Complications and mortality of surgical therapy for esophageal cancer: 10 years single center experience.

A single-center retrospective study the complication and mortality of surgical treatment of esophageal cancer 2006 to 2015 is presented. A total of 212 patients with esophageal cancer were operated at the First Department of Surgery University Hospital Olomouc, Czech Republic in the period between 2006 and 2015. Adenocarcinoma was histologically described in 127 patients (59.9%), squamous cell carcinoma in 82 patients (38.7%), and other types of carcinoma were described in 3 cases. According to the preoperative staging of esophageal cancer, the patients with early stage disease (T1-2N0M0) had primary surgery, while the patients with advanced stage (T3-4N0-2M0) were indicated for neoadjuvant chemoradiation with the surgery being performed subsequently. Transhiatal laparoscopic esophagectomy was performed in 183 patients, and Orringer esophagectomy in 4 patients. Thoracoscopic esophagectomy was performed in 17 patients and thoracotomy in 30 patients. Respiratory failure with the development of ARDS syndrome accompanied by multiple-organ failure occurred in 21 patients. Statistically significant association between mortality and ASA (p = 0.009) and between respiratory complications and ASA (p = 0.006) was demonstrated. The majority of patients who died were under 60 years of age (p = 0.039). Further, significant association between 30-day mortality and tumor stage (p = 0.021), gender (p = 0.022) and age (p = 0.018) was evident. A significant association between tumor stage and fistula in anastomosis, (p = 0.043) was observed. Esophagectomy is a procedure, which should be performed in specialized high-volume centers experienced in treatment of this serious malignancy and by certified oncology surgeons with long time experience in esophageal surgery.

Sarcomatoid carcinoma of the lung -  a case report.

BACKGROUND: Sarcomatoid carcinoma (SARC) of the lung is a very rare and aggressive type of nonsmall cell lung cancer. It belongs to a group of poorly differentiated carcinomas with partial sarcomatoid differentiation or with a direct sarcoma component. Characteristic findings include a large tumor with an invasive tendency, early recurrence and systemic metastases. CASE: The authors present a case of SARC in the 77-year-old patient. Preoperative staging confirmed sarcomatoid carcinoma of the lower lobe of the left lung without generalization on PET/CT. However, an infiltration of more than 2/3 of the diaphragm was ascertained. A resection was performed -  a left lower lobectomy with resection of the diaphragm and its replacement by a muscle flap made from the latissimus dorsi muscle with vascular pedicle. Histological findings confirmed the dia-gnosis of sarcomatoid (pleomorphic) carcinoma pT3N0M0. The patient underwent adjuvant chemotherapy; recurrence and systemic dissemination of the disease occurred after 20 months; the patient died 21 months after the surgery.

Strategies of treatment of chest wall tumors and our experience.

INTRODUCTION: The only curative treatment of tumors of the chest wall (primary or secondary),despite all the progress in oncological therapy, is a surgical radical resection. The goal of the paper is the identification of a complication occurring after chest wall resections for a tumor (evaluation of morbidity and mortality). Furthermore, the tumor type and employed reconstruction method were analyzed. METHODS: A group of patients who underwent resection of the chest wall for primary or secondary tumors at the 1st Dept. Of Surgery, University Hospital Olomouc, was retrospectively analyzed. Age, diagnosis, procedure, histopathology of the tumor, preoperative and postoperative oncological treatment, preoperative co-morbidities, postoperative complications, the use of artificial lung ventilation and recurrences were recorded for all patients. RESULTS: 57 patients aged 16 to 86 years underwent a chest wall resection, 51% for a primary tumor and 49% for a secondary tumor. Resection of at least one rib or partial resections of the sternum were performed in every patient. Reconstruction with a mesh was employed in 22 patients; in 10 patients the mesh was covered with a muscle flap. Postoperative complications occurred in 10 patients (17.5%). CONCLUSION: It is necessary to follow the basic principles of treatment of chest wall tumors; therefore surgery of these tumors should be concentrated to specialized centers. Always before surgery, diagnosis should be established by means of a biopsy and generalization of the disease should be excluded, ideally using PET/CT. Most important for successful treatment is experience and interdisciplinary cooperation of the team. This results in a low mortality and morbidity rate, which was confirmed by our results. KEYWORDS: chest wall tumors chest reconstruction sternum resection - treatment of chest wall tumors chondroma.

