RESUMO
Various vasodilator medications are used in the treatment of pulmonary arterial hypertension (PAH), such as endothelin receptor antagonists (ERA) or phosphodiesterase-5-(PDE-5-)inhibitors. In a human ex vivo model, we investigated whether the combination of two substance classes could achieve a higher effect or - without loss of vasodilatation - a lower dosage of the individual substances might be sufficient. We established an ex vivo organ bath model to evaluate the dose-dependent effects of ERA and PDE-5-inhibitors on pulmonary vessels harvested from patients who underwent surgery (lung resection/transplantation). We compared the combined use of both substance classes with administration of one class of drugs alone. Due to the limitations of the experimental design, it is not possible to extrapolate our results to the conditions in vivo. Nevertheless, organ bath proved to be helpful in evaluating the dose-dependent effects of ERA and PDE-5 inhibitors, which is not practical in everyday clinical practice. In this setting, the effectiveness of the combination therapy and the potential for dose reduction depended on the concentrations used and on the influence of previous illnesses on blood vessel function. This article describes the most important results of our experimental investigations and suggestions for future projects.
Assuntos
Hipertensão Pulmonar , Preparações Farmacêuticas , Hipertensão Arterial Pulmonar , Anti-Hipertensivos , Quimioterapia Combinada , Humanos , Hipertensão Pulmonar/tratamento farmacológico , Inibidores da Fosfodiesterase 5/uso terapêuticoRESUMO
PURPOSE: Medical combination therapy of pulmonary arterial hypertension (PAH) may alleviate the drawbacks of monotherapy by avoiding drug tolerance and by increasing effectiveness, as shown by the combination of ambrisentan and tadalafil (AMBITION trial). The present ex-vivo study evaluated the combination of the endothelin receptor antagonists (ERA) macitentan and bosentan with the phosphodiesterase-5 (PDE-5) inhibitor vardenafil in pulmonary arteries from patients suffering from terminal lung disease as a model of PAH. METHODS: Segments of the pulmonary vessels were excised from resected lungs of patients requiring lung transplantation (LTX). Contraction of pulmonary arteries (PA) was elicited by consecutive dose-response curves of endothelin-1 (ET-1) followed by norepinephrine (NE) to allow inhibition by different pathways. Forces were measured isometrically in an organ bath in the presence and absence of ERA and PDE-5 inhibitors and their combination. RESULTS: PA of 38 patients were examined between October 2016 and November 2019. Bosentan (1E-7 M) and macitentan (1E-8 M, 3E-8 M, 1E-7 M) inhibited ET-1 induced contractions, whereas vardenafil (1E-6 M, 3E-6 M, 1E-5 M) inhibited only the NE induced part of the contractions. Vardenafil enhanced bosentan-induced inhibition of vasoconstriction in a dose-dependent fashion. Combination effects exceeded single bosentan at 3E-6 M and 1E-5 M vardenafil, and they exceeded single vardenafil at the lower vardenafil concentrations. Macitentan showed a more pronounced inhibition than bosentan regardless of the lower concentrations. Accordingly, combination effects with vardenafil resembled those of macitentan alone. CONCLUSIONS: Macitentan and bosentan were potent antagonists of vasoconstriction in PA of LTX patients. The benefit of drug combinations was demonstrated at selected concentrations only owing to a narrow therapeutic range of vardenafil in this ex-vivo model. These results suggest the utility of drug combinations other than the established pair of ambrisentan and tadalafil in PAH treatment but also make a case for a further assessment of vasodilator properties of drugs complementing ERA.
