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Klotz LV, Zimmermann J, Müller K, Kovács J, Hassan M, Koller M, Schmid S, Huppertz G, Markowiak T, Passlick B, Hofmann HS, Winter H, Hatz RA, Eichhorn ME, Ried M. Multimodal Treatment of Pleural Mesothelioma with Cytoreductive Surgery and Hyperthermic Intrathoracic Chemotherapy: Impact of Additive Chemotherapy. Cancers (Basel) 2024; 16:1587. [PMID: 38672669 PMCID: PMC11048892 DOI: 10.3390/cancers16081587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/11/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Cytoreductive surgery (CRS) combined with hyperthermic intrathoracic chemoperfusion (HITOC) is a promising treatment strategy for pleural mesothelioma (PM). The aim of this study was to evaluate the impacts of this multimodal approach in combination with systemic treatment on disease-free survival (DFS) and overall survival (OS). In this retrospective multicenter study, clinical data from patients after CRS and HITOC for PM at four high-volume thoracic surgery departments in Germany were analyzed. A total of 260 patients with MPM (220 epithelioid, 40 non-epithelioid) underwent CRS and HITOC as part of a multimodal treatment approach. HITOC was administered with cisplatin alone (58.5%) or cisplatin and doxorubicin (41.5%). In addition, 52.1% of patients received neoadjuvant and/or adjuvant chemotherapy. The median follow-up was 48 months (IQR = 38 to 58 months). In-hospital mortality was 3.5%. Both the resection status (macroscopic complete vs. incomplete resection) and histologic subtype (epithelioid vs. non-epithelioid) had significant impacts on DFS and OS. In addition, adjuvant chemotherapy (neoadjuvant/adjuvant) significantly increased DFS (p = 0.003). CRS and HITOC within a multimodal treatment approach had positive impacts on the survival of patients with epithelioid PM after macroscopic complete resection. The addition of chemotherapy significantly prolonged the time to tumor recurrence or progression.
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Affiliation(s)
- Laura V. Klotz
- Department of Thoracic Surgery, Thoraxklinik, University Hospital Heidelberg, 69126 Heidelberg, Germany
- German Center for Lung Research (DZL), 69120 Heidelberg, Germany
| | - Julia Zimmermann
- Division of Thoracic Surgery, Ludwig-Maximilians-University Munich, Asklepios Lung Clinic Gauting, 82131 Gauting, Germany; (J.Z.); (J.K.)
| | - Karolina Müller
- Center for Clinical Studies, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Julia Kovács
- Division of Thoracic Surgery, Ludwig-Maximilians-University Munich, Asklepios Lung Clinic Gauting, 82131 Gauting, Germany; (J.Z.); (J.K.)
| | - Mohamed Hassan
- Department of Thoracic Surgery, University Hospital Freiburg, 79106 Freiburg im Breisgau, Germany
| | - Michael Koller
- Center for Clinical Studies, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Severin Schmid
- Department of Thoracic Surgery, University Hospital Freiburg, 79106 Freiburg im Breisgau, Germany
| | - Gunnar Huppertz
- Center for Clinical Studies, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Till Markowiak
- Department of Thoracic Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Bernward Passlick
- Department of Thoracic Surgery, University Hospital Freiburg, 79106 Freiburg im Breisgau, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
- Department of Thoracic Surgery, Barmherzige Brüder Hospital Regensburg, 93049 Regensburg, Germany
| | - Hauke Winter
- Department of Thoracic Surgery, Thoraxklinik, University Hospital Heidelberg, 69126 Heidelberg, Germany
- German Center for Lung Research (DZL), 69120 Heidelberg, Germany
| | - Rudolf A. Hatz
- German Center for Lung Research (DZL), 69120 Heidelberg, Germany
- Division of Thoracic Surgery, Ludwig-Maximilians-University Munich, Asklepios Lung Clinic Gauting, 82131 Gauting, Germany; (J.Z.); (J.K.)