[Chest drainage--physiological and pathophysiological aspects and indications]. / Hrudní drenáz - fyziologické a patofyziologické poznámky a indikace.

INTRODUCTION: Interventions in the chest region still remain a source of concern for the medical community. Surgeons in particular, however, should be well familiar with this technique as it is them who perform the majority of these drainages. OBJECTIVE: The aim of the article is to give an outline of the physiology and pathophysiology of respiration in relation to the chest drainage indication, and to discuss the different indications for this type of drainage. CONCLUSION: Chest drainage is, in case of correct indication and performance, a safe method of therapy for a number of pleural pathologies. It is necessary to consider its employment on a case-by-case basis because it is always essential to assess its benefits versus risks.

[Chest drainage methods. The work is intended for postgraduate medical education]. / Metodika hrudní drenáze. Práce je urcena k postgraduálnimu vzdelávání lékaru.

INTRODUCTION: The mastering of the chest drainage technique should be among the basic skills of any surgeon, pneumologist or critical care specialist. What is essential is the knowledge of the anatomy of the chest, the basic radiologic interpretation of pathological findings in the pleural cavity, and some manual skill. The possibility of complications occurring and the method of their treatment are also important. OBJECTIVE: The aim of the article is to give an outline of the time aspect of the indication, necessary material equipment, the technique of chest drainage itself, differences in the drainage of pneumothorax, free and circumscribed effusion, caring for the chest drain following drainage and also of possible errors and mistakes that may occur. It also deals with methods of solving the complications. CONCLUSION: Chest drainage performed by a physician experienced in the chest drainage technique and keeping its basic principles may be considered to be a safe and effective method.

[Chest drainage systems and the complications associated with drainage]. / Hrudní drenázní systémy a komplikace s drenází spojené

INTRODUCTION: Chest drainage inevitably involves attaching the drain to a chest drainage system. Chest drainage may be related to some specific complications. OBJECTIVE: The aim of the article is to explain the classification and principles of the individual chest drainage systems. They may be divided into passive ones (valve and water seal) and active chest suction. Balanced chest drainage represents a specific method. Further, the article deals with the most common complications of chest drainage, namely prolonged air leak, multifactorial lung oedemas, atrial fibrillation and empyema of the chest cavity. CONCLUSION: The choice of a suitable drainage system is an important factor for the success of chest drainage, including the probability of complications occurring. The knowledge of appropriate methods of solving the complications of chest drainage, including the use of less standard techniques, allows us to treat the majority of even considerably complicated conditions.

[History of thoracic surgery: since the early 20th century to the sixties]. / Historie hrudní chirurgie: od pocátku 20. století do sedesátých let.

The authors give an outline of the history of chest surgery during the 20th century. It was the period when methodology of the procedures for treatment of the respiratory system was mastered. The authors point out the issue of development of the particular procedures which have become a part of daily surgical practice despite all the initial troubles.

[Surgery of the pulmonary metastases]. / Chirurgie plicních metastáz.

