Carinal sleeve resection: last exit for bronchial insufficiency-a 17-year, single-centre experience.

OBJECTIVES: Bronchopleural fistula after pneumonectomy and dehiscence of an anastomosis after sleeve lobectomy are severe complications. Several established therapeutic options are available. Conservative treatment is recommended for a small fistula without pleural infection. In patients with a bronchopleural fistula and subsequent pleural empyema, surgical management is the mainstay. Overall, the associated morbidity and mortality are high. Carinal sleeve resection is the last resort for patients with a short stump after pneumonectomy or anastomotic dehiscence after sleeve resection near the carina. METHODS: All patients with bronchopleural fistula after pneumonectomy or sleeve resection who underwent secondary carinal sleeve resection between 2003 and 2019 in our institution were evaluated retrospectively. Patients with anastomotic dehiscence after sleeve lobectomy underwent a completion pneumonectomy. The surgical approach was an anterolateral thoracotomy; the anastomosis was covered with muscle flap, pericardial fat or omentum majus. In case of empyema, povidone-iodine-soaked towels were introduced into the cavity and changed at least twice. RESULTS: A total of 17 patients with an initial sleeve lobectomy in 12 patients and pneumonectomy in 5 patients were treated with carinal sleeve resection in our department. Morbidity was 64.7% and 30-day survival was 82.4% (n = 14). A total of 70.6% of the patients survived 90 days (n = 12). Median hospitalization was 17 days and the median stay in the intensive care unit was 12 days. CONCLUSIONS: Carinal sleeve resection is a feasible option in patients with a post-pneumonectomy fistula or anastomotic insufficiency following sleeve lobectomy in the absence of alternative therapeutic strategies. Nevertheless, postoperative morbidity is high, including prolonged intensive care unit stay.

Does less surgical trauma result in better outcome in management of iatrogenic tracheobronchial laceration?

BACKGROUND: Iatrogenic tracheobronchial injury is a rare, but severe complication of endotracheal intubation. Risk factors are emergency intubation, percutaneous dilatational tracheostomy and intubation with double lumen tube. Regarding these procedures, underlying patients often suffer from severe comorbidities. The aim of this study was to evaluate the results of a standardized treatment algorithm in a referral center with focus on the surgical approach. METHODS: Sixty-four patients with iatrogenic tracheal lesion were treated in our department by standardized management adopted to clinical findings between 2003 and 2019. Patients with superficial laceration were treated conservatively. In the case of transmural injury of the tracheal wall and necessity of mechanical ventilation, patients underwent surgery. We decided on a cervical surgical approach for lesions limited to the trachea. In case of involvement of a main bronchus we performed thoracotomy. Data were evaluated retrospectively. RESULTS: In 19 patients the tracheal lesion occurred in elective intubation and in 17 patients during emergency intubation. In 23 cases a tracheal tear occurred during percutaneous dilatational tracheostomy and in three patients at replacement of a tracheostomy tube. Two patients received laceration during bronchoscopy. Twenty-nine patients underwent surgery with cervical approach and 14 underwent thoracotomy. There was no difference in the mortality of these groups. Treatment of tracheal tear was successful in 62 individuals. Nine patients died of multi organ dysfunction syndrome (MODS), two of them during surgery. CONCLUSIONS: Iatrogenic tracheal laceration is a life-threatening complication and the mortality after tracheal injury is high, even in a specialized thoracic unit. Conservative management in patients with superficial tracheal lesion is a feasible procedure. In case of complete laceration of tracheal wall, surgical therapy is recommendable, whereby several approaches of surgical management seem to be equivalent.

Lanthanum chloride precipitation-based toxicoproteomic analysis of 3-monochloropropane-1,2-diol toxicity in rat kidney reveals involvement of extracellular signal-regulated kinase 2.

The heat-induced food contaminant 3-monochloropropane-1,2-diol (3-MCPD) and its fatty acid esters exert nephrotoxicity in rodents. Previous studies including a non-targeted toxicoproteomics approach using samples from a 28-day oral toxicity study in rats with 10 mg/kg body weight (b.w.) of 3-MCPD, an equimolar dose of 53 mg/kg b.w. 3-MCPD dipalmitate and a lower dose of 13.3 mg/kg b.w. of 3-MCPD dipalmitate, revealed substance-induced alterations in metabolic pathways, especially for glycolysis and energy metabolism. In order to obtain deeper insight into mechanisms of 3-MCPD toxicity, samples from the above-mentioned study were reanalyzed using a lanthanum chloride precipitation-based toxicoproteomics approach in order to increase the yield of phosphorylated proteins, crucial players in cellular signaling. A comparison of standard 2D-gel-based proteomics and lanthanum chloride precipitation was performed, thus providing a comprehensive case study on these two methods using in vivo effects of an important food toxicant in a primary target organ. While resulting in similar 2D-gel electrophoresis pherograms and spot counts, data analysis demonstrated that lanthanum precipitation yielded more significantly deregulated proteins thus considerably improving our knowledge on 3-MCPD-dependent proteomic alterations in the kidney. 3-MCPD-induced deregulation of the phosphorylated, active version of extracellular signal-regulated kinase 2 (ERK2) in rat kidney was demonstrated using mass spectrometry and immunohistochemistry. In summary, this paper for the first time links 3-MCPD effects to deregulation of the ERK/mitogen-activated protein kinase signaling pathway in rat kidney and demonstrates that lanthanum chloride precipitation is suited to support the gain of mechanistic knowledge on organ toxicity using 2D-gel-based proteomics.