| | - Martin E. Eichhorn
- Department of Thoracic Surgery, Thoraxklinik, University Hospital Heidelberg, 69126 Heidelberg, Germany
- German Center for Lung Research (DZL), 69120 Heidelberg, Germany
| | - Michael Ried
- Department of Thoracic Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
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Ried M, Pfannschmidt LM, Hofmann HS. [Scientific Activity in German Thoracic Surgery, as Measured in Publication Output]. Zentralbl Chir 2024. [PMID: 38382561 DOI: 10.1055/a-2257-9739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
Thoracic surgery in Germany is primarily provided in non-university centres with a clinical focus and less at university hospitals. The extent to which scientific activity can be achieved within these different structures is investigated on the basis of publication output.A PubMed analysis was carried out for selected authors (leader in thoracic surgery in Germany) between Jan 2012 to Dec 2021. University hospitals, DKG-certified lung cancer centres (DKG: German Cancer Society) and DGT-certified thoracic centres (DGT: German Society for Thoracic Surgery) were included.An analysis of n = 54 non-university centres (DKG certificate n = 50 and/or DGT certificate n = 22) and n = 36 university hospitals (n = 9 autonomous clinic/department) was performed. A total of n = 2414 publications were identified, with original papers (n = 1776; 74%) and publications focussing on thoracic surgery (n = 1501; 62%) being found most frequently. The publication performance of the non-university centres was n = 599 publications (11/centre) and thus significantly lower than that of the university hospitals (n = 902; 25/clinic; p ≤ 0.001). Significantly higher publication output was confirmed for autonomous (n = 560; 62/clinic) compared to non-autonomous university thoracic surgery (n = 342; 13/clinic; p = 0.003). A 10-year trend was recorded, with almost doubling of publication output from n = 105 (university: n = 63) to n = 203 (university: n = 124) publications/year. The cumulative impact factors (IF) resulted in 2845 IF (52.7 IF/clinic) for non-university centres, 6361 IF (235.6 IF/clinic) for non-autonomous and 2931 IF (325.7 IF/clinic) for autonomous university thoracic surgery.Scientific activities have increased in non-university centres, but above all in university thoracic surgery. These positive developments are in acute danger due to the upcoming political changes (Hospital Structure Act, minimum volumes). Structural changes such as independent university thoracic surgery or cooperation models with non-university centres could offer solutions.
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Affiliation(s)
- Michael Ried
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | | | - Hans-Stefan Hofmann
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
- Klinik für Thoraxchirurgie, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Deutschland
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Piler T, Creutzenberg M, Hofmann HS, Ried M. [Modern Perioperative Care Concepts in Thoracic Surgery: Enhanced Recovery After Thoracic Surgery (ERATS)]. Zentralbl Chir 2024; 149:116-122. [PMID: 35732185 DOI: 10.1055/a-1823-1207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
In modern perioperative care concepts, multimodal ERAS (Enhanced Recovery After Surgery) is a multimodal perioperative treatment concept for improving postoperative recovery of surgical patients after an operation. This is managed by the so-called ERAS Society and through which hospitals can also be officially certified. The focus of the ERAS concept is on uniform patient care from admission to discharge, with the aim of improving perioperative processes by implementing evidence-based protocols involving a multidisciplinary treatment team. In 2019, ERAS guidelines were published for the first time by the European Society of Thoracic Surgery (ESTS), in cooperation with the ERAS Society, for specific lung resection procedures, and these identified a total of 45 graduated recommendations or Enhanced Recovery Pathways (ERP). The implementation of ERAS concepts in thoracic surgery (ERATS = Enhanced Recovery After Thoracic Surgery) is intended to establish standardised perioperative procedures based on study results and/or expert recommendations. These recommendations take into account organisational aspects as well as thoracic surgical and anaesthesiological procedures, with the overriding goal of creating a structured treatment plan tailored to the patient. All these measures should result in a multimodal overall concept, which should primarily lead to an improved outcome after elective thoracic surgery and secondarily to shorter hospital stays with correspondingly lower costs.This review article describes basic ERAS principles and provides a compact presentation of the most important European ERAS recommendations from the authors' point of view, together with typical obstacles to the implementation of the corresponding ERATS program in German thoracic surgery.
