Comparison of costs of hospitalization of patients with primary lung cancer after lobectomy with access through classic thoracotomy and VATS in the conditions of financing based on diagnosis-related groups.

BACKGROUND: One of serious problems in the management of health care units is rational management of financial resources allocated by the government for health care. This management is significantly influenced by the valuation tariff of health care services, including surgical procedures. The assessment of the cost-effectiveness of a particular service has a key role in the selection of procedures performed in a given health care unit. The aim of the study is to assess the costs of lobectomy via thoracotomy and video-assisted thoracoscopic surgery (VATS) in terms of the impact on the overall hospitalization cost and the answer to the question whether differences in hospitalization costs depending on the access are large enough to justify different valuation tariffs for surgery via traditional and minimally invasive access. METHODS: This is a retrospective analysis of data on the costs of treatment of patients who underwent lobectomy via traditional access or VATS due to non-small cell lung cancer. Data concerning valuation of the procedure and hospitalization were compared with general costs of hospital treatment of these patients. RESULTS: The study has proven that duration of the procedure (VATS: 145 min, thoracotomy: 143 min) and total value of hospitalization costs depending on the type of access (VATS: €2,235, thoracotomy: €1,500) were similar-the differences did not show statistical significance (P=0.96 and 0.05118). In contrast, the average time of patient stay in the hospital after surgery and the average cost of surgery were significantly different (3.69 for VATS vs. 5.71 days for thoracotomy with P=0.0000084 and €1,705 for VATS and €682 for thoracotomy with P=0.0114). CONCLUSIONS: The total cost of patient hospitalization after lobectomy via VATS is similar to the cost of hospitalization after thoracotomy. Similar costs of both treatments with well-known benefits of VATS including shorter hospitalization and better quality of life of the patient speak in favor of a wider use of minimally invasive access with a good effect in the form of economical use of financial resources.

Chest reconstruction using a custom-designed polyethylene 3D implant after resection of the sternal manubrium.

INTRODUCTION: Resection of manubrium or body of the sternum is associated with a necessity of chest wall reconstruction. Large sternal defects require the use of different types of implants to ensure acceptable esthetic effect for the patient and chest stabilization. AIM: The purpose of this case report is to present a novel method of reconstruction of manubrium removed due to renal cancer metastasis to the sternum. CASE: We present the case of a patient, who had underwent right nephrectomy for clear cell kidney cancer, diagnosed with a metastatic tumor in the sternum resulting in destruction of manubrium. The patient undergone tumor resection with primary reconstruction with an individual prosthesis. Sternal defect was filled with a personalized, computed tomography scan-based 3D-milled implant made of polyethylene. RESULTS: Sternal reconstruction was uneventful. The patient endured surgery well, and has been under surveillance in outpatient clinic, without any respiration disorders, implant movement or local recurrence. CONCLUSION: Custom-designed sternal implants created by 3D technique constitute an interesting alternative for previous methods of filling defects after resection of a tumor in this location.

A new technique of pulmonary hernia surgical repair using intramedullary titanium implants.

INTRODUCTION: In this paper we present a new method of pulmonary hernia surgical treatment. Pulmonary hernia is a rare pathology. The first description of pulmonary hernia was made by Roland in 1499. The world literature describes only a little more than 300 cases of pulmonary hernia. Pulmonary hernia is defined as the projection of the lung tissue covered by the parietal pleura beyond the normal boundaries of the pleural cavity, through the pathological holes in the chest wall. During our work as thoracic surgeons, we have used different ways of thoracic chest wall reconstructive operations and anastomoses of the broken ribs. AIM OF THE STUDY: To search for optimal methods of pulmonary hernia surgery and to evaluate a new technique of pulmonary hernia surgical repair using intramedullary titanium implants. MATERIAL AND METHODS: In 2013 in our clinic, we diagnosed and cured two patients with idiopathic pulmonary hernia. We performed a reconstructive operation of the chest wall with anastomosis of the broken ribs using titanium intramedullary stabilization implants - splints. RESULTS: To date, the annual observation has revealed no recurrence of pulmonary hernia or postoperative complications. At present, the patients demonstrate full life activity. CONCLUSIONS: So far, in the world literature, we have not encountered any information about using such methods to repair pulmonary hernia. We regard our method as safe, easy to use and giving good therapeutic results.

Repair of postpneumonectomy bronchopleural fistula using pedicled pericardial flap supported by fibrin glue.

