[Radical pleurectomy and hyperthermic intrathoracic chemotherapy for treatment of thymoma with pleural spread]

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.

Extracorporeal lung support in trauma patients with severe chest injury and acute lung failure: a 10-year institutional experience

Introduction

Severe trauma with concomitant chest injury is frequently associated with acute lung failure (ALF). This report summarizes our experience with extracorporeal lung support (ELS) in thoracic trauma patients treated at the University Medical Center Regensburg.

Methods

A retrospective, observational analysis of prospectively collected data (Regensburg ECMO Registry database) was performed for all consecutive trauma patients with acute pulmonary failure requiring ELS during a 10-year interval.

Results

Between April 2002 and April 2012, 52 patients (49 male, three female) with severe thoracic trauma and ALF refractory to conventional therapy required ELS. The mean age was 32 ± 14 years (range, 16 to 72 years). Major traffic accident (73%) was the most common trauma, followed by blast injury (17%), deep fall (8%) and blunt trauma (2%). The mean Injury Severity Score was 58.9 ± 10.5, the mean lung injury score was 3.3 ± 0.6 and the Sequential Organ Failure Assessment score was 10.5 ± 3. Twenty-six patients required pumpless extracorporeal lung assist (PECLA) and 26 patients required veno-venous extracorporeal membrane oxygenation (vv-ECMO) for primary post-traumatic respiratory failure. The mean time to ELS support was 5.2 ± 7.7 days (range, <24 hours to 38 days) and the mean ELS duration was 6.9 ± 3.6 days (range, <24 hours to 19 days). In 24 cases (48%) ELS implantation was performed in an external facility, and cannulation was done percutaneously by Seldinger's technique in 98% of patients. Cannula-related complications occurred in 15% of patients (PECLA, 19% (n = 5); vv-ECMO, 12% (n = 3)). Surgery was performed in 44 patients, with 16 patients under ELS prevention. Eight patients (15%) died during ELS support and three patients (6%) died after ELS weaning. The overall survival rate was 79% compared with the proposed Injury Severity Score-related mortality (59%).

Conclusion

Pumpless and pump-driven ELS systems are an excellent treatment option in severe thoracic trauma patients with ALF and facilitate survival in an experienced trauma center with an interdisciplinary treatment approach. We encourage the use of vv-ECMO due to reduced complication rates, better oxygenation and best short-term outcome.

Extended surgical resections of advanced thymoma Masaoka stages III and IVa facilitate outcome

OBJECTIVE

Extended thymoma resections including adjacent structures and pleurectomy/decortication (P/D) with hyperthermic intrathoracic chemotherapy (HITHOC) perfusion were performed in a multidisciplinary treatment regime.

PATIENTS AND METHODS

Between July 2000 and February 2012, 22 patients with Masaoka stage III (n = 9; 41%) and Masaoka stage IVa (n = 13; 59%) thymic tumors were included.

RESULTS

Mean age was 55 years (25-84 years) and 50% (11 out of 22) of patients were female. World Health Organization histological classification was as follows: B2 (n = 15), A (n = 1), B1 (n = 1), B3 (n = 2), and thymic carcinoma (C; n = 3). Radical thymectomy and partial resection of the mediastinal pleura and pericardium were performed. Of the 13, 9 patients with pleural involvement (stage IVa) received radical P/D followed by HITHOC (cisplatin). Macroscopic complete resection (R0/R1) was achieved in 19 (86%) patients. All patients received multimodality treatment depending on tumor stage, histology, and completeness of resection. Thirty-day mortality was 0% and three (13.6%) patients needed operative revision. Recurrence of thymoma was documented in five (22.7%) patients (stage III, n = 1; stage IVa, n = 4). Mean disease-free interval of patients with complete resection (n = 14 out of 22) was 30.2 months. After a mean follow-up of 29 months, 18 out of the 22 (82%) patients are alive. After P/D and HITHOC, 89% (8 out of 9 patients) are alive (current median survival is 25 months) without recurrence.

CONCLUSIONS

Extended surgical resection of advanced thymic tumors infiltrating adjacent structures (stage III) or with pleural metastases (stage IVa) is safe and feasible. It provides a low recurrence rate and an acceptable survival. Additional HITHOC in patients with pleural thymoma spread seems to offer a better local tumor control.

[Regional treatment of malignant pleural mesothelioma: results from the tumor centre Regensburg]

INTRODUCTION

Malignant pleural mesothelioma (MPM) is an aggressive, malignant tumor of the pleural surface and is strongly associated with asbestos exposure. Incidence of MPM will reach its peak over the coming years. Most patients present with advanced tumor stages and therefore surgical options are limited.

PATIENTS AND METHODS

Retrospective analysis of all patients with MPM reported to the tumor centre Regensburg between January 1998 and August 2011.