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Affiliation(s)
- Tomas Piler
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Marcus Creutzenberg
- Klinik für Anästhesiologie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Hans-Stefan Hofmann
- Klinik für Thoraxchirurgie, KH Barmherzige Brüder Regensburg, Regensburg, Deutschland
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Michael Ried
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
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Treitschke S, Weidele K, Varadarajan AR, Feliciello G, Warfsmann J, Vorbeck S, Polzer B, Botteron C, Hoffmann M, Dechand V, Mederer T, Weber F, Werner-Klein M, Robold T, Hofmann HS, Werno C, Klein CA. Ex vivo expansion of lung cancer-derived disseminated cancer cells from lymph nodes identifies cells associated with metastatic progression. Int J Cancer 2023; 153:1854-1867. [PMID: 37555668 DOI: 10.1002/ijc.34658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 05/24/2023] [Accepted: 06/19/2023] [Indexed: 08/10/2023]
Abstract
The cellular basis of the apparent aggressiveness in lung cancer is poorly understood but likely associated with functional or molecular features of disseminated cancer cells (DCCs). DCCs from epithelial cancers are mostly detected by antibodies directed against histogenetic markers such as cytokeratin or EpCAM. It has been argued that marker-negative metastatic founder cells might escape detection. We therefore used ex vivo sphere formation for functional detection of candidate metastasis founders. We generated cell suspensions from 199 LN samples of 131 lung cancer patients and placed them into non-adherent cell culture. Sphere formation was associated with detection of DCCs using EpCAM immunocytology and with significantly poorer prognosis. The prognostic impact of sphere formation was strongly associated with high numbers of EpCAM-positive DCCs and aberrant genotypes of expanded spheres. We also noted sphere formation in patients with no evidence of lymphatic spread, however such spheres showed infrequent expression of signature genes associated with spheres from EpCAM-positive samples and displayed neither typical lung cancer mutations (KRAS, TP53, ERBB1) nor copy number variations, but might be linked to disease progression >5 years post curative surgery. We conclude that EpCAM identifies relevant disease-driving DCCs, that such cells can be expanded for model generation and that further research is needed to clarify the functional and prognostic role of rare EpCAM-negative sphere forming cells.
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Affiliation(s)
- Steffi Treitschke
- Fraunhofer Institute for Toxicology and Experimental Medicine, Division of Personalized Tumor Therapy, Regensburg, Germany
| | - Kathrin Weidele
- Fraunhofer Institute for Toxicology and Experimental Medicine, Division of Personalized Tumor Therapy, Regensburg, Germany
| | - Adithi Ravikumar Varadarajan
- Fraunhofer Institute for Toxicology and Experimental Medicine, Division of Personalized Tumor Therapy, Regensburg, Germany
| | - Giancarlo Feliciello
- Fraunhofer Institute for Toxicology and Experimental Medicine, Division of Personalized Tumor Therapy, Regensburg, Germany
| | - Jens Warfsmann
- Fraunhofer Institute for Toxicology and Experimental Medicine, Division of Personalized Tumor Therapy, Regensburg, Germany
| | - Sybille Vorbeck
- Fraunhofer Institute for Toxicology and Experimental Medicine, Division of Personalized Tumor Therapy, Regensburg, Germany
| | - Bernhard Polzer
- Fraunhofer Institute for Toxicology and Experimental Medicine, Division of Personalized Tumor Therapy, Regensburg, Germany
| | - Catherine Botteron
- Fraunhofer Institute for Toxicology and Experimental Medicine, Division of Personalized Tumor Therapy, Regensburg, Germany
| | - Martin Hoffmann
- Fraunhofer Institute for Toxicology and Experimental Medicine, Division of Personalized Tumor Therapy, Regensburg, Germany
| | - Vadim Dechand
- Fraunhofer Institute for Toxicology and Experimental Medicine, Division of Personalized Tumor Therapy, Regensburg, Germany
| | - Tobias Mederer
- Experimental Medicine and Therapy Research, University of Regensburg, Regensburg, Germany
| | - Florian Weber
- Fraunhofer Institute for Toxicology and Experimental Medicine, Division of Personalized Tumor Therapy, Regensburg, Germany
- Institute for Pathology, University of Regensburg, Regensburg, Germany
| | - Melanie Werner-Klein
- Experimental Medicine and Therapy Research, University of Regensburg, Regensburg, Germany
| | - Tobias Robold
- Department of Thoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Christian Werno
- Fraunhofer Institute for Toxicology and Experimental Medicine, Division of Personalized Tumor Therapy, Regensburg, Germany
| | - Christoph A Klein
- Fraunhofer Institute for Toxicology and Experimental Medicine, Division of Personalized Tumor Therapy, Regensburg, Germany
- Experimental Medicine and Therapy Research, University of Regensburg, Regensburg, Germany