Effective closure of the postpneumonectomy bronchopleural fistula (PBF) with the use of different techniques still remains a challenge for thoracic surgeons. The aim of this study was to evaluate the efficacy of modified method of PBF closure using pedicled pericardial flap (PPF) supported by fibrin glue (FG). The efficacy of the late PBF closure with the use of two surgical methods was compared. In 10 patients, the edges of the PBF were covered with FG and PPF. In the second group of nine patients, myoplasty was used to close the bronchial fistula. Postsurgical follow-up was for 1 year. In the first group, the healing of the fistula was achieved in 100% of the cases, whereas in the second, myoplasty group, healing was achieved in only 66·67% of the cases. The number of complications was similar in both groups. Pericardial flap supported by fibrin glue can be an effective method adjunctive to the treatment of PBF in selected patients.

Pericardial flap: an effective method of surgical repair of late post-pneumonectomy fistula.

BACKGROUND: We report our experience with the surgical closure of late post-pneumonectomy bronchopleural fistula (PBF) using our own method of coverage of the bronchial stump: Pedicled pericardial flap in combination with fibrin glue. METHODS: We reviewed the surgical results of 33 patients who underwent surgical closure of PBF by thoracotomy access using three methods: Myoplasty (MYO)-12, omentoplasty (OMT)-10, and pedicled pericardial flap (PPF) with fibrin glue-11. Post-operative follow up was six months. RESULTS: The patients' demography was comparable among the groups. The diameter of the fistulas ranged from 5 mm to total dehiscence. The mean time of the fistula manifestation (in weeks) was 21.5 in the MYO group, 19.50 in the OMT, and 20.1 in the PPF group. The shortest period of hospital drainage of the pleural space was noted in the PPF group. Healing of the fistula was obtained in 66.67% in the MYO group, 80% in the OMT, and 100% in the PPF group. The number of complications was similar in all groups. The hospitalization time was significantly shorter in the PPF group (13.00 d) versus the MYO group (19.58 d) and the OMT (20.01 d). Overall mortality rate was 18.18%; 33.33% of the patients in the MYO group and 20% in the OMT group died. There were no hospital deaths in the PPF group. CONCLUSION: Pericardial flap supported by fibrin glue can be an effective method adjunctive to the treatment of postpneumonectomy PBF in selected patients. Compared with other methods of bronchial stump coverage (omentopasty and myoplasty), this one showed a higher percentage of healing of the fistulas and shorter duration of hospital drainage and hospitalization.

Efficacy assessment of the drainage with permanent airflow measurement in the treatment of pneumothorax with air leak.

AIM: The aim of this study was to compare the efficacy of the treatment of patients with spontaneous pneumothorax with air leak (AL) using two different chest drainage systems. METHODS: Patients were randomized into two groups: group A included 30 patients (23 males and 7 females, mean age 41.1 ± 16.29 y, range 17-71 y) in which digital drainage system was used, group B with 30 patients (22 males and 8 females, mean age 40.3 ± 15.74 y, range 18-72 y) in which traditional suction drainage system was applied.The following variables were evaluated: intensity of AL, duration of the chest tube drainage, delay in surgery, length of stay, and the overall hospitalization costs. RESULTS: In group A the mean drainage duration was 47.63 hours, the hospitalization time was about 5.10 days, and the cost of hospitalization was €1,495. In group B the mean drainage duration was 84.93 hours, the hospitalization time was 6.97 days, and the hospitalization cost was €1,925. CONCLUSION: The digital drainage system applied in the treatment of AL in patients with pneumothoraces reduced the duration of the drainage, the length of hospital stay, and overall hospitalization costs.

Application of biochemical markers CA 19-9, CEA and C-reactive protein in diagnosis of malicious and benign pancreatic tumors.