Assuntos
Hipertensão Pulmonar , Hipertensão Arterial Pulmonar , Nucleotídeo Cíclico Fosfodiesterase do Tipo 5 , Antagonistas dos Receptores de Endotelina/farmacologia , Humanos , Hipertensão Pulmonar/tratamento farmacológico , Inibidores da Fosfodiesterase 5/farmacologia , Artéria PulmonarRESUMO
In regional chemotherapy of the pleural space a differentiation is made between intrapleural hyperthermic perfusion (IHP) and hyperthermic intrathoracic chemotherapy (HITOC). The HITOC in particular is carried out as an additive procedure after surgical cytoreduction of the pleural tumor manifestation. The main indications are for malignant pleural mesothelioma and thymoma with pleural spread (stage IVa), whereas treatment of secondary pleural carcinomatosis is indicated only in selected patients suitable for resection followed by HITOC. Cisplatin is the standard chemotherapeutic agent and a concentration of 150-175â¯mg/m2 body surface area is recommended. Postoperative, HITOC-related complications (e.g. renal insufficiency) can be minimized by an adapted perioperative management. Safety measures should be accomplished adhered to for the protection of personnel. The aim of HITOC is to achieve a better local tumor control with a corresponding longer recurrence-free and overall survival.
Assuntos
Hipertermia Induzida , Mesotelioma , Neoplasias Pleurais , Protocolos de Quimioterapia Combinada Antineoplásica , Quimioterapia do Câncer por Perfusão Regional , Cisplatino , Terapia Combinada , Humanos , Recidiva Local de Neoplasia , Neoplasias Pleurais/terapia , Cirurgia Torácica/tendênciasRESUMO
BACKGROUND: A tracheoarterial fistula (TAF) is an uncommon but life-threatening complication after tracheostomy. Only an immediate and targeted treatment provides a chance to survive. OBJECTIVE: Surgical treatment of TAF. METHODS: Selective review of the literature and case description. RESULTS: A TAF leads to an acute bleeding complication with displacement of the respiratory tract. The mortality rate is nearly 100% without a surgical intervention. In the literature various interventional and surgical treatment procedures are described. Rapid control of bleeding via manual compression and overinflation of the tracheal cuff are the most important steps of treatment. Subsequent emergency surgery with ligation or resection of the TAF and covering of the tracheal lesion should be performed. Extracorporeal membrane oxygenation (ECMO) and a heart-lung machine can sometimes be necessary. CONCLUSION: Despite all treatment options the mortality rate of TAF remains high. The critical steps are a quick diagnosis of TAF, securing the airway and immediate bleeding control.
Assuntos
Oxigenação por Membrana Extracorpórea , Fístula do Sistema Respiratório , Doenças da Traqueia , Humanos , Fístula do Sistema Respiratório/cirurgia , Traqueia , Doenças da Traqueia/cirurgia , TraqueostomiaRESUMO
BACKGROUND: The lungs are the second most common organ site for metastases in patients with colorectal cancer (CRC). Lymph node metastasis of CRC represents a prognostic factor for survival. OBJECTIVE: The present study investigated the influence of CRC lymph node metastasis on lung metastasis, in particular thoracic lymph node metastasis. MATERIAL AND METHODS: A retrospective analysis of 88 patients (nâ¯= 56 male) with curative resection of lung metastases of CRC was performed. Primary endpoint: influence of lymph node status of CRC on lung metastases. Secondary endpoints: disease-free survival and overall survival. Statistical evaluation was carried out with SPSS. RESULTS: In 48 patients a positive lymph node status of CRC and in 9 patients an N+ status of lung metastases were determined. The lymph node status of the CRC significantly affected the incidence of synchronous metastases (pâ¯= 0.03), disease-free interval until formation of metachronous lung metastases (pâ¯= 0.012) and the overall survival of patients with CRC (pâ¯= 0.048). The 5year survival rate for CRC patients with lung metastases was 48.7% after pulmonary metastasectomy. Thoracic lymph node involvement also significantly affected survival (pâ¯= 0.001). CONCLUSION: Screening for pulmonary metastases should be included in the staging and follow-up of all patients with CRC, especially in patients with a positive lymph node status of the CRC.