RESULTS

A total of 118 patients (85 % male) with cytologically or histologically confirmed MPM were reported. The mean age at diagnosis was 67 years (range 45-84 years) and 65 % of patients had a history of asbestos exposure. The incidence of MPM at the tumor centre Regensburg was 0.8/100,000 inhabitants with obvious regional differences depending on asbestos exposure. Staging was completed in 81 patients (67 %): stage I 9 %, stage II 22 %, stage III 23 % and stage IV 46 %. Of the patients 87 (74 %) underwent at least one surgical procedure: diagnostic thoracoscopy with biopsy (n = 37, 43 %), debulking surgery or talcum pleurodesis (n = 33, 38 %) and potentially curative resection (n = 17, 19 %). After a mean follow-up of 20 months the overall median survival was 14 months (1 year survival rate 62 %, 3 year survival rate 15 %). Patients had a significantly better median survival of 18 months after curative resection.

CONCLUSIONS

The distribution of MPM varies according to regional and industrial asbestos exposure. Screening and diagnostics should concentrate on locations with higher incidence of MPM to facilitate surgical therapy in a multimodal treatment regime.

Radiotherapy in the treatment of postoperative chylothorax

Background

Chylothorax is characterized by the presence of chyle in the pleural cavity. The healing rate of non-operative treatment varies enormously; the maximum success rate in series is 70%. We investigate the efficacy and outcomes of radiotherapy for postoperative chylothorax.

Methods

Chylothorax was identified based on the quantity and quality of the drainage fluid. Radiation was indicated if the daily chyle flow exceeded 450 ml after complete cessation of oral intake. Radiotherapy consisted of opposed isocentric portals to the mediastinum using 15 MV photon beams from a linear accelerator, a single dose of 1–1.5 Gy, and a maximum of five fractions per week. The radiation target area was the anatomical region between TH3 and TH10 depending on the localization of the resected lobe. The mean doses of the ionizing energy was 8.5 Gy ± 3.5 Gy.

Results

The median start date of the radiation was the fourth day after chylothorax diagnosis. The patients’ mediastinum was radiated an average of six times. Radiotherapy, in combination with dietary restrictions, was successful in all patients. The median time between the end of the radiation and the removal of the chest tube was one day. One patient underwent wound healing by secondary intention. The median time between the end of radiation and discharge was three days, and the overall hospital stay between the chylothorax diagnosis and discharge was 18 days (range: 11–30 days). After a follow-up of six months, no patient experienced chylothorax recurrence.

Conclusions

Our results suggest that radiotherapy in combination with dietary restriction in the treatment of postoperative chylothorax is very safe, rapid and successful. This novel interventional procedure can obviate repeat major thoracic surgery and shorten hospital stays and could be the first choice in the treatment of postthoracotomy chylothorax.

Emergency coronary artery bypass grafting using minimized versus standard extracorporeal circulation--a propensity score analysis

Background

The impact of minimized extracorporeal circulation (MECC) for emergency revascularization remains controversial.

Methods

A total of 348 patients underwent emergency CABG with MECC (n=146) or conventional extracorporeal circulation (CECC; n=175) between January 2005 and December 2010. Using propensity score matching after binary logistic regression, 100 patients, who underwent CABG with MECC could be matched with 100 patients, who underwent CABG with CECC. Primary outcome was 30-day mortality.

Results

Unadjusted 30-day mortality was 14.8% in patients with CECC and 6.9% in those with MECC (mean difference −7.9%; p=0.03). The adjusted mean difference (average treatment effect of the treated, ATT) after matching was −1.0% (95% CI −8.6 to 7.6; p=1.0). Intensive care unit stay (adjusted mean difference 1.0; 95% CI −0.2 to 3.2; p=0.70) and hospital stay (adjusted mean difference 1.0; 95% CI −2.0 to 3.6; p=0.40) did not show significant differences between both groups. The adjusted mean difference for postoperative low cardiac output syndrome was −1.1% (95% CI −7.3 to 7.1; p=0.83) without significant differences between CECC and MECC. Postoperative mechanical ventilation time, drain loss, postoperative rethoracotomy, postoperative neurological events, new onset renal replacement therapy and respiratory failure also had insignificant average treatment effects of the treated. In addition, all average treatment effects (ATEs) did not significantly differ between both groups.

Conclusion

Using propensity score estimation and matching, we did not observe significant differences in terms of survival and further outcomes in patients who undergo emergency CABG with CECC or MECC, but our results call for further analysis.

Minimally invasive vacuum-assisted closure therapy in the management of complex pleural empyema

OBJECTIVES

The pool of potential candidates for pleural empyema is expanding. In a previous technical report, we tested the feasibility of the minimally invasive insertion of a vacuum-assisted closure (Mini-VAC) system without the insertion of an open-window thoracostomy (OWT). In this study, we describe a consecutive case series of complex pleural empyemas that were managed by this Mini-VAC therapy.