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Kaltenhauser S, Niessen C, Zeman F, Stroszczynski C, Zorger N, Grosse J, Großer C, Hofmann HS, Robold T. Diagnosis of sarcopenia on thoracic computed tomography and its association with postoperative survival after anatomic lung cancer resection. Sci Rep 2023; 13:18450. [PMID: 37891259 PMCID: PMC10611729 DOI: 10.1038/s41598-023-45583-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 10/21/2023] [Indexed: 10/29/2023] Open
Abstract
Computer tomography-derived skeletal muscle index normalized for height in conjunction with muscle density enables single modality-based sarcopenia assessment that accounts for all diagnostic criteria and cutoff recommendations as per the widely accepted European consensus. Yet, the standard approach to quantify skeletal musculature at the third lumbar vertebra is limited for certain patient groups, such as lung cancer patients who receive chest CT for tumor staging that does not encompass this lumbar level. As an alternative, this retrospective study assessed sarcopenia in lung cancer patients treated with curative intent at the tenth thoracic vertebral level using appropriate cutoffs. We showed that skeletal muscle index and radiation attenuation at level T10 correlate well with those at level L3 (Pearson's R = 0.82 and 0.66, p < 0.001). During a median follow-up period of 55.7 months, sarcopenia was independently associated with worse overall (hazard ratio (HR) = 2.11, 95%-confidence interval (95%-CI) = 1.38-3.23, p < 0.001) and cancer-specific survival (HR = 2.00, 95%-CI = 1.19-3.36, p = 0.009) of lung cancer patients following anatomic resection. This study highlights feasibility to diagnose sarcopenia solely by thoracic CT in accordance with the European consensus recommendations. The straightforward methodology offers easy translation into routine clinical care and potential to improve preoperative risk stratification of lung cancer patients scheduled for surgery.
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Affiliation(s)
- Simone Kaltenhauser
- Department of Thoracic Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.
| | - Christoph Niessen
- Department of Radiology, Caritas-Krankenhaus St Josef, Regensburg, Germany
| | - Florian Zeman
- Center of Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | | | - Niels Zorger
- Department of Radiology, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Jirka Grosse
- Department of Nuclear Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Christian Großer
- Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
- Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Tobias Robold
- Department of Thoracic Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
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Larisch C, Markowiak T, Ried M, Nowak D, Hofmann HS, Rakete S. The Excretion of Cisplatin after Hyperthermic Intrathoracic Chemotherapy. Cancers (Basel) 2023; 15:4872. [PMID: 37835566 PMCID: PMC10571901 DOI: 10.3390/cancers15194872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 10/15/2023] Open
Abstract
Hyperthermic intrathoracic chemotherapy (HITOC) is an additional intraoperative treatment option within the multimodality therapy of pleural malignancies. A chemotherapy perfusion with high-dose cisplatin is performed over a period of 60 min after surgical cytoreduction to improve local tumour control through the eradication of residual tumour cells. Although HITOC is increasingly used, there is only little scientific evidence about the necessary safety measures after HITOC. Therefore, the objective of this study was an analysis of cisplatin excretion via various body fluids after HITOC, with the aim of providing recommendations on occupational health and safety. Five patients undergoing HITOC were included. Before and after the HITOC, as well as during the following days, serum, urine, and bronchial secretion, as well as pleural effusion, were sampled. The platinum levels in the samples were measured using ICP-MS (inductively coupled plasma-mass spectrometry). Immediately after the HITOC, the mean levels of cisplatin increased dramatically in the serum (from 0.79 to 1349 µg/L), urine (from 3.48 to 10,528 µg/g creatinine), and bronchial secretion (from 0.11 to 156 µg/L). Thereafter, the cisplatin levels dropped to 133 µg/L in the serum and 994 µg/g creatinine in the urine within nine days after the HITOC. The AUC ratio shows 59% of the cisplatin being excreted via the urine after 48 h. The sampling of pleural effusion started 24 h after the HITOC, and the cisplatin levels decreased from 618 to 93 µg/L within nine days. Although the cisplatin levels in the body fluids of HITOC patients are much lower compared to patients receiving intravenous chemotherapy, a significant amount of cisplatin is excreted via these body fluids. Consequently, safety precautions must be implemented in the post-HITOC care of patients to avoid occupational exposure to cisplatin.
