[Functional Outcome after Chest Wall Stabilisation]. / Rippenosteosynthesen - funktionsverbessernd?

This overview reviews the current literature to compare the functional results after surgical and conservative treatment of patients with flail chest and multiple rib fractures. Regarding functional aspects, patients in the early phase after a thoracic trauma are those that benefit most from the stabilisation of the chest wall by internal fixation of the ribs. Patients recover faster from restrictive respiratory disorders, have less pain and return to the workplace earlier after an operation compared with those that receive conservative treatment. In the medium term, however, patients that are treated conservatively also achieve normal pulmonary function values and become free of pain. The period of convalescence after blunt thoracic trauma is generally underestimated. Future studies of the functional outcome after severe chest injuries should take this into account and the development of functional parameters should be monitored for at least 24 months. A prospective data collection of early and long-term surgical results in registries would be suitable to evaluate benefits and indications of chest wall stabilisation.

[The German cigarette industry association--obstructing effective tobacco control in Germany]. / Der Verband der Cigarettenindustrie--Verhinderung wirksamer Tabakkontrollpolitik in Deutschland.

In spite of up to 140,000 tobacco-related deaths each year, Germany still lacks comprehensive tobacco control policies. Through systematic analysis of internal tobacco industry documents we examined how and to what extent the German Cigarette Industry Association (Verband der Cigarettenindustrie, VdC), which is the tobacco industry's trade organisation in Germany, contributed to this lack of more effective tobacco control. The role and strategies of the VdC are illustrated by using selected case studies. The evaluated documents reveal a profound influence of the VdC on political decision-makers in Federal and State Ministries as well as on German governments. The VdC successfully curbed and delayed the national adoption of EU legislation on tobacco advertising and product regulation, public smoking bans, legislation to protect the youth, and rises in tobacco taxation. The VdC's influence has played a key role in obstructing the development and implementation of effective tobacco control policies in Germany.

[Smoking, chronic obstructive pulmonary disease and lung cancer]. / Tabakrauchen, chronisch obstruktive Lungenerkrankung und Lungenkarzinom.

Smoking is the main risk factor for chronic obstructive pulmonary disease (COPD) and lung cancer. Being a chronic disease, COPD severely impairs the quality of life. Lung cancer is the leading cause of death among German males and the third most important cause of death among German females. This review gives data on the primary prevention of both diseases and the beneficial effects of smoking cessation following disease manifestation. Smoking-induced oxidative stress triggers a chronic inflammation which is central to the pathogenesis of COPD. Smoking causes lung cancer by oncogenic mutations as well as inhibition of tumour-supressor genes. Women have an increased risk to develop COPD and lung cancer as compared to men when exposed to the same amounts of tobacco smoke. Smoking cessation is the only treatment capable of reducing exacerbations and mortality as well as sustainedly improving lung function. The high level of nicotine dependence in COPD patients mandates an intensive smoking cessation treatment including pharmacotherapy and psychosocial intervention. In patients with lung cancer, smoking cessation has confirmed favourable effects on body weight, performance status, postoperative complications and mortality. Thus, smoking cessation should be an integral part of lung cancer treatment. Further research is needed to better delineate the effects of smoking cessation in relation to other treatment modalities.

[Surgical curriculum. A model from thoracic surgery]. / Chirurgisches Curriculum. Ein Modell aus der Thoraxchirurgie.

There is a shortage of new surgeons in Germany. The blame for this is laid on poor working and training conditions in German hospitals. Professional associations suggest restructuring teaching plans to improve surgical education. The study conditions, postgraduate education, and surgical training in a thoracic surgical department are presented as a model curriculum. Surgical training can be structured. Curricula can be delineated for colleagues and applicants and comply with quality management standards. Clear and fair courses would improve surgical training and satisfy the expectations of contemporary surgeons.

[Endoluminal therapy of the trachea and bronchus]. / Die endoluminale Therapie in Trachea und Bronchus.

The application of endoscopic techniques is common in the treatment of tracheal and bronchial diseases today. Bronchoscopic interventions are used in both elective and emergency situations. Laser therapy for malignant tumors is purely palliative in most cases and should only be performed in nonsurgical patients. However, 30% of lung cancers cause obstruction in the trachea and main bronchi. Benign tumors and tracheal stenoses could require laser recanalization or the implantation of stents, if surgery will be the second step or will not be possible. In patients with foreign body aspiration, massive hemoptysis, or severe obstruction of the trachea, emergency bronchoscopy is necessary. A more recent type of bronchoscopic intervention is the treatment of bronchial stump or anastomosis insufficiency as well as minimal iatrogenic injuries using spongiotic fillings or stent implantation. The use of therapeutic bronchoscopy requires great experience in rigid and flexible bronchoscopy, the possibility of high-frequency jet ventilation as well as laser and argon application, and the possibility to implant different types of stents. More advanced bronchoscopic interventions should only be done if a department of thoracic surgery exists, in view of the potential need to control complications or perform further treatment. Especially the bronchoscopic treatment of tracheal stenosis should be performed by the thoracic surgeon himself or in close contact with a thoracic surgeon who is experienced in tracheal resections.