Assuntos
Neoplasias Colorretais , Neoplasias Pulmonares , Neoplasias Colorretais/patologia , Neoplasias Colorretais/cirurgia , Feminino , Humanos , Neoplasias Pulmonares/secundário , Neoplasias Pulmonares/cirurgia , Linfonodos , Masculino , Pneumonectomia , Prognóstico , Estudos RetrospectivosRESUMO
A young patient presented himself to the emergency department with sudden-onset, breathing-dependent right-sided thoracic pain. The auscultation revealed diminished breath sounds on the right. The radiograph showed a pneumothorax which was immediately dealt with chest tube drainage. The CT scan of the thorax showed minuscule subpleural bullae. Video-assisted thoracoscopic surgery (VATS) was performed due to persistent fistulae formation through the drain. The subpleural, bullous and emphysematous changes were histologically confirmed. Investigations into the cause showed evidence of alpha-1-antitrypsin deficiency (AATD). The patient is a Pi MZ type. Few cases of spontaneous pneumothorax as the first manifestation of alpha-1-antitrypsin deficiency have been described. Conclusion: When diagnosing primary spontaneous pneumothorax, alpha-1-antitrypsin deficiency should be considered.
Assuntos
Pneumotórax/etiologia , Enfisema Pulmonar/diagnóstico , Deficiência de alfa 1-Antitripsina/diagnóstico , Diagnóstico Diferencial , Drenagem , Seguimentos , Humanos , Pulmão/patologia , Masculino , Pneumonectomia , Pneumotórax/diagnóstico , Pneumotórax/patologia , Pneumotórax/cirurgia , Enfisema Pulmonar/patologia , Enfisema Pulmonar/cirurgia , Toracoscopia , Tomografia Computadorizada por Raios X , Adulto Jovem , Deficiência de alfa 1-Antitripsina/patologia , Deficiência de alfa 1-Antitripsina/cirurgiaRESUMO
UNLABELLED: Parapneumonic pleural effusion (PPE) occurring in early-stage (stage I) pleural empyema (PE) can be managed by chest tube drainage, which should be performed as soon as possible, to achieve re-expansion of the pulmonary parenchyma. Chronic disease leads to fibrin deposits on both pleural surfaces (stage II), followed by a thickened pleura peel (stage III). A trapped or compressed lung can only be released by surgical decortication, which may be performed with a minimally-invasive approach (video-assisted thoracoscopy) or an open technique (thoracotomy). This article reviews effects on pulmonary function after decortication in chronic empyema patients. MATERIAL AND METHODS: Selective literature research using Medline (key words: pleural empyema, decortication, lung function). A comparative analysis was performed on functional parameters obtained before and after surgical decortication in patients with chronic pleural empyema. RESULTS: Decortication in chronic PE significantly enhanced spirometric parameters (FEV1, VC/FVC) in all analysed studies. Considerable differences were observed regarding the mean follow-up time (early postoperative to several months after surgery). Computed tomography scans were usually analysed after a minimum of 6 months postoperatively. Measurements of anterior-posterior and transverse diameters as well as volume quantification of the operated and non-operated lung were performed in pre- and postoperative imaging. Statistical comparison revealed a significant decrease in thoracic asymmetry. In addition to static and dynamic pulmonary performance, pulmonary perfusion improved significantly after decortication as demonstrated by lung perfusion scans performed immediately after surgery and during a period of 7 to 10 months thereafter. CONCLUSION: Surgical decortication in chronic pleural empyema improves lung function and increases perfusion. Besides a significant enhancement of spirometric parameters, re-expansion of the diseased lung leads to equalisation of thoracic asymmetry and may even prevent loss of volume in the affected lung.
Assuntos
Empiema Pleural/cirurgia , Pleura/cirurgia , Testes de Função Respiratória , Humanos , Complicações Pós-Operatórias/etiologia , Cirurgia Torácica Vídeoassistida/métodos , Toracotomia/métodosRESUMO
Sternal osteomyelitis as a direct consequence of advanced mediastinitis or as in most cases after median sternotomy is still associated with a prolonged hospital stay, increased morbidity and postoperative mortality. Early diagnosis and an adequate surgical treatment are decisive for the prognosis. Prerequisites for a secondary stabilization of the chest wall using wires or plates are sterile wound conditions. Diverse reconstructive techniques are available for anterior chest wall reconstruction depending on the defect size and localization. The various reconstructive methods including local and free flap coverage are described in this review article.