INTRODUCTION: We would save many lives and spare a lot of suffering if we could only detect and accurately determine the character and TMN staging of pancreatic tumors (PTs). With improved diagnosis, we could offer specific treatment that would result in better treatment outcome. The aim of study was to determine the significance of neoplastic markers CA 19-9 and CEA for prognosis in inflammatory and carcinomatous PTs. MATERIAL AND METHODS: We based our research upon a group of 170 patients. The patients were treated in our Oncologic Surgery Department from January 2007 to December 2010 for PTs. The patients were divided into four groups depending on the character of the tumor and underwent the following treatments: group 1 - 34 patients with carcinoma of the ampulla of Vater, group 2 - 64 patients with PTs at different stages (1, 2, 3) according to TMN classification, group 3 - 62 patients with PTs at stage 4 on the TMN scale (unresectable tumors), group 4 - 28 patients with inflammatory PTs. RESULTS: The results of Ca 19-9 in group 2 were 736.00 (25-75% 220.40-4285.00) ng/ml before surgery, 53.00 (25-75% 12.60-84.00) ng/ml in the 7 days after surgery, 29.4 (25-75% 7.90-113.00) ng/ml at day 30, and 119.00 (25-75% 96.30-621.00) ng/ml 3 months after the operation. These results were significantly higher than the control group but were significantly lower than the results for group 3 (unresectable tumors). The highest average concentration and median for CA 19-9 and CEA were noted in patients with unresectable PTs (the 3(rd) group). The average concentration for CEA was lowest in group 4, but much higher than the lab limits. CONCLUSIONS: The sensitivity of the CA 19-9 marker may be as high as 88%. Values of CA 19-9 above 852 U/ml may indicate TNM stage 4, consistent with an unresectable PT. In the cases where CA 19-9 is within normal limits but C-reactive protein is above normal limits (often thirty times the upper limit), in comparison to the control group and to patients with pancreatic neoplasms, strong consideration should be given towards the inflammatory characteristics of the pancreatic changes and conservative treatment should be applied.

A case of upper gastrointestinal acute bleeding as a complication of renal carcinoma metastases to the papilla Vateri.

Acute bleeding from metastatic tumour of the papilla Vateri is an extremely rare case. In this report the case of a woman who suffered from complications after a metastatic tumour of the papilla is described. Seventeen years following resection of the kidney due to clear cell carcinoma the patient was admitted to the clinic because of massive bleeding (Forrest IB) to the upper digestive tract in the form of sanguineous vomiting. The conducted diagnostics revealed a bleeding tumour of the papilla Vateri. Endoscopic treatment could not effectively stop the bleeding. A surgical procedure was performed by Whipple's method. A histopathological examination showed a metastatic clear cell tumour of the kidney. The patient was discharged from hospital on the 8(th) day following her admission and was also referred for further oncological treatment. The discussion is based on other cases of rare bleeding from the digestive tract within tumours of the bile duct and papilla Vateri.

Gastric tube resection due to metachronic cancer and a recurrence in anastomosis after Ivor-Lewis esophagectomy--case report.

Gastric tube after esophagectomy can be the site of local recurrence or the development of second primary tumor which implies poor prognosis. The study presents an extremely rare case of a patient after Ivor-Lewis esophagectomy for squamous cell carcinoma, in whom there was detected local recurrence in the anastomosis associated with metachronous primary tumor in gastric tube. Esophageal reresection with the upper part of the stomach was performed. Left colonic segment supplied by middle colic vessels transposed through retrosternal route was used as new esophageal substitute.

Evaluation of prognostic value of selected biochemical markers in surgically treated patients with acute mediastinitis.

BACKGROUND: Monitoring of biochemical markers of inflammation in acute mediastinitis (AM) can be useful in the modification of treatment. This study was a retrospective evaluation of selected biochemical parameters with negative impact on the prognosis in surgically treated patients. MATERIAL/METHODS: There were 44 consecutive patients treated surgically due to AM of differentiated etiology. Selected biochemical markers (WBC, RBC, HGB, HCT, PLT, CRP, PCT, ionogram, protein and albumins) were assessed before surgery and on the 3rd day after surgery. ANOVA was applied to find factors influencing observations. Numerical data [laboratory parameters] were compared by means of medians. RESULTS: The overall hospital mortality rate was 31.82%. In the group of dead patients, there were observed statistically significant lower mean preoperative values of RBC [p=0.0090], HGB [p=0.0286], HCT [p=0.0354], protein [p= 0.0037], albumins [p=0.0003] and sodium [p<0.0001] and elevated values of CRP [P=0.0107] and PCT p<0.0001]. High level of inflammatory markers on day 3 after surgery was found to increase the risk of death - for WBC (by 67%), for CRP (by 88%) and for PCT (by 100%). CONCLUSIONS: Poor prognosis was more frequent in patients with preoperative high levels of CRP, PCT, anemia, hypoproteinemia and hyponatremia. The risk of death increases significantly if in the immediate postoperative period no distinct decrease in WBC count and of the CRP and PCT level is observed. In such a situation the patients should be qualified earlier for broadened diagnostic workup and for reoperation.

Assessment of quality of life in patients with non-operated pancreatic cancer after videothoracoscopic splanchnicectomy.

