[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.

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.

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.

Operative technique for thoracoscopic thymectomy.

In most cases, myasthenia gravis (MG) and thymoma require complete removal of the thymus gland and resection of the pericardial fatty tissue. There is some debate however, over which surgical approach is best for thymectomy. We have developed a new technique for complete thoracoscopic thymectomy. Between October 1994 and February 1998, we performed a prospective observational study of thoracoscopic thymectomy in 19 patients. The results were analyzed with special reference to perioperative morbidity, short- and intermediate-term improvement of MG, and quality of life. This study showed the feasibility of complete thoracoscopic thymectomy. The procedure was successfully applied in 19 of 20 cases. Thoracoscopic thymectomy was accomplished with zero mortality and a very low perioperative morbidity. While the short-term improvement of MG after this procedure was comparable to that seen with conventional surgery, the short- and intermediate-term quality of life was much better. The preliminary results of thoracoscopic thymectomy appear to be excellent for both patients and neurologists. A prospective randomized trial has been designed to compare thoracoscopic thymectomy with the gold standard of median sternotomy for thymectomy.

Recurrence of the Budd-Chiari syndrome after orthotopic liver transplantation.

Obstruction of the hepatic venous outflow with or without involvement of the vena cava results in the Budd-Chiari syndrome (BCS). BCS may be limited to the liver but there is a variety of systemic disorders forming the etiology of BCS in the majority of cases. Surgery has a major impact on treatment of the BCS within a wide range of therapeutic strategies. The ultimate option of surgical management of the BCS is orthotopic liver transplantation (OLTx). The case of a patient with recurrent disease more than 5 years after OLTx for BCS due to paroxysmal nocturnal hemoglobinuria is analyzed with complete documentation. The literature is reviewed and the probable underlying causes for recurrent disease after OLTx for BCS are discussed including therapeutic consequences.

Primary hepatic neuroendocrine tumor: successful hepatectomy in two cases and review of the literature.

BACKGROUND/AIMS: Primary hepatic neuroendocrine tumor represents an extremely rare clinical entity with only very few cases having been reported to date. METHODS: The case histories of 2 patients with presumably primary hepatic neuroendocrine tumor were analyzed and a complete follow-up obtained. The literature was reviewed to provide comprehensive data collection. RESULTS: Both patients underwent partial hepatic resection. Histomorphologic diagnosis revealed a neuroendocrine tumor in both cases. Extensive preoperative as well as intra- and postoperative search for the primary tumor did not identify another site of neuroendocrine tumor tissue. Six and ten years after hepatic segmentectomy, the 2 patients are alive and show no clinical signs of malignancy. Their most recent thorough follow-up included computed tomography and somatostatin receptor scintigraphy. Neither a nonhepatic primary neuroendocrine tumor site nor recurrent disease was found in the 2 patients. The literature review resulted in a complete survey of all previously reported cases of primary hepatic neuroendocrine tumors. CONCLUSION: We conclude that the liver was the primary site of the neuroendocrine tumor in both patients. Radical surgery was successfully performed as the only treatment option with curative intention.

Scintigraphic localization of lymphatic leakage site after oral administration of iodine-123-IPPA.

UNLABELLED: Chylothorax can occur secondary to traumatic lesions of the thoracic duct caused by chest injuries, surgical procedures involving the pleural space, neoplasms or malformations of the lymphatics. METHODS: Lymphatic leakage sites were localized by scintigraphy after oral administration of the 123I-labeled long-chain fatty acid derivative iodophenyl pentadecanoic acid (IPPA). We report on three patients with different lymphatic leakage sites and on one normal control subject. RESULTS: IPPA scintigraphy localized the lymphatic leakage site correctly in all three patients. In two of them, the method even guided the successful surgical treatment of the leakage. CONCLUSION: This approach is suitable for detecting lymphatic leakages of intestinal origin.

[Thoracoscopic thymectomy for treatment of myasthenia gravis]. / Die thorakoskopische Thymektomie zur Behandlung der Myasthenia gravis.

BACKGROUND: While thymectomy has been established for most of the stages of myasthenia gravis (MG) the optimal surgical approach for thymectomy remains a matter of discussion. Complete thoracoscopic thymectomy has been developed as a minimally invasive technique. Clinical application of thoracoscopic thymectomy has been investigated. PATIENTS/METHODS: A standardized technique for thoracoscopic thymectomy has been developed. In the the supine position with the operated left side elevated at approximately 30 degrees from the horizontal 3 trocars were placed between 3rd and 5th left intercostal spaces. Between 10/1994 and 5/1997 16 patients (12 female, 4 male, mean age 35 +/- 12 years) were prospectively selected for thoracoscopic thymectomy. RESULTS: In 15 cases the indication was MG (Ossermann stage 1-1, stage 2a-7, stage IIb-7 patients), 3 patients had a thymoma, in 2 of these patients both MG and thymoma were found. In 1 case a conversion to median sternotomy was necessary for technical reasons. The mean operation time was 132 +/- 47 minutes. All of the histological findings of the thymus were benign. Preliminary results with a mean follow-up of 16.4 +/- 10.1 months showed equal improvement rates of MG after thoracoscopic thymectomy as compared to conventional thymectomy. There was no perioperative mortality, and morbidity comprised one bleeding, one leakage of the thoracic duct and two pleural effusions. DISCUSSION: Complete thoracoscopic thymectomy is technically feasible with an acceptable learning curve. A very low postoperative morbidity and convincing short-term results have led to high acceptance by patients and neurologists. Long-term results and prospective comparison with median sternotomy may result in thoracoscopic thymectomy to become the operative approach of choice for selected cases.