Assuntos
Mediastinite/cirurgia , Osteomielite/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Esterno/cirurgia , Parede Torácica/cirurgia , Placas Ósseas , Fios Ortopédicos , Diagnóstico Precoce , Intervenção Médica Precoce , Retalhos de Tecido Biológico , Humanos , Mediastinite/diagnósticoRESUMO
BACKGROUND: The surgical treatment of pleural empyema should be carried out depending on the stage of the disease and the patient's symptoms. The aim of this study was to evaluate the outcomes of surgical pleural empyema treatment. PATIENTS AND METHODS: Retrospective analysis of all patients with pleural empyema treated surgically between January 2008 and December 2013. The primary endpoint of the study was inpatient lethality. Secondary endpoints included duration of inpatient stay, type of treatment (surgical/conservative), proof of pathogen and type, alteration and duration of antibiotic therapy. RESULTS: Of 359 patients, 0.8â% (n = 3) had stage I empyema, 50.4â% (n = 181) had stage II and 48.7â% (n = 175) had stage III. The most frequent causes (32.4â%) included acute pneumonia (parapneumonic pleural empyema), surgery (usually thoracic) in 18.0â% of cases and previous pneumonia (postpneumonic pleural empyema) in 15.4â%. Surgery was performed in 86â% of cases (operative procedures: open thoracotomy 85â%, VATS 15â%). The average duration of inpatient stay was 20 days for stages II and III. Recovery following VATS was significantly shorter in stage II compared to thoracotomy (p = 0.022). Hospital lethality amounted to 7.0â% (25 patients). The lethality rate was 5.5â% (10/185) in stage II and 8.6â% (15/175) in stage III. Patients with confirmed pathogens had a significantly worse mortality rate across all stages (9.8â%) than patients with no confirmed pathogens (4.0â%, p = 0.034). Age, malignant underlying disease, multiple comorbidities, immunosuppression, a change in antibiotic regimens and sepsis were significant risk factors. CONCLUSION: The inpatient lethality of patients with pleural empyema correlates with the stage of the condition. Positive confirmation of pathogens, sepsis, a higher age, multiple comorbidities, malignant tumour disease, immunosuppression and a change of antibiotics are negative prognostic factors.
Assuntos
Infecções Bacterianas/classificação , Infecções Bacterianas/cirurgia , Empiema Pleural/classificação , Empiema Pleural/cirurgia , Adulto , Idoso , Antibacterianos/uso terapêutico , Infecções Bacterianas/mortalidade , Terapia Combinada , Empiema Pleural/mortalidade , Feminino , Alemanha , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pneumonectomia/métodos , Estudos Retrospectivos , Fatores de Risco , Toracentese/métodos , Cirurgia Torácica Vídeoassistida/métodos , Toracotomia/métodosRESUMO
INTRODUCTION: Parapneumonic pleural effusions arise from pneumonia and may develop into pleural empyema (PE). PE is defined as collection of pus in the pleural space with secondary inflammation of the visceral and parietal pleura. This review article describes the current treatment strategies for para- and postpneumonic PE both in children and adults. MATERIAL AND METHODS: Selective literature research via Medline (key words: pleural empyema, pleural empyema in children, thoracic empyema) and presentation of our own clinical experience with therapy recommendations. RESULTS: The incidence of postpneumonic PE is increasing in both children and adults. PE is associated with a high morbidity and mortality if it is not treated early and adequate. Progression of PE follows a characteristic morphological course, which is classified in three stages: the exsudative, fibrinopurulent, and organizing phase. Treatment should be adapted to these three phases including systemic antibiotic therapy and drainage of the pleural space. Intrapleural fibrinolysis can be performed with good success independent of age in the transition of stage 1 and 2. In persistent PE (stage 2), thoracoscopic decortication is recommended to avoid progression into the organizing phase (stage 3) with the need of an open decortication. In debilitated elderly patients the increasing use of intrathoracic vacuum therapy (Mini-VAC/Mini-VAC-instill) offers an effective and less invasive therapy option. CONCLUSION: Para- and postpneumonic PE requires an individualized and stage adapted therapy using a combination of medical and surgical treatment strategies with the aims of removing the source of infection and ensuring re-establishment of lung expansion.