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Affiliation(s)
- Christopher Larisch
- Department of Thoracic Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Till Markowiak
- Department of Thoracic Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Michael Ried
- Department of Thoracic Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Dennis Nowak
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, 80539 Munich, Germany
- Comprehensive Pneumology Center Munich, German Center for Lung Research, 81377 Munich, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
- Department of Thoracic Surgery, Hospital Barmherzige Brueder, 93047 Regensburg, Germany
| | - Stefan Rakete
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, 80539 Munich, Germany
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Seebauer CT, Völkl M, Kunkel J, Künzel J, Kühnel T, Hofmann HS, Bohr C. Tracheoesophageal Fistula Closure in a Pediatric Patient Using a Supraclavicular Artery Island Flap. Plast Reconstr Surg Glob Open 2023; 11:e5250. [PMID: 37744771 PMCID: PMC10513133 DOI: 10.1097/gox.0000000000005250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/20/2023] [Indexed: 09/26/2023]
Abstract
Acquired tracheoesophageal fistulas can lead to large defects with fatal complications. Surgical management is challenging but necessary to prevent respiratory infections and poor weight gain. Therefore, a reliable and pliable flap like the pedicled supraclavicular artery island flap with its wide arc of rotation and robust vascularization is needed for reconstruction. We highlight the surgical technique and postoperative measures in managing a tracheoesophageal fistula due to button battery ingestion in a 9-month-old boy with the supraclavicular artery island flap. In summary, the supraclavicular artery island flap is a safe and successful tool for closure of large acquired tracheoesophageal fistulas in pediatric patients.
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Affiliation(s)
- Caroline T. Seebauer
- From the Department of Otorhinolaryngology, University Medical Center Regensburg, Regensburg, Germany
| | - Melanie Völkl
- Department of Pediatrics, University Medical Center Regensburg, Regensburg, Germany
| | - Jürgen Kunkel
- Department of Pediatrics, University Medical Center Regensburg, Regensburg, Germany
| | - Julian Künzel
- From the Department of Otorhinolaryngology, University Medical Center Regensburg, Regensburg, Germany
| | - Thomas Kühnel
- From the Department of Otorhinolaryngology, University Medical Center Regensburg, Regensburg, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Christopher Bohr
- From the Department of Otorhinolaryngology, University Medical Center Regensburg, Regensburg, Germany
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Hofmann HS. [Robotic-assisted Thoracic Surgery: Currently Available Standard Systems and Future Developments]. Zentralbl Chir 2023; 148:S11-S16. [PMID: 36167312 DOI: 10.1055/a-1844-0434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
The trend towards performing robotic-assisted operations in thoracic surgery has been increasing in the last decade. The well-known advantages of video-assisted thoracic surgery (VATS) in comparison to the open approach are also valid for robotic surgery, with the addition of a 3D-view camera, wristed instrumentation, and an ergonomic console. The application of robotic technology to thoracic surgical procedures has been shown to be safe and possibly with equivalent oncological outcomes. The Da Vinci Surgical System became the first robotic surgical platform that was commercially available. Several other robotic systems have entered the market in recent years. The current robot systems differ in structure and application.The aim of this review is to describe the current systems in robotic-assisted thoracic surgery (RATS), as well as future developments in RATS.