INTRODUCTION: Surgical resection of lung metastases of epithelial and mesenchymal tumors has an irreplaceable position in the complex treatment of advanced stages of these malignancies. Among the most significant prognostic factors affecting longterm survival of these patients are: parameter of complete resection, number and size of metastases, histological type of primary tumor, lymph node involvement, DFI (Disease Free Interval) and biological aggressiveness of the tumor or TDT (Tumor Doubling Time). AIM: retrospective analysis of patients with lung metastases of epithelial and mesenchymal tumors operated on at the I. Department of Surgery from 2005 to 2011. MATERIAL AND METHODS: The authors present a set of 50 patients and evaluation of their age, gender, type of primary tumor, number of metastases, occurrence of bilateral metastases, repeat metastasectomies, duration of DFI, type of operation and selected approach and performance of mediastinal lymphadenectomy. The probability of five-year survival, relationship between survival on DFI, difference in survival between metastases of colorectal cancer versus renal cancer and the influence of repeated metastasectomies and number of metastases on survival were statistically analyzed. RESULTS: Sixty operations were performed on a set of 50 patients (average age 61.2 years). Forty-two procedures were performed by thoracotomic approach. A solitary metastasis was discovered in 43 patients; in 8 patients, more than 3 metastases were resected. Repeated metastasectomies were performed 10 times. Mediastinal lymphadenectomy was performed in 21 cases. The most frequent procedure was extraanatomic resection (28×). Fourteen patients had DFI < 12 months, 19 patients had DFI 12-36 months and 17 patients had DFI > 36 months. Average survival was 66.9 months; the probability of five-year survival was 0.549 (54.9%). A relationship between DFI and survival was not discovered. There was no statistically significant difference in survival after metastasectomy for colorectal cancer and renal cancer. A relationship between survival interval and number of metastases and repeated metastasectomies was not discovered. CONCLUSION: Surgical resection of lung metastases plays an important role in multidisciplinary care, assuming a precise selection of patients indicated for this treatment. When properly adhering to the indication criteria, very positive results of long-term survival may be expected.

[History of thoracic surgery: from the beginnings to the end of the 19th century]. / Historie hrudní chirurgie: od nejstarsích dob do konce 19. století

The authors give an outline of the history of chest surgery from ancient times to the end of the 19th century. They point out the individual milestones of human knowledge which opened the pathway for successful surgical treatment of intrathoracic diseases after solving the many physiologic and pathophysiologic problems that had made these procedures impossible.

[Biomarkers in the detection of minimal systemic dissemination in lung cancer patients]. / Biomarkery detekce minimální systémové diseminace u nemocných s karcinomem plic.

INTRODUCTION: Minimal systemic disease (MSD) means the presence of circulating or disseminated tumour cells in mesenchymal compartments of a patientts' body (lymphatic nodes, blood or bone marrow). The aim of our pilot study was to identify sensitive and specific markers for MSD detection in 50 lung cancer patients, who underwent curative surgery in the I. Department of Surgery, Faculty of Medicine and Dentistry, Palacky University and Faculty Hospital Olomouc in 2009 and 2010. MATERIAL AND METHODS: Absolute gene expression of carcinoembryonic antigen (CEA), epidermal growth factor receptor (EGFR1), lung-specific X protein (LUNX) and hepatocyte growth factor receptor (c-met) was determined in peripheral blood, bone marrow and pulmonary blood of 50 lung cancer patients using real-time reverse transcriptase-polymerase chain reaction (real-time RT-PCR). RESULTS: (1) The LUNX marker is specific and sensitive for MSD detection in lung cancer patients. (2) The CEA positivity for MSD in the bone marrow correlated significantly with histopathological grading (GI-GIII). (3) Higher expression of CEA and c-met was found in pulmonary blood of patients with hilar or mediastinal lymphadenopathy. (4) Higher expression of MSD markers (CEA in bone marrow, c-met in peripheral blood and LUNX in pulmonary blood) correlated with higher pTNM classification. CONCLUSION: Minimal systemic disease detection in lung cancer patients is technically feasible using sufficiently sensitive and specific markers for RT-PCR. Minimal systemic disease detection can be used to guide further systemic treatment. This theory must be validated in a larger group of patients and correlated with clinical data, especially with survival data.

[Acute mediastinitis]. / Akutní mediastinitida.

