[Tracheal bronchus and contralateral pneumonectomy]. / Trachealer Bronchusabgang und kontralaterale Pneumonektomie.

One-lung ventilation is a standard procedure for many types of lung surgery. The anesthesiologist can be challenged if unknown anomalies of the bronchial tree occur. We report a patient with a tracheal bronchus on the right side presenting for left pneumonectomy, and present one possible solution to airway management.

Second primary malignancies in head and neck cancer patients: high prevalence of curable-stage disease.

BACKGROUND AND PURPOSE: Patients treated for squamous cell carcinoma of the head and neck (HNSCC) carry a high risk of second primary malignancies (SPM). Recently, computed tomography (CT) of the chest was shown to significantly decrease the risk of death due to bronchial carcinoma (BC) in a cohort of smokers whose risk of BC is increased but might be lower than that of patients previously treated for HNSCC. Thus, the present study evaluated the potential benefit of CT and other examinations in the detection of SPM in HNSCC patients. PATIENTS AND METHODS: Between July 2008 and November 2011, 118 participants underwent a prospective, systematic examination for SPM (13 women, 105 men, median age 62 years). All patients had been previously treated for HNSCC and showed no recurrence or distant metastases at the time of the study start. CT scans, ear-nose-throat endoscopy, and endoscopy of the esophagus and stomach were performed. RESULTS: Overall, 33 suspicious findings were clarified by additional investigations. In all, 26 SPM were confirmed in 21 of 118 patients (18%; 10 lung, 7 HNSCC, 3 gastrointestinal, 1 renal). Eighteen of these 21 patients (86%) underwent therapy with curative intent. CONCLUSION: The examinations revealed a high prevalence of curable stage SPM in HNSCC patients. Adapting a surveillance scheme including a chest CT is recommended.

[Preoperative smoking cessation in patients with lung cancer]. / Präoperative Tabakentwöhnung bei Patienten mit Bronchialkarzinom.

Successful smoking cessation is associated with a survival benefit for patients with lung cancer. However, smokers newly diagnosed with non-small cell lung cancer and scheduled for curative resection are frequently discouraged from stopping smoking in the immediate preoperative period. This recommendation is based on the results of one single prospective cohort study published in 1998 which reported an increased risk of perioperative pulmonary complications in patients undergoing non-thoracic surgery who had reduced their tobacco consumption within the two months leading up to the operation. During the past 12 years, numerous observational studies have investigated the impact of preoperative smoking cessation on perioperative risk for thoracic and non-thoracic surgery. However, no more than six studies included patients with pulmonary neoplasms. Owing to methodological limitations and considerable heterogeneity of the included patient groups, the existing data are insufficient to support or refuse any recommendation regarding cessation advice for patients during the immediate preoperative phase. In view of the post-cessation recovery time-course of pathophysiological alterations relevant to the occurrence of perioperative complications, a smoke-free preoperative interval of 2 - 6 weeks appears most favourable. However, this is difficult to achieve as a curative resection should not be postponed. Since there is no scientific evidence demonstrating a negative impact of preoperative smoking cessation on prognosis, patients newly diagnosed with lung cancer should be encouraged to make an attempt to quit while waiting for thoracic surgery.

[Role of mediastinoscopy and repeat mediastinoscopy today]. / Heutige Rolle der Mediastinoskopie und der Remediastinoskopie.

For patients with lung cancer preoperative evaluation of the mediastinal lymph nodes is important to estimate local operability and/or to consider the necessity of neoadjuvant treatment. Cervical mediastinoscopy is generally accepted as a safe and highly accurate procedure in the staging of lung cancer. Nodes accessible to CM are the levels of the superior (level 2R and 2L) and inferior (level 4R and 4L) paratracheal and subcarinal (level 7) nodal stations. Additionally extended CM and left parasternal mediastinotomy allow the exploration of the aortopulmonary window (level 5) and anterior mediastinal nodes (level 6). In locally advanced lung cancer repeat mediastinoscopy was used after induction chemotherapy or chemoradiation to reexplore the upper mediastinum in order to select patients with a higher probability to undergo complete resection. Operative mortality of both investigations is less than 0.5%; the preoperative complication rate is very low (less than 4%). Because of the higher sensitivity, specificity, and accuracy, mediastinoscopy and repeat mediastinoscopy are superior to new methods like FDG-PET, FDG-PET/CT, EBUS-FNA, and EUS-FNA.

Repeat mediastinoscopy as a restaging procedure.

BACKGROUND: Repeat cervical mediastinoscopy is a diagnostic surgical procedure for preoperative nodal staging in patients with insufficient first mediastinoscopy, with recurrent or second primary lung neoplasms, and following induction chemotherapy or chemo-/radiotherapy for locally advanced lung cancer. The aim of this study was to critically analyse indications, technical characteristics, intra- and postoperative complications, also to define selection criteria for patients with a higher probability of successful complete resection. MATERIAL AND METHODS: 279 patients with lung cancer (66 female and 213 male patients, mean age 58 years, range 28 to 78 years) underwent repeat mediastinoscopy from 1968 to 2004, 12 because of inadequate first procedure (group A), 67 because of recurrent lung cancer (group B) 35 because of second primary lung cancer (group C), and 165 following induction chemo-/radiotherapy for IIIa and IIIb disease (group D). The interval between first and second procedure was 17 days (range, 12 - 38) in group A, 14 months (range, 5 - 29) in group B, 27 months (range, 19 - 124) in group C, and 132 days (range, 113 - 145) in group D. RESULTS: No intra- or postoperative deaths were observed, 7 patients developed minor complications. N2 or N3 disease was found in 3/12 patients of group A (25 %), in 17/67 patients of group B (25.4 %) and in 6/35 patients of group C (17.1 %). Of the 116 patients with N2, and 49 with N3 disease before induction treatment (group D), repeat mediastinoscopy showed 126 N0, 20 N2 and 14 N3 status. Because of the presence of inseparable adhesions repeat mediastinoscopy was not possible in 5 cases. Five-year survival for patients with persistent N2 in repeat mediastinoscopy was despite surgery only 5 %. CONCLUSION: Repeat mediastinoscopy is a safe explorative procedure for the restaging of patients with primary locally advanced, recurrent or second primary lung cancer. In patients after induction treatment it is, however, less sensitive than the primary mediastinoscopy because of adhesions and fibrotic tissue. Patients with persistent N2 or N3 disease in repeat mediastinoscopy have a poor survival so that the indication for surgery has to be taken into consideration very carefully.