Assuntos
Empiema Pleural/cirurgia , Pneumonia Bacteriana/cirurgia , Adulto , Idoso , Antibacterianos/uso terapêutico , Criança , Terapia Combinada , Estudos Transversais , Empiema Pleural/classificação , Empiema Pleural/diagnóstico , Empiema Pleural/mortalidade , Humanos , Pleura/cirurgia , Pneumonia Bacteriana/classificação , Pneumonia Bacteriana/complicações , Pneumonia Bacteriana/diagnóstico , Pneumonia Bacteriana/mortalidade , Taxa de Sobrevida , Toracentese , Toracoscopia , Terapia TrombolíticaRESUMO
Video-assisted thoracoscopic surgery (VATS) has revolutionized the practice of thoracic surgeons and improved patient experiences and outcomes worldwide. The VATS approach has matured over the past decades and now accounts for approximately 50 % of all operations in specialized thoracic surgery units. The VATS procedure is less invasive and therefore allows a faster recovery of patients. Over the last 20 years VATS has developed into a safe and effective technique for the diagnostics and therapy of many thoracic diseases. With increasing experience thoracic surgeons can carry out more advanced and technically challenging interventions. Nowadays, VATS is the superior technique in many cases of thoracotomy.
Assuntos
Doenças Torácicas/cirurgia , Neoplasias Torácicas/cirurgia , Cirurgia Torácica Vídeoassistida/instrumentação , Cirurgia Torácica Vídeoassistida/métodos , Desenho de Equipamento , Alemanha , Humanos , Imagem Multimodal/instrumentação , Imagem Multimodal/métodos , Tomografia por Emissão de Pósitrons/instrumentação , Tomografia por Emissão de Pósitrons/métodos , Procedimentos Cirúrgicos Robóticos/instrumentação , Procedimentos Cirúrgicos Robóticos/métodos , Instrumentos Cirúrgicos , Tomografia Computadorizada por Raios X/instrumentação , Tomografia Computadorizada por Raios X/métodosRESUMO
BACKGROUND: Complex pleural empyema or lung abscesses are either characterised by long-standing treatment (including treatment failure) or by a bad general condition of the patient (multiple morbidity, sepsis). The operative rectification is often associated with increased morbidity and mortality rates in these cases. Traditionally, the therapeutic tendency for such patients was towards primary creation of a thoracic window including open wound treatment, but this was always also associated with a long sickness and restrictions in the quality of life. The intrathoracic vacuum treatment (VAC) offers here entirely new options in the treatment of complicated pleural empyema and lung abscesses. METHOD: We present an illustration of our own clinical experience associated with a selective literature research via Medline (keywords: VAC, vacuum-assisted closure, thoracic empyema). RESULTS: After the initial successes of the extrathoracic application of the VAC treatment, the procedure was also analysed for its intrathoracic/pleural use to treat pleural empyema and lung abscesses with and without bronchus stump insufficiency. Initially, the use of the intrathoracic VAC treatment was carried out via a thoracic window (with rib resection), later we developed a minimally invasive procedure (Mini-VAC) while relieving the osseous thorax. An additional intrapleural rinsing with antiseptics (Mini-VAC-Instill) is very practical in cases of proven germ populations. The benefits of the Mini-Vac/Mini-VAC-Instill are: immediate secretion suction with quick local cleaning, rapid germ eradication with a small risk of a fresh population, improvement of the expansion behaviour of the lung as well as short treatment times with quick reclosure of the thorax. In addition to many retrospective examinations, there has so far only been one cohort study in which the classic thoracic window was compared with the VAC treatment. The duration of the stomatic situation as well as the long-term survival in the VAC group were better here than those in the non-VAC group. CONCLUSION: The intrathoracic VAC treatment (Mini-Vac/Mini-VAC-Instill) is an innovative procedure that promotes wound cleaning and wound healing in complicated pleural empyema and lung abscesses. Due to the benefits of this procedure, including the improvement of the patient's comfort and the quality of life, the procedure has seen a rapid and broad clinical acceptance.