INTRODUCTION: Pancreatic tumours are a crucial medical issue. The majority of patients report sick in the late stage of carcinoma clinical advancement, which considerably limits the possibility of surgical treatment. Pancreatic cancer patients with no other alternative but palliative treatment constitute a large group. AIM: To assess pain intensity levels and quality of life of pancreatic cancer patients after videothoracoscopic splanchnicectomy. MATERIAL AND METHODS: Between 2001 January and 2010 November in the Department of Thorax, General Surgery and Oncology of the Medical University of Lodz 262 patients with pancreatic tumours were hospitalized. In 121 cases grade 3 and grade 4 tumours were observed. Hundred and twenty-one videothoracoscopic procedures of sympathetic trunk and ganglion excision were performed in 89 patients. RESULTS: Before the procedure the pain intensity level according to VAS was 5.66 (3.9-7.2; SD 1.24) in the trial group and 5.46 (4.1-7.1; SD 1.15) in the control group. The quality of life average assessment in both groups did not differ statistically (p = 1.07) and was 46.3 (32-66; SD 0.92) in patients before the operation and in the control group 50.3 (41-63; SD 0.75). On the 7(th) postoperative day the pain intensity on average was 2.33 (1.2-3.9; SD 0.78) and 4.57 (3.6-5.5; SD 0.69) respectively. One week after the procedure the quality of patients' life was estimated at 64.1 (39-83; SD 1.38) and in the control group at 52.2 (42-65; SD 0.71); the differences are significant (p < 0.05). Thirty days after the procedure 12 patients did not take any painkillers (13.5%), and in the others a considerable decrease of the taken drugs was observed. On average, the pain intensity was estimated at 1.78 (0.6-3.6; SD 0.68). The quality of life, on the other hand, improved considerably in relation to the state prior to the procedure, but increased insignificantly in relation to the state on the 7(th) postoperative day to 70.9 (52-88; SD 1.14). CONCLUSIONS: Splanchnicectomy is a safe method of cancer pain treatment in patients with advanced pancreatic tumours. Videothoracoscopic excision of visceral nerve thoracic section contributes to the statistically significant decrease of cancer pain intensity and considerably improves the quality of patients' lives.

[Postraumatic rupture of diaphragm with projection of the liver into the right pleural cavity--the case description]. / Pourazowe rozerwanie przepony z przemieszczeniem watroby do prawej jamy oplucnej--opis przypadku.

The proper initial diagnosis of acute diaphragm rupture in patients with multiple blunt trauma can be found difficult. It is the result of non specific clinical picture and dominating signs of injuries of other organs. Delayed diagnosis has a serious impact on worse conditions of diaphragm reconstruction and prognosis. A 53-year-old woman, with a severe abdomen injury after a car accident, is reported with perforation of the alimentary tract in two places (the small bowel and the sigmoid) and respiratory insufficiency caused by the projection of the liver into the thoracic cavity due to a large rupture of the right hemidiaphragm. The patient was initialy treated in another hospital in the intensive care ward where she was operated on three times by laparotomy acces owing to the perforations of the small and large bowels and the following complications. Eventually, she was admitted to our hospital one month after the accident so as to be treated for respiratory insufficiency. We described the difficulties in the treatment of this case in the late period after the injury. Finally the woman was treated with moderate success. Diaphragm laceration was repaired by the right thoracotomy access. In the next stage we performed the reconstruction of the alimentary tract and eliminated iloeostomy and colostomy during the fourth in turn laparotomy. Afterwards the patient in the state of the relative respiratory sufficiency was sent to the original hospital for further treatment.

[The case of numerous foreign bodies in bronchial tree of both lungs and digestive tract]. / Przypadek wystepowania mnogich cial obcych w drzewie oskrzelowym obu pluc i w przewodzie pokarmowym.

The article shows the description of the seldom met case of simultaneous appearing of numerous foreign bodies situated both in air passages and in the alimentary canal at patient of mentally handicapped with the tendency to swallowing of small objects. After observing by guardians of the patients fact of swallowing metallic foreign bodies by him the specified research were made (X-ray pictures, computer tomography) and the presence in the bronchial tree of both lungs and in the upper and lower section of the alimentary canal were confirmed. Swallowed and aspirated objects did not cause no complaints at the patient. Revealed foreign bodies were removed from air passages by using of the bronchofiberoscopy method and the surgical treatment. Foreign bodies of the alimentary canal were voided by patient through natural tract.