The authors give an outline of the issue of acute mediastinitis. It is a severe infection of connective tissue of the mediastinum. Timing of recognition and accuracy of drainage are the most essential conditions of successful treatment. Acute mediastinitis may be divided in the postoperative sternal infections with infection of the mediastinum, mediastinitis due to perforation of the aero-digestive tract and descending necrotizing mediastinitis. The authors describe etiopathogenesis, diagnostics and therapy in each particular type of mediastinitis.

[Neoadjuvant chemotherapy and surgical treatment in advanced stages of non-small cell lung cancer]. / Neoadjuvantní chemoterapie a chirurgická lécba u pokrocilých stadií nemalobunecného karcinomu plic.

INTRODUCTION: Lung cancer takes first place in both incidence and mortality in the Czech Republic. This is associated with the disease being diagnosed in late stages, which limits the possibility of radical therapy. Five-year survival of patients operated on with stage IIIA is low and doesn't even reach 20%. These poor results and the development of systemic chemotherapy in the 1990's led to an effort to treat locally advanced disease by administering chemotherapy before the surgical procedure- induction chemotherapy. Its benefit, however, unlike that of adjuvant chemotherapy, remains unclear. AIM: To analyze and compare the results between a set of patients with non-small cell lung cancer (NSCLC) with stage III A-B, operated on at the I. Department of Surgery at the University Hospital and Palacky Medical Faculty in Olomouc between the years 2000-2008, who underwent preoperative chemotherapy with the results of patients with stage III A-B diagnosed after the operation based on histological findings. Three- and five-year survivals, as well as survival median, were evaluated in both groups. RESULTS: A statistically significant difference in survival between the two groups was not observed. CONCLUSION: Neoadjuvant chemotherapy remains controversial in the treatment of NSCLC. The initially promising results have not been unequivocally confirmed in later studies and its role remains a question to be answered in future extensive randomized studies.

[Solitary fibrous tumor of pleural cavity]. / Solitární fibrózní tumor pleurální dutiny.

INTRODUCTION: Solitary fibrous pleural tumor (SFT) is, in most cases, a benign tumor arising from mesenchymal cells. A malignant version of the tumor is rare and its histopathological evaluation is quite difficult. Usually, SFT affects visceral, as well as parietal pleura, most commonly in a form of a pedunculated tumor. The treatment is primarily surgical, with the aim to perform radical resection even in case of infiltrative growth. Adjuvant therapy is indicated in malignant varieties of the tumor, however, its outcome is uncertain. SFTs have fairly high relaps rates and their prognosis and the risk of relaps can be estimated based on morphological indicators and assessment of their biological characteristics. AIM: Retrospective analysis of SFT group of patients, who were operated from 2006 to 2009. SUBJECTS AND METHODS: The authors present a group of 11 patients with solitary fibrous pleural tumors, who were operated at the Ist Faculty Hospital Surgical Clinic of the LF UP (Medical Faculty of the Palacky University) in Olomouc from 2006 to 2009. The authors assessed the patient's age, size of the tumors, types of the procedures, biological characteristics of the tumors, duration of hospitalization and complication rates. CONCLUSION: Solitary pleural tumors are fairly rare tumors arising from fibroblastic cells, Its biological characteristics is uncertain and, in some cases, is difficult to assess based on immunohistochemical, as well as morphological indicators. The treatment is surgical--removal of the tumor as far as the healthy tissue. Adjuvant therapy is indicated in malignant varieties of the tumor. SFT relaps rate is fairly high, depending on the tumor biological characteristics and its morphological features.

[Analysis of regressive changes in the lung carcinoma lymphatic metastases following induction chemotherapy]. / Analýza regresivních zmen v lymfatických metastázách plicního karcinomu po indukcní chemoterapii.