Reduced blood loss by aprotinin in thoracic surgical operations associated with high risk of bleeding. A placebo-controlled, randomized phase IV study.

OBJECTIVE: Although the blood-saving effect of aprotinin has been well documented in cardiac surgery and lung transplantation, its use in lung surgery has received less attention. We present our experience with the intraoperative application of aprotinin in lung resections with a predicted high risk of bleeding. METHODS: Thirty-eight patients undergoing major thoracic surgical procedures were randomized into treatment and placebo groups. The treatment group (n=18) received a bolus of 2 x 10(6) kallikrein inhibitor units (KIU) of aprotinin followed by 5 x 10(5) KIU/h during surgery. The placebo group (n=20) received an isotonic saline infusion instead. RESULTS: There was no significant difference between the groups concerning diagnosis, co-morbidity, age, sex, height, and weight. The mean intraoperative blood loss in the treatment group was significantly reduced (342 vs. 808 ml, P<0024), postoperative blood loss was also reduced (623 vs. 1282 ml, P<0.0007) and the need for blood transfusion was less (14 vs. 60, n.s.). No severe side effects of aprotinin were registered. Re-thoracotomy was necessary in two patients of the placebo group because of postoperative bleeding. CONCLUSION: Aprotinin reduces the perioperative blood loss and the need for blood transfusion in thoracic surgical procedures in patients with an increased risk of bleeding.

[Secondary spontaneous pneumothorax in tuberous sclerosis]. / Sekundärer Spontanpneumothorax bei tuberöser Sklerose.

Secondary pneumothorax occurs as a symptom of an underlying pulmonary disease. We report the case of an 18-year-old woman with tuberous sclerosis (Bourneville's disease) and recurrent pneumothoraces. Clinical outcome was favorable 6 months after bilateral videothoracoscopic pleurectomy. The complete triad of tuberous sclerosis (TS) (mental retardation, seizures, adenoma sebacium) is not always present in those who develop pulmonary involvement. When TS involves the lung it is clinically and pathologically indistinguishable from lymphangioleiomyomatosis (LAM). The very rare pulmonary involvement of TS and LAM are problems primarily of women in childbearing age. A pneumothorax can be the first symptom of TS or LAM.

Neoadjuvant chemoradiotherapy of stage III non-small-cell lung cancer.

Twenty to 30% of patients with non-small-cell lung cancer (NSCLC) in stage III are not resectable primarily with 5-year survival less than 10%. Since the majority of patients die from metastases, efforts have been made in the past to improve prognosis by application of neoadjuvant chemoradiotherapy regimens followed by subsequent resection. In a phase II study performed between 1993 and 1998, 93 patients in stage III (IIIA, 16%; IIIB, 84%) received an induction chemotherapy consisting of two cycles cisplatin (100 mg/m2) and vindesine (3 mg/m2) with subsequent sequential radiotherapy of 36 Gy. Sixty-five patients demonstrated partial or complete remission. Sixty underwent surgery; in 49 of them complete resection was possible. Five-year survival in the whole group was 24%, and that in the surgical cohort 39%. Six patients had no residual tumor. Postoperative N0 status was associated with a 5-year survival of 75%, and stage N1-3 with 13%. Thirty-day mortality was 7% postoperatively. Neoadjuvant chemoradiotherapy can significantly improve long-term survival in stage III NSCLC with an acceptable therapy-induced mortality.

Resection of pulmonary metastases from renal cell carcinoma.

Between 1980 and 1995, 77 patients underwent complete resection of pulmonary metastases from a renal cell carcinoma after exclusion of a primary tumor recurrence and other metastatic localizations. 30-day mortality was 3%. The Median follow-up was 34 months (M). Cumulative 5-year survival (5-YS) was 39%. Prognostic criteria are the duration of the disease-free interval (DFI) and the number of metastases. Patients with a DFI > or = 48 M had a 5-YS of 46% compared to 26% for a DFI of < 48 M. Patients with a solitary metastasis had a 5-YS of 49% compared to 19% for multiple metastases. There was no significant difference in terms of sex, kind of access, kind of operation, and unilateral or bilateral affection. Since metastases from renal cell carcinomas are almost resistant to chemotherapy and radiotherapy and immunotherapy at present does not considerably improve long-term survival, surgical resection currently is the only effective therapeutic access in renal cell cancer metastasized to the lung.