[Thoracic sympathectomy performed by videothoracoscopic technique]. / Zabiegi sympatektomii piersiowej wykonywane metoda wideotorakoskopowa.

UNLABELLED: Thoracic sympathectomy is a method for a segmental elimination of functions of the sympathetic system by the excision of its Th2-Th3 ganglia. The procedure can be performed both using open and videoscopic technique. OBJECTIVE: The purpose of the study was the evaluation of efficacy of videoscopic thoracic sympathectomy. MATERIAL AND METHOD: From 1993 to 2003 we performed 53 videoscopic thoracic sympathectomies in patients with Raynaud's syndrome and upper limb hyperhidrosis. RESULTS: In all patients that underwent thoracic sympathectomy we obtained a positive reaction to a segmental excision of the sympathetic trunk. Patients with Raynaud's showed a significant improvement in symptoms in 76% of cases after a 4-year observation while patients with hyperhidrosis in 100%. The time of hospitalisation was 3.5 days in average. Postoperative complications were observed in two patients (3.7%). Videoscopic thoracic sympathectomy provides good therapeutic and cosmetic results and deserves more common use compared with open technique.

[The results of treatment of acute haemorrhagic necrotizing pancreatitis in the own material]. / Wyniki leczenia martwiczo-krwotocznej postaci ostrego zapalenia trzustki w materiale wlasnym.

AIM OF WORK: The retrospective estimation of surgical procedure and the results of treatment of haemorrhagic necrotizing pancreatitis in the own material. MATERIAL AND METHODS: The estimated group consist of 161 patients from the clinic treated for heavy grade of acute pancreatitis. Characteristics which qualified patients to the chosen group were: aggravating general condition, biochemical parameters of disease's progression, results of radiological investigations (USG, CT of abdomen) and bacteriological culture from peritoneal cavity. RESULTS: 142 patients (88.2%) were surgically treated in different duration periods of illness (from 0 to 53 day of illness). Firstly, they were intensively treated with conservative treatment. After about 9.6 days they were operated on (from 0 to 51 day of treatment). Clinical symptoms such as: rapid aggravating general condition of patients, septic shock, as well as infected necrosis in radiological and bacteriological investigations, were indication to surgical intervention. The methods of surgical treatments were: laparotomy and flow drainage 73 patients, closed drainage 31 patients, repeated relaparotomy 25, Bradley's method 13. Mortality in the group of operated patients was 5.9%. The most common causes of death were: respiratory insufficiency 29.4%, multiorgan insufficiency 21.6%, circulatory insufficiency 13.8%, insufficiency of kidneys 9.8% CONCLUSIONS: The authors suggest that the most important in deciding about necessity and time of surgical intervention of haemorrhagic necrotizing acute pancreatitis are individual clinical characteristics of patients. The lowest mortality was in the group of operated patients in later period of illness and who did not required reoperation.

Ischemic preconditioning diminishes oxygen demand and increases coronary flow in the early phase of reperfusion in rat heart.

BACKGROUND: Ischemic preconditioning (IPC) can be defined as an adaptive mechanism induced by a brief period of reversible ischemia increasing the heart's resistance to a subsequent longer period of ischemia. The objective of our research was to describe the effects of IPC on the hemodynamic function and metabolism of the myocardium during postischemic reperfusion. MATERIAL/METHODS: 20 rat hearts were assigned to a preconditioning group (n=10) or to a control group (n=10). Preconditioning was achieved with 5 min. of global ischemia and 10 min. of reperfusion followed by 40 min. of ischemia. We investigated the postischemic recovery of aortic pressure, cardiac output, and coronary flow, as well as oxygen consumption, carbon dioxide release, and [H+] release. RESULTS: No significant intergroup differences in aortic pressure and cardiac output were observed during reperfusion. In both groups, increased coronary flow (greater in the IPC group: 11.4+/-0.6 ml/min. vs 9.1+/-0.5 ml/min. in control group) was observed in the early phase of reperfusion. This was accompanied by a rise in CO2 and [H+] release, which was also greater in the IPC group. Oxygen consumption was significantly lower in the IPC group in the later phase of reperfusion (9.39+/-0.53 vs 11.79+/-0.54 micromol/min/g dry weight), as were CO2 and [H+] release. CONCLUSIONS: IPC diminishes oxygen demand during reperfusion without changing the hemodynamic function considerably. IPC results in a transient increase of coronary flow accompanied by a rise in CO2 and [H+] release.