gravis (MG) without thymoma, age, gender, and severity of MG. Twenty patients each who had Thx through anterolateral thoracotomy (aThx), extended median sternotomy (sThx), and tThx were compared for length of operation, postoperative morbidity, complete remission, quantification of improvement of MG, and cosmetic results. RESULTS: Complete tThx required 197 +/- 35 min as compared to 113 +/- 43 min for sThx and 82 +/- 27 min for aThx (P <0.001). With zero mortality the overall postoperative morbidity rate was 25% for sThx versus 15% for aThx and 5% for tThx (P <0.05). There was no difference in complete remission of MG. The median activities of daily living (ADL) scores improved by 6.0 (1-19) after tThx, 5.5 (2-4) after sThx, and 7.5 (0-12) after aThx. Best cosmetic results were achieved after tThx. CONCLUSIONS: There was adequate cumulative medium-term improvement of MG and less postoperative morbidity after tThx, which may become the preferred technique for Thx.

[Virtual bronchoscopy]. / Virtuelle Bronchoskopie.

Flexible bronchoscopy represents a clinically well-established invasive diagnostic tool. Virtual bronchoscopies, calculated from thin-slice CT sections, allow astonishing immitations of reality although principal differences exist between both technologies: the fact that colour representation is artificial and concommitant interventions are impossible limits the clinical use of virtual bronchoscopy. However, its value increases when calculations can be attained within minutes due to technological advancements, and when virtually any chest CT is suitable for further postprocessing. Indications, findings and the clinical role of virtual bronchoscopy are discussed.

Thoracic epidural anesthesia combined with general anesthesia: the preferred anesthetic technique for thoracic surgery.

UNLABELLED: Thoracic epidural anesthesia (TEA) combined with general anesthesia (GA) as well as total-IV anesthesia (TIVA) are both established anesthetic managements for thoracic surgery. We compared them with respect to hypoxic pulmonary vasoconstriction, shunt fraction and oxygenation during one-lung ventilation. Fifty patients, ASA physical status II-III undergoing pulmonary resection were randomly allocated to two groups. In the TIVA group, anesthesia was maintained with propofol and fentanyl. In the TEA group, anesthesia was maintained with TEA (bupivacaine 0.5%) combined with low-dose concentration 0.3-0.5 vol% of isoflurane (end-tidal). Changing from two-lung ventilation to one-lung ventilation caused a significant increase in cardiac output (CO) in the TIVA group, whereas no change was observed in the TEA group. One-lung ventilation caused significant increases in shunt fraction in both groups which was associated per definition with a significant decrease in PaO(2) in both groups but PaO(2) remained significantly increased in the TEA group (P < 0.05). We conclude that both anesthetic regimens are safe intraoperatively. However, TEA in combination with GA did not impair arterial oxygenation to the same extent as TIVA, which might be a result of the changes in CO. Therefore, patients with preexisting cardiopulmonary disease and impaired oxygenation before one-lung ventilation might benefit from TEA combined with GA. IMPLICATIONS: Fifty patients underwent lung surgery through the opened chest wall requiring ventilation of only one lung. Patients were randomly assigned to receive either general anesthesia alone or in combination with regional anesthesia via a catheter in the back. Oxygen content in the blood and blood pressure was better maintained in the group receiving the combination of general with regional anesthesia.

Colonography using multislice CT.

Computed tomography (CT) represents the preferred imaging modality for imaging the large bowel when virtual endoscopic reconstructions are desired. Using the spiral acquisition technique, it has become possible to scan the entire abdomen within a single breathhold, however, slice thicknesses of 5 mm or more are necessary should the breathhold not last longer than 30-40 s. With the advent of multislice CT, contiguous 1-mm slices can be obtained through the entire abdomen while even shortening the breathhold to 25-30 s. The improved speed and spatial resolution of multislice CT results in remarkably sharp virtual reconstructions allowing detection of polyps with sizes less than 3 mm. The disadvantages must still be considered including a dataset consisting of up to 800 images representing a new challenge for postprocessing hard- and software.

Pulmonary function after thoracoscopic thymectomy versus median sternotomy for myasthenia gravis.