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Affiliation(s)
- Hans-Stefan Hofmann
- Universitätsklinikum Regensburg, Abteilung Thoraxchirurgie, Regensburg, Germany
- KH Barmherzige Brüder Regensburg, Klinik für Thoraxchirurgie, Regensburg, Germany
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Schauer MI, Jung EM, Platz Batista da Silva N, Akers M, Loch E, Markowiak T, Piler T, Larisch C, Neu R, Stroszczynski C, Hofmann HS, Ried M. Intraoperative Contrast-Enhanced Ultrasonography (Io-CEUS) in Minimally Invasive Thoracic Surgery for Characterization of Pulmonary Tumours: A Clinical Feasibility Study. Cancers (Basel) 2023; 15:3854. [PMID: 37568670 PMCID: PMC10417103 DOI: 10.3390/cancers15153854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/19/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND The intraoperative detection of solitary pulmonary nodules (SPNs) continues to be a major challenge, especially in minimally invasive video-assisted thoracic surgery (VATS). The location, size, and intraoperative frozen section result of SPNs are decisive regarding the extent of lung resection. This feasibility study investigates the technical applicability of intraoperative contrast-enhanced ultrasonography (Io-CEUS) in minimally invasive thoracic surgery. METHODS In this prospective, monocentric clinical feasibility study, n = 30 patients who underwent Io-CEUS during elective minimally invasive lung resection for SPNs between October 2021 and February 2023. The primary endpoint was the technical feasibility of Io-CEUS during VATS. Secondary endpoints were defined as the detection and characterization of SPNs. RESULTS In all patients (female, n = 13; mean age, 63 ± 8.6 years) Io-CEUS could be performed without problems during VATS. All SPNs were detected by Io-CEUS (100%). SPNs had a mean size of 2.2 cm (0.5-4.5 cm) and a mean distance to the lung surface of 2.0 cm (0-6.4 cm). B-mode, colour-coded Doppler sonography, and contrast-enhanced ultrasound were used to characterize all tumours intraoperatively. Significant differences were found, especially in vascularization as well as in contrast agent behaviour, depending on the tumour entity. After successful lung resection, a pathologic examination confirmed the presence of lung carcinomas (n = 17), lung metastases (n = 10), and benign lung tumours (n = 3). CONCLUSIONS The technical feasibility of Io-CEUS was confirmed in VATS before resection regarding the detection of suspicious SPNs. In particular, the use of Doppler sonography and contrast agent kinetics revealed intraoperative specific aspects depending on the tumour entity. Further studies on Io-CEUS and the application of an endoscopic probe for VATS will follow.
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Affiliation(s)
- Martin Ignaz Schauer
- Department of Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany (T.P.); (C.L.); (H.-S.H.); (M.R.)
| | - Ernst-Michael Jung
- Institute for Radiology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany; (N.P.B.d.S.); (M.A.); (C.S.)
| | - Natascha Platz Batista da Silva
- Institute for Radiology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany; (N.P.B.d.S.); (M.A.); (C.S.)
| | - Michael Akers
- Institute for Radiology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany; (N.P.B.d.S.); (M.A.); (C.S.)
| | - Elena Loch
- Department of Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany (T.P.); (C.L.); (H.-S.H.); (M.R.)
| | - Till Markowiak
- Department of Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany (T.P.); (C.L.); (H.-S.H.); (M.R.)
| | - Tomas Piler
- Department of Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany (T.P.); (C.L.); (H.-S.H.); (M.R.)
| | - Christopher Larisch
- Department of Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany (T.P.); (C.L.); (H.-S.H.); (M.R.)
| | - Reiner Neu
- Department of Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany (T.P.); (C.L.); (H.-S.H.); (M.R.)
| | - Christian Stroszczynski
- Institute for Radiology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany; (N.P.B.d.S.); (M.A.); (C.S.)
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany (T.P.); (C.L.); (H.-S.H.); (M.R.)
| | - Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany (T.P.); (C.L.); (H.-S.H.); (M.R.)