METHODS

In this retrospective study, we investigated 6 patients with multimorbidity (Karnofsky index ≤ 50%) who were consecutively treated with Mini-VAC for a primary, postoperative or recurrent pleural empyema between January 2011 and February 2012.

RESULTS

Local control of the infection and control of sepsis were satisfactory in all 6 of the patients treated by Mini-VAC therapy. The suction used did not create any air leaks or bleeding from the lung or mediastinal structures. Mini-VAC therapy allowed a reduction of the empyema cavity and improved the re-expansion of the residual lung. Mini-VAC therapy resulted in a rapid eradication of the empyema. The chest wall was closed in all patients during the first hospital stay. All patients left the hospital in good health (Karnofsky index >70%) and with a non-infected pleural cavity at a mean of 22 ± 11 days after Mini-VAC installation. Pleural empyema was not detected in any of the 6 patients at the 3-month follow-up appointment.

CONCLUSIONS

The Mini-VAC procedure with the abdication of an OWT offers a rapid treatment for complex pleural empyema with minimal surgical effort and the opportunity for a primary closure of the empyema cavity.

Local and systemic exposure of cisplatin during hyperthermic intrathoracic chemotherapy perfusion after pleurectomy and decortication for treatment of pleural malignancies

BACKGROUND

Assessing the pharmacokinetics of intrapleurally administered cisplatin during hyperthermic intrathoracic chemotherapy perfusion (HITHOC) following pleurectomy/decortication in patients with malignant pleural mesothelioma or advanced thymoma with pleural spread.

METHODS

Pharmacokinetic analysis (ICP-MS) of intrapleural cisplatin with a dosage of 100 mg/m(2) (n = 5) or 150 mg/m(2) (n = 5) at 42°C perfusate temperature. Simultaneous pleural perfusion fluid and serum samples were collected at the beginning and every 15 min. Serum samples were collected at the end of the operation, 6, 12, and 24 hr postoperative.

RESULTS

Mean cisplatin levels in the perfusate slightly decreased during the HITHOC. The mean area under the curve ratios (AUC perfusate :AUC serum ) of cisplatin were nearly similar. The mean AUCs of cisplatin in the perfusate were approximately 58 and 55 times greater than detected in the serum. The mean peak of cisplatin in the serum was reached after 1 hr of HITHOC. The AUC of cisplatin in the serum did not significantly differ (P = 0.18) between both groups up to 24 hr after perfusion.

CONCLUSIONS

HITHOC with cisplatin provides a pharmacological advantage of high local intrapleural cisplatin concentrations. Elevation of the cisplatin dosage to 150 mg/m(2) did not lead to a significant increase of the systemic cisplatin concentration.

Shock or no shock - a question of philosophy or should intraoperative implantable cardioverter defibrillator testing be recommended?

OBJECTIVES

Implantation of implantable cardioverter defibrillators (ICDs) in patients with a high risk for life-threatening ventricular arrhythmias is a standard therapy. The development of new ICD leads, shock algorithms, high-energy defibrillators and rapid energy supply has improved the devices. Nevertheless, the discussion regarding 'shock or no shock' to test the system intraoperatively has not silenced yet.

METHODS

In this study, all 718 patients (60.0 ± 14.2 years old, 570 male) who were treated with a first ICD at our institution since 2005 were analysed. The indication for implantation was primarily prophylactic in 511 patients (71.3%). Underlying diseases included ischaemic cardiomyopathy (358 patients, 50%), dilated cardiomyopathy (270 patients, 37.7%) and others (12.3%). Mean ejection fraction was 27.4 ± 11.8%. Intraoperative ventricular fibrillation was induced with a T-wave shock or burst stimulation. The primary end-point was failing the initial intraoperative testing.

RESULTS

During the initial testing, 28 patients (3.9%) had a defibrillation threshold (DFT) >21 J. The mean age of these patients was 51 ± 14 years, ranging from 22 to 71 years, 20 were male, and the ejection fraction was 23.8 ± 11.8%. The indication for ICD implantation was prophylactic in 13 patients. Twenty-one of the 28 patients suffered from dilated cardiomyopathy, whereas seven patients had ischaemic cardiomyopathy. Twenty-four ICDs were implanted on the left side and four on the right side. None of the patients had been treated with amiodarone at the time of implantation. All patients achieved a sufficient DFT ≤ 21 J by changing the ICD leads, device repositioning and/or optimizing the shock configuration.

CONCLUSIONS

The standard of care intraoperative ICD testing remains necessary.

