Initial experience with lung transplantation in Estonia.

BACKGROUND: A lung transplant program in Estonia was initiated in cooperation with the Medical University of Vienna. The first lung transplantation for an Estonian patient was performed in Vienna on April 28, 2009. The waiting list in Estonia was opened on May 28, 2010; the first transplantation was performed on October 7, 2010. The aim of this study was to present our initial results. PATIENTS AND METHODS: All lung transplantations performed in Estonia through the end of January 2012 included 2 female and 3 male patients of age from 52 to 64 years. Data regarding the donor, the transplant operation, postoperative period, and follow-up were extracted from case records. RESULTS: The cases included 1 bilateral lobar, 3 double, and 1 single lung transplantations. Two patients had chronic obstructive pulmonary disease, one alpha-1 trypsin deficiency, and two idiopathic pulmonary fibrosis. The operative duration varied from 172 to 337 minutes; the ischemia times for the first and second lung ranged from 191 to 351 and 303 to 455 minutes, respectively. Duration of postoperative mechanical ventilation ranged from 2 to 14 days (median 3) and the hospital stay from 28 to 72 days. The following complications were observed: prolonged air leak in 2 patients, one of whom required rethoracotomy; phrenic nerve palsy in 2, atrial fibrillation in 2, and mild renal failure in 1 subject. One patient needed readmission to the intensive care unit owing to acute respiratory failure; one, a tracheostomy for weaning from the ventilator, and one, noninvasive ventilation owing to hypercapnia. All patients remain well at 4-19 months after transplantation. No episodes of acute rejection or bronchiolitis obliterans have been diagnosed. CONCLUSION: The first 1.5-year experience with lung transplantation in Estonia has been satisfactory. Although there have been several complications, no posttransplant or waiting list mortality has occurred.

Thoracoscopic resection of a solitary pulmonary nodule in patients with a known history of malignancy.

BACKGROUND: Solitary pulmonary nodules found during the follow-up of cancer patients are generally considered to be lung metastases. However, a definite diagnosis should be established. METHODS: Between 1995 and 2005, all patients with a solitary lung nodule considered removable by a thoracoscopic approach and with a history of malignancy were included in this study. Lung wedge resection was performed to establish the morphological diagnosis. During follow-up further metastases and local recurrences were registered. Survival data were obtained in February 2007. RESULTS: Among our 34 patients (17 male and 17 female with a median age of 67.5 years), the most common primary cancers were colorectal (n = 12) and kidney (n = 6). Two patients had a history of 2 cancers. Twenty-two patients (65 %) had lung metastases and 12 (35 %) had benign nodules. During follow-up (median 2.4 years) 7 patients (21 %) developed further lung metastases. Overall postoperative five-year survival was 50 % (95 % CI: 35 - 73 %). CONCLUSION: Not all solitary lung nodules in patients with previous malignancy are metastases. According to our survival results the thoracoscopic removal of a single lung metastasis was curative in many patients.

Tuberculosis as an occupational hazard for health care workers in Estonia.

SETTING: Tuberculosis incidence has been increasing in the Baltic states since the 1990s, accompanied by the emergence of drug resistance, including multidrug resistance (MDR). In this changing situation, the potential threat of nosocomial spread of tuberculosis to other patients and health care workers (HCW) has remained unrecognised. OBJECTIVE: To investigate the risk of tuberculosis in health care workers in Estonia. DESIGN: Cases of tuberculosis registered among HCWs from 1994 to 1998 were evaluated. The case records were analysed retrospectively and combined with bacteriological data including data on drug resistance. RESULTS: Sixty-seven HCWs (23 physicians, 23 nurses and seven laboratory technicians, 12 assistant nurses and two cleaners), all of whom tested negative for human immunodeficiency virus, were diagnosed as having active tuberculosis. The incidence of tuberculosis among HCWs (mean 91/100,000/year) was 1.5 to three times higher than in the general population. In a chest hospital in charge of regional tuberculosis care, the incidence was 30 to 90 times higher, and was highest among physicians. In 49 HCWs tuberculosis was confirmed by culture. Among these, drug resistance was detected in 23 (49%), 18 (38%) of whom had MDR tuberculosis. CONCLUSIONS: Health care workers, especially those working in a chest hospital where tuberculosis patients were treated, were found to be at an elevated risk of tuberculosis. MDR tuberculosis poses a particular threat which is difficult to combat.

Surgical treatment of pleural empyema--changing priorities.