Assuntos
Empiema Pleural/cirurgia , Abscesso Pulmonar/cirurgia , Tratamento de Ferimentos com Pressão Negativa/instrumentação , Tratamento de Ferimentos com Pressão Negativa/métodos , Desenho de Equipamento , Alemanha , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos/instrumentação , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/prevenção & controle , Toracostomia/instrumentação , Toracostomia/métodos , Cicatrização/fisiologiaRESUMO
BACKGROUND: Persistent postoperative pleural effusion can occur after thoracic surgery and might lead to progressive dyspnea with a subsequent complicated and prolonged hospital stay. OBJECTIVES: The etiology, prevention and therapy of persistent pleural effusion after thoracic surgical interventions are presented. MATERIAL AND METHODS: A selective literature search was carried out in Medline (pleural effusion, pleural empyema and chylothorax). RESULTS: Persistent pleural effusions were observed especially after lung resection due to disorders in the pleural fluid balance and reduced postoperative lung expansion. An adequate chest tube management and postoperative physical therapy can reduce the incidence of postoperative pleural effusion. Relevant postoperative bleeding causes a hemothorax. An infection of the pleural effusion is defined as pleural empyema. These patients suffer from a significantly higher postoperative morbidity and require an adjusted multimodal treatment. Intraoperative injury of the thoracic duct can result in a postoperative chylothorax, which should be diagnosed early with specific laboratory investigations of the milky fluid. Interventional radiological procedures have now taken their place alongside conservative measures and surgical procedures in the therapy of chylothorax. CONCLUSION: Persistent postoperative pleural effusion after thoracic surgical interventions warrant early diagnosis and an adjusted treatment in order to avoid further complications and to shorten the postoperative hospital stay.
Assuntos
Derrame Pleural/etiologia , Complicações Pós-Operatórias/etiologia , Procedimentos Cirúrgicos Torácicos/efeitos adversos , Quilotórax/etiologia , Quilotórax/prevenção & controle , Quilotórax/terapia , Dispneia/etiologia , Dispneia/prevenção & controle , Dispneia/terapia , Diagnóstico Precoce , Intervenção Médica Precoce , Empiema Pleural/etiologia , Empiema Pleural/prevenção & controle , Empiema Pleural/terapia , Humanos , Tempo de Internação , Derrame Pleural/prevenção & controle , Derrame Pleural/terapia , Pneumonectomia/efeitos adversos , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/terapia , Ducto Torácico/lesõesRESUMO
INTRODUCTION: In Germany no official guidelines exist for a specific perioperative antibiotic prophylaxis (PAP) in thoracic surgery. In this review, data regarding the PAP as well as antibiotic therapy of the postoperative pneumonia (POP) in thoracic surgery are described. METHODS: Selective literature researches were carried out in Medline with consideration of the official recommendations of the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) as well as Paul-Ehrlich-Gesellschaft für Chemotherapie e.âV. (PEG). RESULTS: The PAP is defined as a short and single application of an antibiotic agent preoperatively or during a surgical intervention. A PAP with first-generation or second-generation cephalosporins could significantly reduce the rate of surgical site infections after thoracic surgery. However, these few randomised trials could not demonstrate a distinct effect on the rate of POP and postoperative empyema. The incidence of POP is approximately 20-25â% after major thoracic surgery. Antibiotic therapy of POP should be performed early and be based on antibiotic sensitivity. CONCLUSION: Based on the few prospective, randomised studies a single dose of intravenous PAP with a cephalosporin is recommended in thoracic surgery. Therapy of the POP should include general procedures combined with a specific antibiotic therapy according to antibiotic sensitivity.