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10
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Ried M, Hassan M, Passlick B, Schmid S, Markowiak T, Müller K, Huppertz G, Koller M, Winter H, Klotz LV, Hatz R, Kovács J, Zimmermann J, Hofmann HS, Eichhorn ME. Surgical cytoreduction and hyperthermic intrathoracic chemotherapy for thymic tumours with pleural spread is effective on survival: results from the multicentre German HITOC-study. Interdiscip Cardiovasc Thorac Surg 2023:7034105. [PMID: 37192006 DOI: 10.1093/icvts/ivad032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/01/2022] [Accepted: 02/09/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVES Cytoreductive surgery and hyperthermic intrathoracic chemotherapy (HITOC) is effective on survival for patients with pleural metastatic thymic tumours. METHODS Multicentre, retrospective analysis of patients with stage IVa thymic tumours treated with surgical resection and HITOC. Primary end-point was overall survival, secondary end-points were recurrence-/progression-free survival and morbidity/mortality. RESULTS A total of n = 58 patients (thymoma n = 42, thymic carcinoma n = 15, atypical carcinoid of the thymus n = 1) were included, who had primary pleural metastases (n = 50; 86%) or pleural recurrence (n = 8; 14%). Lung-preserving resection (n = 56; 97%) was the preferred approach. Macroscopically complete tumour resection was achieved in n = 49 patients (85%). HITOC was performed with cisplatin alone (n = 38; 66%) or in combination with doxorubicin (n = 20; 34%). Almost half of the patients (n = 28; 48%) received high-dose cisplatin > 125 mg/m2 body surface area. Surgical revision was required in eight (14%) patients. In-hospital mortality rate was 2%. During follow-up tumour recurrence/progression was evident in n = 31 (53%) patients. Median follow-up time was 59 months. The 1-, 3-, and 5-year survival rates were 95%, 83%, and 77%, respectively. Recurrence/progression free survival rates were 89%, 54%, and 44%, respectively. Patients with thymoma had significantly better survival compared to patients with thymic carcinoma (p-value ≤0.001). CONCLUSIONS Promising survival rates in patients with pleural metastatic stage IVa in thymoma (94%) and even in thymic carcinoma (41%) were achieved. Surgical resection and HITOC is safe and effective for treatment of patients with pleural metastatic thymic tumours stage IVa. CLINICAL REGISTRATION NUMBER DRKS-ID DRKS00015012.
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Affiliation(s)
- Michael Ried
- Department of Thoracic Surgery, University Hospital Regensburg, Germany
| | - Mohamed Hassan
- Department of Thoracic Surgery, Medical Center-, University of Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Germany
| | - Bernward Passlick
- Department of Thoracic Surgery, Medical Center-, University of Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Germany
| | - Severin Schmid
- Department of Thoracic Surgery, Medical Center-, University of Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Germany
| | - Till Markowiak
- Department of Thoracic Surgery, University Hospital Regensburg, Germany
| | - Karolina Müller
- Center for Clinical Studies, University Hospital Regensburg, Germany
| | - Gunnar Huppertz
- Center for Clinical Studies, University Hospital Regensburg, Germany
| | - Michael Koller
- Center for Clinical Studies, University Hospital Regensburg, Germany
| | - Hauke Winter
- Department of Thoracic Surgery, Thoraxklinik, University Hospital Heidelberg, Germany
- Translational Lung Research Center (TLRC) Heidelberg, Germany, Member of the German Center for Lung Research (DZL)
| | - Laura V Klotz
- Department of Thoracic Surgery, Thoraxklinik, University Hospital Heidelberg, Germany
- Translational Lung Research Center (TLRC) Heidelberg, Germany, Member of the German Center for Lung Research (DZL)
| | - Rudolf Hatz
- Department of Thoracic Surgery, Ludwig-Maximilians-University of Munich and Asklepios Lung Clinic Gauting, Germany
| | - Julia Kovács
- Department of Thoracic Surgery, Ludwig-Maximilians-University of Munich and Asklepios Lung Clinic Gauting, Germany
| | - Julia Zimmermann
- Department of Thoracic Surgery, Ludwig-Maximilians-University of Munich and Asklepios Lung Clinic Gauting, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Hospital Regensburg, Germany
- Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Germany
| | - Martin E Eichhorn
- Department of Thoracic Surgery, Thoraxklinik, University Hospital Heidelberg, Germany
- Translational Lung Research Center (TLRC) Heidelberg, Germany, Member of the German Center for Lung Research (DZL)
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11
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Schauer MI, Jung EM, Hofmann HS, Ried M. Intraoperative ultrasound in minimally invasive thoracic surgery for the detection of pulmonary tumors: First intrathoracic application of TE9 and laparoscopic probe Lap 13-4cs (Mindray). Clin Hemorheol Microcirc 2023; 85:87-92. [PMID: 37599526 DOI: 10.3233/ch-231718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
AIM To apply intraoperative ultrasound (IO-US) for the first time using a laparascopic probe to detect malignancy-susceptible solitary pulmonary nodules (SPN) and assess macrovascularization using color-coded doppler sonography or power doppler. Description of technical feasibility. METHODS Technical description on intrathoracic endoscopic ultrasound. A positive ethics vote from the local ethics committee and written patient consent were available. Intraoperative ultrasound was performed using a laparascopic probe (Lap 13-4cs, Mindray) on the T9 ultrasound machine (Mindray, China). B-scan was used to detect the SPN. Color-coded doppler sonography (CCS) and power doppler were used to assess macrovascularization. Primary end point was the description of the technical performance of the Io-US. Secondary endpoints were the functions of Io-US in characterizing SPN. RESULTS Io-US was successfully applied using (n = 2) cases in video-assisted thoracic surgery. All SPN were successfully detected intraoperatively with the intrathoracically placed laparascopy probe using B-mode and examined using CCS or power Doppler (100%). Resection was sonography-guided with marking of the tumor area in all cases without complications. Histological workup revealed malignancy in both cases. CONCLUSION Intrathoracic application of laparascopically guided Io-US was technically feasible. In addition to B-mode detection, Io-US using power doppler and color-coded doppler sonography provided initial evidence for characterization of SPN based on macrovascularization.