The surgical management of pleural empyema and post-traumatic clotted haemothorax is described. The study included 15 cases of post-thoracotomy empyema, 23 of empyema of other aetiology and five of post-traumatic haemothorax. Chest-tube drainage was the first measure in most cases. Post-pneumonectomy empyema was treated with partial thoracoplasty plus omentoplasty (8 cases) or plus myoplasty (1 case). Empyema after lobectomy or bilobectomy (4 cases) or after failed decortication (1 case) was managed with thoracoplasty or, in cases of concomitant wound infection, with open-window thoracostomy followed by thoracoplasty. Empyema after subclavian artery reconstruction (1 case) was cleared by removal of a previously unrecognized foreign body. For early empyema of other aetiology or haemothorax (10 cases in total), treatment comprised debridement by video-assisted thoracoscopic surgery (VATS). VATS was also used to establish suitable pleural drainage prior to elective thoracotomy (2 cases). Decortication and partial parietal pleurectomy were performed for organizing-stage empyema (16 cases). Three of the 15 patients with post-thoracotomy empyema died perioperatively, one died two months postoperatively and one had recurrence of bronchopleural fistula during follow-up. One patient with VATS debridement subsequently required thoracotomy and lobectomy for lung abscess. All the others with VATS or decortication recovered without complications. During follow-up there was no mortality or recurrence of empyema.

Video-assisted thoracoscopic surgery in the management of acute purulent mediastinitis and pleural empyema.

Management of acute purulent mediastinitis requires broad-spectrum antibiotics and proper surgical drainage-routine use of thoracotomy is recommended by several authors. We describe two cases where video-assisted thoracoscopic surgery (VATS) was used instead of thoracotomy. Etiology of mediastinitis in one patient was a stab wound and in the other an iatrogenic esophageal perforation. In addition, the first patient had purulent pericarditis and suppurated haemothorax and the second a pleural empyema. In both cases VATS allowed debridement of the entire thoracic cavity and subsequent drainage of the mediastinum. Continuous irrigation was used postoperatively until pleural fluid became clear. Both patients recovered without a need for further surgical treatment. They are doing well 8 and 9 months later. Adequate debridement and drainage of pleural empyema and mediastinitis can be achieved using VATS instead of a thoracotomy approach.

Omentoplasty together with partial thoracoplasty: a one-stage operation for postpneumonectomy pleural empyema.

BACKGROUND AND AIMS: Postpneumonectomy pleural empyema is a rare but life-threatening complication in thoracic surgery. This article describes our treatment strategy of this condition with omentoplasty plus partial thoracoplasty. MATERIAL AND METHODS: During a 2-year period 5, patients were treated. Three patients had clinical signs of bronchial stump fistula confirmed by bronchoscopy and during thoracotomy. Four patients were preoperatively treated with tube thoracostomy and pleural irrigation (median 21 days). In one case no preoperative drainage procedure was used. All patients were treated by partial thoracoplasty and omental transfer as a single-stage operation. Thoracoplasty was performed extrapleurally according to CT findings to reduce the volume of the empyema cavity. Subsequently, the empyema cavity was opened and cleaned. Upper midline incision was used to mobilize omentum majus and transfer it through the diaphragm into the thoracic cavity. RESULTS AND CONCLUSIONS: In 3 patients, the omentum filled the cavity only partially but that did not influence the results. All patients recovered without major complications. Two patients had nausea during the first postoperative days. No recurrence of pleural empyema occurred. Omentoplasty together with partial thoracoplasty is a safe and effective method in the treatment of postpneumonectomy pleural empyema both with and without broncial stump fistula. It can be performed as a single-stage operation without a pre- or postoperative open-window thoracostomy.

Early administration of intrapleural streptokinase in the treatment of multiloculated pleural effusions and pleural empyemas.

In the treatment of multiloculated pleural effusions and empyemas tube thoracostomy often fails and more aggressive surgical therapy is required. Intrapleural administration of fibrinolytics is a valuable alternative. Between October 1994 and December 1995 28 patients (aged 22 to 62 years) with multiloculated pleural effusions were treated with intrapleural instillations of streptokinase after unsuccessful conventional chest tube drainage. Twenty-three pleural effusions were grossly purulent, others were loculated effusions with low pH. The most common cause of the pleural effusions was pneumonia. Duration of illness before hospitalization was 3 to 105 (mean 21.8) days. Treatment with streptokinase was started most commonly one day after chest tube placement. Once a day after clamping the chest tube streptokinase was administered intrapleurally for 10-15 minutes as a solution of 250,000 units in 100 ml normal saline. The tube remained clamped for 3 hours. Two to 8 (mean 3.7) instillations per patient were needed. Twenty-one cases (72.4%) showed excellent resolution of pleural effusion and needed no more therapy. However, one patient died in hospital due to purulent meningitis and bilateral pneumonia. Eight patients needed further surgical treatment, e.g. decortication, in 5 cases together with wedge lung resection. Eleven patients experienced some adverse effects of streptokinase therapy, most frequently chest pain and elevation of body temperature in one case pleural effusion became hemorrhagic, and one patient had nasal bleeding. We conclude that usage of intrapleural streptokinase in the treatment of multiloculated pleural effusions (including pleural empyemas) reduces the need for major surgical interventions in quite a large group of patients.