Reduced 30-day mortality in men after elective coronary artery bypass surgery with minimized extracorporeal circulation-a propensity score analysis

Background

Impact of minimized extracorporeal circulation (MECC) for coronary surgery on mortality remains controversial and gender significantly influence outcome.

Methods

We analyzed 3,139 male patients undergoing elective coronary surgery between 01/2004 and 05/2009. Using propensity score matching after binary logistic regression, 1,005 patients (from 1,119 patients) undergoing surgery with MECC could be matched with 1,005 patients (from 2,020 patients) undergoing surgery with conventional extracorporeal circulation (CECC). Primary outcome was 30-day mortality.

Results

Unadjusted 30-day mortality was 2.7% in patients with CECC and 0.8% in those with MECC (mean difference -1.9%; p < 0.001). The adjusted mean difference (average treatment effect of the treated) after matching was -1.5% (95% confidence interval (CI) -2.6 to -0.4; p = 0.006). Postoperative hospital stay was shorter in patients operated with minimized systems (adjusted mean difference -0.8 days; 95% CI -1.46 to -0.09; p = 0.03) and incidence of postoperative neurocognitive dysfunction was also lower (adjusted mean difference -1.3%; 95% CI -2.2 to -0.4; p = 0.001). Chest tube drainage (adjusted mean difference +22 mL; 95% CI -47 to 91; p = 0.5) and risk for acute kidney injury, kidney injury and failure according to RIFLE criteria (adjusted mean difference -1.0%; 95% CI -2.5 to 0.6; p = 0.24) proved to be insignificant between both groups. Apart from reduced 30-day mortality, however, average treatment effects for intensive care unit stay, postoperative hospital stay, chest tube drainage and kidney injury did not significantly differ.

Conclusion

Using propensity score analysis, we observed an association between MECC and reduced 30-day mortality in men, but our results call for further analysis.

Gender's impact on outcome in coronary surgery with minimized extracorporeal circulation

BACKGROUND

The role of female gender in cardiac surgery is still controversial. We examined the impact of gender on mortality after coronary artery bypass grafting (CABG) with minimized extracorporeal circulation (MECC).

METHODS

Between January 2004 and May 2009, 1,662 patients (439 females, 1,223 males) underwent CABG with MECC at the University Medical Center Regensburg. Perioperative data were retrospectively analyzed; primary end point was in-hospital mortality.

RESULTS

At operation, women were older, had a higher prevalence of diabetes and impaired renal function, and underwent more often non-elective surgery. Unadjusted mortality was significantly lower for men and than for women (2.3 vs. 5.7%; p = 0.001). Risk-adjusted mortality rates were derived by stepwise logistic regression. The final model reduced the gender-related mortality gap from 147 to 32%. Goodness of fit and discriminatory performance (AUC = 0.83) were good. Female gender, however, could not be identified as an independent risk factor for adverse outcome (OR 1.6; 95% CI 0.8-3.4). Risk-adjusted mortality was calculated as 4.9% in females and 2.6% in males. Low body surface area (<1.66 m(2)) was associated with excess mortality in females.

CONCLUSIONS

Gender-related disparity in outcome still remains present after surgery with minimized extracorporeal circulation. However, female gender per se is not an independent risk factor for in-hospital mortality, but close attention should be paid on modifiable risk factors.

Ventricular assist device implantation in patients on percutaneous extracorporeal life support without switching to conventional cardiopulmonary bypass system

OBJECTIVES

Ventricular assist device (VAD) implantation using cardiopulmonary bypass (CPB) is an established procedure. However, the well-described complications of CPB may exacerbate multiple organ failure and increase blood product transfusions especially in end-stage heart failure patients.

METHODS

We describe our successful experience in six consecutive patients with profound cardiogenic shock, who were provided on an emergency basis with a percutaneous extracorporeal life support (ECLS) system via the peripheral vessels. After stabilization, a VAD was implanted using ECLS without switching to a conventional CPB system to reduce its side effects. We compared the data with those of 11 patients in whom the VAD was placed with the aid of an additional CPB system.

RESULTS

The six patients demonstrated a shorter duration of operating room time compared with the patients requiring CPB for device placement. During and after surgery, blood loss and blood product transfusions were lower in these patients. The need for mechanical ventilation and inotropic support was shorter and the survival rate (100% at 30 days, 83.3% at 3 months and 83.3% at 6 months) was higher when compared with patients who were operated upon with CPB. Two patients were successfully bridged to transplantation. One patient died due to cerebral bleeding after 7 weeks.

CONCLUSIONS

Our experience suggests that VAD implantation using percutaneous ECLS without switching to conventional CPB is a safe alternative in the bridge to bridge concept, especially in high-risk patients with cardiogenic shock who would benefit from the avoidance of the adverse sequels associated with conventional CPB.