Completion pneumonectomy: current indications, complications, and results.

OBJECTIVE: Completion pneumonectomy is reported to be associated with high morbidity and mortality, especially when done in patients with benign disease. We review our 9 years of experience with this operation to evaluate the postoperative outcome and long-term results of various indications. METHODS: Between January 1990 and December 1998, 66 consecutive patients underwent completion pneumonectomy (6.8% of all pneumonectomies), and their cases were retrospectively reviewed. The indication was benign disease in 17 patients and malignant disease in 49 patients. In patients with malignant indications there were 14 local recurrences, 4 second primary tumors, 5 metastatic diseases, and 26 indications because of incomplete initial resection. RESULTS: There were no intraoperative deaths, and the postoperative mortality rate was 7.6%. Complications were encountered in 32 (53%) patients, without any significant difference between benign indication (71%) and malignant indication (47%; P =.0923). Bronchopleural fistula was encountered in 5 (7.6%) patients, and empyema was encountered in 7 (11%) patients. The actuarial 5-year survival was 57% for all patients, 65% for those with benign indications, and 54% for those with malignant indications (60% for local recurrence, 50% for second primary tumor, and 56% for incomplete resection), without any difference between benign and malignant indications (P =.9478). CONCLUSIONS: Completion pneumonectomy can be performed with acceptable mortality and morbidity, even in patients with benign disease. Patients with preoperative infection can be managed with bronchial stump covering and adequate postoperative drainage. Although complications are common, they can successfully be managed with a proper understanding of them.

[Diagnosis of liver tumors--what is necessary for therapy planning?]. / Diagnostik bei Lebertumoren--Was ist notwendig für die Therapieplanung?

For the surgical treatment of liver tumors, two initial steps are necessary: functional operability must be proven and oncological and local inoperability must be ruled out. The diagnostic process consists of a series of steps, beginning with non-invasive procedures such as laboratory findings and sonography, continuing with CT, CTAP, laparoscopy in the case of hepatic cirrhosis, up to explorative laparotomy. The potential operability is re-checked after each step. Punction, MRI and scintigraphy are implemented in special cases. The early implementation of MRI is of particular value for the diagnosis of certain benign processes.

[Spontaneous liver rupture after thrombolytic therapy with streptokinase]. / Spontane Leberruptur nach Lysetherapie mit Streptokinase.

Two months after an osteosynthesis of a Maisonneuve-fracture a 45-year-old patient developed a thrombosis of the deep veins on the side of the fracture. Subsequent to two days of lysis with Streptokinase a rupture of the liver occurred and was treated by hemihepatectomy. A traumatic event or a tumor could be excluded as reason for the rupture. Therefore a rupture of the liver due to the application of Streptokinase has to be assumed.

Inhibition of noradrenaline release in the rat brain cortex via presynaptic H3 receptors.

The effects of histamine and related drugs on the evoked tritium overflow from superfused rat brain cortex slices preincubated with 3H-noradrenaline were determined. Tritium overflow was stimulated electrically (3 Hz; slices superfused with normal physiological salt solution) or by introduction of CaCl2 1.3 mmol/l (slices superfused with Ca2(+)-free medium containing K+ 20 mmol/l). Histamine slightly decreased the electrically evoked 3H overflow in slices superfused in the presence of desipramine. The degree of inhibition obtained with histamine was doubled when both desipramine and phentolamine were present in the superfusion medium (pIC15 6.46). Under the latter condition, the evoked overflow was inhibited by the H3 receptor agonist R-(-)-alpha-methylhistamine and its S-(+) enantiomer (pIC15 7.36 and 5.09, respectively), but was not affected by the H2 receptor agonist dimaprit and the H1 receptor agonist 2-thiazolylethylamine (both at up to 32 mumols/l). The concentration-response curve of histamine was shifted to the right by the H3 receptor antagonists thioperamide, impromidine and burimamide (apparent pA2 8.37, 6.86 and 7.05, respectively), by the H2 receptor antagonist ranitidine (apparent pA2 4.27) and was not affected by the H1 receptor antagonist dimetindene (32 mumols/l). The inhibitory effect of R-(-)-alpha-methylhistamine on the evoked overflow was also counteracted by thioperamide. Given alone, none of the five histamine receptor antagonists affected the evoked overflow. In the absence of desipramine plus phentolamine, impromidine and burimamide facilitated the electrically evoked 3H overflow whereas thioperamide had no effect. The facilitatory effects of impromidine and burimamide were abolished by phentolamine, but not affected by desipramine.(ABSTRACT TRUNCATED AT 250 WORDS)