BACKGROUND: Prognosis of higher stages of non-small cell lung cancer (NSCLC) is very poor. Only 13% of patients in stage IIIA survive 5 years after the diagnosis determination. The purpose of neoadjuvant (inductive) therapy is to eliminate haematogenous and lymphogenous metastases and to cause a cytoreduction in the primary tumor before the resection. Especially detection of lymphogenous metastases is the main factor in the indication of the pre-operative chemotherapy, but this therapy is frequently indicated according to CT without any bioptic verification. The authors suppose such a discrepancy in radiological and histo-pathological staging to influence in a positive sense rather optimistic results of therapeutic protocols, which include the pre-operative chemotherapy. METHODS: A biopsy of the lymph nodes was performed as a part of the staging. If the metastasis was proved, the lymph node was labeled and the patient was treated by 3 cycles of the pre-operative chemotherapy. The 57 labeled lymph nodes were removed during the subsequent lung resection and lymphadenectomy. An analysis of regressive alterations in the lymphatic metastases of lung cancer after an inductive chemotherapy and comparison with the pre-operative bioptic findings have quantificated the chance of the inductive therapy to eliminate lymphatic metastases. RESULTS: The clinical down-staging was stated in 21 cases (36.8%), but the viable malignant cells rested in the majority 50 (87.7%) of the taken labeled lymph nodes 57 (100%) even after the neoadjuvant therapy. On the other hand, the satisfactory tumor regression changes was proven in 49 (86%) lymphatic metastases. CONCLUSIN: The results of the study may modify an indicating judgment in the therapy of locally advanced stages of lung cancer because it has brought a new view to the results of neoadjuvant therapy.

Temporary aorto-aortal bypass used during extended pneumonectomy for lung cancer.

Involvement of the aortic arch, or the descending aorta, is not uncommon in left-sided lung tumours. The direct invasion of the aortic wall is generally considered a contraindication in lung resection. However, there are a limited number of reports of full thickness resections of the aorta during lung cancer surgery. They may be accomplished as a partial resection using a patch, or as a local tubular resection with reconstruction by a graft. In order to prevent ischaemia of the spinal cord, a cardiopulmonary bypass is usually recommended. The authors present a case report of a full thickness tubular resection of the descending aorta during pneumonectomy for centrally located lung carcinoma. The direct invasion to the descending aorta was only confirmed intraoperatively. After tumour dissection, two aortal cannulas were inserted into the aorta: the first one into the aortic arch over the left subclavian artery, the other one into the descending aorta over the diaphragm. They were then bypassed without a pump. The descending aorta was cross-clamped and replaced by a Dacron graft. There were no early complications : the patient has already survived two years after surgery with no recurrence.

[The technique of securing sentinel lymph nodes in tumors of the distal oesophagus and the stomach ]. / Technika získání sentinelových uzlin u tumoru v oblasti distálního jícnu a zaludku.

The authors discuss the technique of identification and biopsy of sentinel lymph nodes in tumors of the upper gastrointestinal tract. They describe difficulties and problems of the technique, in which the identified sentinel lymph node is obtained mainly employing endoscopical and minimally invasive techniques.

[Detection of the sentinel lymph nodes in lung carcinoma cases using patent blue and its clinical significance]. / Detekce sentinelové uzliny u plicního karcinomu pomocí patentní modri a její klinický význam.

INTRODUCTION: Views on significance and the most appropriate approach to lymphadenectomy in the non-small-cell lung carcinoma cases, have not been consistent. The method of the sentinel lymphonode identification and biopsy, which has been verified for other tumor types, may become a promising alternative or, at least, a supplement to currently applied procedures in cases of the lung carcinoma. STUDY GROUP AND RESULTS: This prospective, non-randomized study was conducted in the Faculty Hospital in Olomouc between the years 2000-2003. The sentinel lymphonode identification was conducted in the group of 48 patients suffering from the non-small cell lung carcinoma, using the patent blue lymphatic mapping method. The sentinel lymphonode was identified in 40 patients (83.3%), a false negativity of the sentinel lymphonode was detected in 3 cases (7.5%). CONCLUSION: The study proved the clinical benefit of the sentinel lymphonode identification and biopsy method in cases of the non-small cell lung carcinoma using the patent blue dye. Under the circumstance of certain experience with the technology, the reliability of the detection approaches that of the radionuclide sentinel lymphonode detection method. However, the clinical significance of the above method must be further tested on larger patient groups.