BACKGROUND: Impaired pulmonary function due to myasthenia gravis (MG) is further compromised by thymectomy, which is necessary in most cases. Thoracoscopic thymectomy (tThx) can achieve the same resection and functional improvement of MG as median sternotomy (sThx). The possible advantage of tThx in maintaining better perioperative lung function was quantified. METHODS: In a prospective trial, 20 patients with MG were randomly allocated to undergo tThx (n = 10) by three-trocar left-sided approach or sThx (n = 10) performed as an extended procedure. Complete pulmonary function was measured at 12-hour intervals, beginning 6 hours postoperatively. Effective postoperative pain control in both groups was achieved by patient-controlled analgesia with morphine sulfate assessed by a visual analogue scale. Statistical analysis for comparison of tThx and sThx was performed using the Mann-Whitney U test. RESULTS: Postoperative vital capacity, forced vital capacity, forced expiratory volume per second, and peak expiratory flow, measured as a percentage of the individual preoperative capacity, were significantly better with tThx compared with sThx. Immediate postoperative lung function was reduced to 35% and 65% after tThx and sThx, respectively. By the third postoperative day, recovery of pulmonary function was complete after tThx but only 55% after sThx. CONCLUSIONS: Less pronounced impairment and faster recovery of pulmonary function after tThx characterize this new approach for thymectomy as minimally invasive. These results could make tThx the preferred surgical treatment of MG, which was improved to the same extent as after sThx.

[Postoperatively detected gallbladder carcinoma. Follow-up or reoperation?]. / Das postoperativ nachgewiesene Gallenblasenkarzinom. Nachbeobachtung oder Nachoperation?

BACKGROUND: The prognosis of gallbladder carcinoma is generally poor. The 5-year survival rate amounts to less than 5% in most series due to the high proportion of advanced stages at the time of diagnosis. Early stages are commonly found only with histological work-up after cholecystectomy (CCE). In these cases the question arises whether or not reoperation for completion resection would be indicated. PATIENTS/METHODS: A retrospective analysis examined all patients of the Clinic of Surgery (Charité) in Berlin with gallbladder carcinoma operated on between January 1981 and August 1993. A literature search was carried out using the MEDLINE retrieval system for the key words "gallbladder carcinoma", "surgical therapy", and "reoperation" limited to the period after 1970. RESULTS: The retrospective results of the own clinic and the analysis of the literature review demonstrate significantly higher survival rates after reoperation compared to CCE alone and observation for all cases of gallbladder carcinoma with stages T1b or higher stages. The extended radical CCE can be performed with low morbidity. With preceding laparoscopic CCE the trocar sites have to be completely excised. DISCUSSION: To avoid the situation of postoperative diagnosis of gallbladder carcinoma, the surgeon should intraoperatively during CCE perform a careful macroscopic control of the gallbladder. Suspect findings should be followed intraoperatively by histological examination. Nevertheless, local spread of GBCa and distribution of lymphatic metastases can certainly not be assessed completely after simple CCE. Based on the published results and because of low morbidity reoperation is indicated for most cases of GBCa when diagnosed postoperatively.

Dissecting aneurysm of the infrarenal abdominal aorta.

The aim of this study was to report the case of a patient with chronic dissecting infrarenal abdominal aortic aneurysm (AAA) and to review the literature for this rare vascular disorder. The preoperative assessment, surgical treatment, and postoperative course of a patient with a dissecting AAA and associated left iliac artery dissection were analyzed. The literature is reviewed with respect to etiology and pathogenesis as well as diagnostic and therapeutic management of infrarenal dissecting AAA. The preoperative diagnosis of dissecting infrarenal AAA was made by computed tomography and aortography and confirmed during surgery. Successful repair was accomplished by use of a bifurcated aortobiiliacal Dacron graft. A review of the literature demonstrates the rarity of dissecting aneurysm exclusively involving the infrarenal aortic segment. Primary dissecting aneurysm of the infrarenal abdominal aorta is a rare morphologic finding. Principles of diagnostic and therapeutic management of common atherosclerotic AAA also apply to dissecting AAA.