Assuntos
Antibioticoprofilaxia , Empiema/prevenção & controle , Assistência Perioperatória/métodos , Infecção da Ferida Cirúrgica/prevenção & controle , Procedimentos Cirúrgicos Torácicos , Cefalosporinas/uso terapêutico , Humanos , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
BACKGROUND: Glycated proteins (advanced glycation endproducts, AGE) in tissue are associated with degenerative diseases. This study evaluated the role of sRAGE (soluble receptor for advanced glycation endproducts), a decoy receptor of AGEs in blood, for the outcome of patients after coronary artery bypass grafting (CABG). METHODS: A total of 90 patients undergoing CABG were analysed in two centres. Perioperative blood samples were collected before surgery up to 1 week postoperatively. sRAGE was measured by ELISA. Patients were subdivided regarding age (< 64 versus > 70 years, 14 % versus 35 % female), euroSCORE (< 3 versus > 4, 14 % versus 29 % female) and sRAGE changes between sternotomy and end of the operation (< 30 % versus > 45 %, 33 % versus 33 % female) and subsequently analysed with respect of postoperative outcome parameters. RESULTS: Preoperative sRAGE values did not correlate with the outcome of the patients. sRAGE levels increase within 10 min from 1,539 ± 96 to 5,311 ± 187 pg/ml after sternotomy, then returning to baseline levels within 2 days after surgery. Comparing the analysed possible risk factors age, euroSCORE and sRAGE changes, no difference was observed regarding 30-day mortality. Age and the euroSCORE are superior with respect of tachyarrythmia, whereas sRAGE kinetics seems to be superior with respect of prolonged postoperative respiration time/stay in the intensive care unit or catecholamine support. CONCLUSION: A prolonged, increased intraoperative sRAGE level is a new outcome predictor for patients undergoing CABG surgery, mutually complementary to the euroSCORE.
Assuntos
Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/cirurgia , Avaliação de Resultados em Cuidados de Saúde/métodos , Receptores Imunológicos/sangue , Distribuição por Idade , Idoso , Biomarcadores/sangue , Doença da Artéria Coronariana/sangue , Feminino , Alemanha/epidemiologia , Humanos , Masculino , Taxa de Depuração Metabólica , Pessoa de Meia-Idade , Monitorização Intraoperatória/estatística & dados numéricos , Prevalência , Prognóstico , Receptor para Produtos Finais de Glicação Avançada , Reprodutibilidade dos Testes , Fatores de Risco , Sensibilidade e Especificidade , Distribuição por Sexo , Taxa de Sobrevida , Resultado do TratamentoRESUMO
INTRODUCTION: Patients with pleural thymoma spread (Masaoka stage IV a) should be treated within a multimodal treatment regime. However, the extent of local surgical resection to achieve optimal tumour control remains controversial. PATIENTS AND METHODS: Prospective analysis between September 2008 and April 2013 of all patients with a Masaoka stage IV a thymoma, who underwent radical pleurectomy/decortication (P/D) followed by hyperthermic intrathoracic chemotherapy (HITHOC). RESULTS: A total of 11 patients (male n = 7; mean age 46.5 ± 11.4 years) with a primary stage IV a thymoma (n = 3) or thymoma with pleural relapse (n = 8) were included after successful transsternal thymoma resection. WHO histological classification was: B1 n = 1, B2 n = 6, B3 n = 3 and C n = 1. A radical P/D (5/11; 45 %) was extended with resection of the pericardium and diaphragm in 6/11 (55 %) patients. After surgical resection (91 % complete macroscopic R0/R1-resection) the HITHOC with cisplatin (100 mg/m2 body surface area (BSA) n = 7; 150 mg/m2 BSA n = 4) was performed for one hour at 42 °C. Operative revision was necessary in two patients (chylo- and hematothorax) with one patient also requiring temporary renal replacement therapy due acute renal failure (cisplatin 150 mg/m2 BSA). 30-day mortality was 0 %. Local recurrence (pulmonary n = 1, paravertebral n = 2) was documented in 3/10 (30 %) patients after R0/R1 resection. After a mean follow-up of 23 months the overall median survival was 27 months and 82 % (9/11) patients are still alive at the end of the study period. CONCLUSIONS: Masaoka stage IV a thymoma could be safely treated with lung-sparing radical P/D and HITHOC with cisplatin in a multimodality treatment regime. Early results with respect to recurrence and survival are encouraging, but further studies are warranted and we have to await long-term results.