[Complications of extended lung resection procedures following the neoadjuvant therapy]. / Komplikace rozsírených plicních resekcí po neoadjuvantní lécbe.

UNLABELLED: Local tumor expansion in the sense of the tumor invasion into the extrapulmonary structures, which must be removed in one step, preferably en-bloc, together with the primary tumor, is the reason for extending the lung resection procedure. Although verified lymphogenic metastasing into either unilateral, eventually into contralateral mediastinal lymphonodes (stage N2 resp. N3, according to the TNM), remains the commonest indication for the induction therapy in cases of the lung carcinoma, application of the neoadjuvant therapy in cases when extended resections may be expected, is indicated in case the tumor expands into the surrounding structures, which signifies opening of new, unnatural routes of possible lymphogenic and haematogenic dissemination, and thus, a significantly higher risk of the surgical therapy failure. During the period 1995-2002, our team conducted 15 extended lung resection procedures following the preceding induction therapy in patients suffering from the IIB-IIIB stage of the non-small cellular lung carcinoma (NSCLC). The 30-day lethality rate equalled zero. We recorded two rare complications and the postoperative morbidity was acceptable. CONCLUSION: Exhausting staging, the best possible prediction of the tumor behaviour following the surgical procedure and minimal surgical complications remain the prerequisite for good long-term results following the extended lung resections for the lung carcinoma. Application of the neoadjuvant therapy prior to the resection procedure need not increase the risk of surgical complications and, furthermore, may positively affect the disease prognosis.

[Atypical portocaval anastomosis for hemorrhage in portal hypertension]. / Atypické portokavální anastomózy pro krvácení pri portální hypertenzi.

The success of endoscopy in treating esophageal varices and the later introduction of liver transplantation into the algorithm of therapy for liver failure shifted surgery of portal hypertension out of sight of hepatologists and surgeons. This decline from surgical treatment was further confirmed by introduction of TIPS into clinical practice. It is completely out of question that only liver transplantation is the causal solution of decompensated liver disease and a series of reliable and less invasive methods may be selected for acute treatment of bleeding from varices. However, even at the present time the portal-systemic shunt may be used in its own indication in repeatedly bleeding patients with a good liver capacity, where it can play a role by bridging the time to liver transplantation in a way similar to TIPS or even to provide a final solution, which makes it possible to live the life expectancy in adequate comfort without the risk of bleeding complications. However, it is not always possible to place a surgical shunt on some of the main branches of the portal vein. In such cases, devascularization is often successfully applied. Atypical shunts represent an exceptional alternative, because side feeder veins of the portal vein are rarely of sufficient caliber for placing a hemodynamically significant shunt. The authors describe two cases, in which stubborn anemia-causing bleeding events in portal hypertension were treated with left-side epiploic-renal shunt or anastomosis between the mesenteric and left-side iliac vein.

[Retroperitoneal liposarcoma--case report]. / Liposarkom retroperitonea--kazuistické sdelení.

The authors present surgical therapy of liposarcoma in retroperitoneum. These mesenchymal tumors occur rarely in the population. The strategy for therapy requires determination of the relations to adjacent organs on the basis of precise preoperation examination of the patient. Surgery is considered as the basic therapy, provided radical extirpation of the tumor is possible. Our case report describes a huge liposarcoma in retroperitoneum with histology evolving from myxoid to low differentiated liposarcoma of retroperitoneum. The repeated relapse of the tumor was, as fart as possible, treated by extirpation of the tumor.