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Affiliation(s)
- Martin Ignaz Schauer
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Ernst Michael Jung
- Institute for Radiology, University Medical Center Regensburg, Regensburg, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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Hofmann HS, M. Scheule A, Markowiak T, Ried M. The Treatment of Malignant Pleural Effusion With Permanent Indwelling Pleural Catheters. Dtsch Arztebl Int 2022; 119:595-600. [PMID: 35734918 PMCID: PMC9749840 DOI: 10.3238/arztebl.m2022.0229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/07/2022] [Accepted: 05/10/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND 40 000 to 60 000 people develop malignant pleural effusion (MPE) in Germany each year. The most common causes are lung cancer and breast cancer. Patients with pleural carcinomatosis have a median survival time of four months. METHODS We investigated the current health services situation regarding treatment with indwelling pleural catheters (IPC) versus talc pleurodesis (TP) in Germany based on registry data from the Federal Statistical Office, the Pleural Tumor Registry of the German Society for Thoracic Surgery, and the IPC registry of the ewimed GmbH company. In addition, we conducted a selective literature review on IPC and TP. RESULTS The symptoms of dyspnea and thoracic pressure determine the need for therapy in MPE. Both TP and IPC are effective treatment options for MPE. Both therapeutic procedures are considered equally effective with respect to the relief of dyspnea, post-interventional quality of life, and complication rates. TP yields a higher rate of successful pleurodesis than IPC (relative risk: 1.56; 95% confidence interval: [1.26; 1.92]; p < 0.0001), while patients who receive an IPC stay in the hospital for a shorter time than those who undergo TP (a difference of slightly more than two days). The survival of patients with MPE is not affected by which of the two local therapeutic procedures is chosen. CONCLUSION The indication for either IPC or TP needs to be determined individually for each patient on the basis of his or her general condition, symptoms, clinical situation ("trapped lung"), and prognosis.
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Affiliation(s)
- Hans-Stefan Hofmann
- University Hospital Regensburg, Department of Thoracic Surgery,*Department for Thoracic Surgery University Hospital of Regensburg Franz-Josef-Strauss-Allee 11 93053 Regensburg
| | | | - Till Markowiak
- University Hospital Regensburg, Department of Thoracic Surgery
| | - Michael Ried
- University Hospital Regensburg, Department of Thoracic Surgery
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Rathberger K, Ried M, Hofmann HS. [Case-based learning in thoracic surgery : A comparison between online and face-to-face teaching]. Chirurgie (Heidelb) 2022; 93:870-875. [PMID: 35362738 PMCID: PMC8973651 DOI: 10.1007/s00104-022-01626-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 10/27/2022]
Abstract
BACKGROUND In modern medical education, traditional face-to-face teaching is increasingly being supplemented by innovative teaching methods, such as case-based learning or e‑learning. AIM OF THE WORK Design and evaluation of a new course concept in thoracic surgery to motivate students and at the same time find ways to relieve the medical staff in their teaching activities. MATERIAL AND METHODS All students of the third clinical semester at the University of Regensburg completed a case-based course on the topic of pulmonary nodules in the summer semester 2016 and winter semester 2016/2017 as part of the practical course in thoracic surgery. This involved a moderated face-to-face seminar for one group of students and a purely online event for the other group. The knowledge gain and the subjective learning experience of the students were evaluated via questionnaires. RESULTS A total of 190 students took part in the courses, 88 in the face-to-face course and 102 in the online course. Although both groups recorded a significant increase in knowledge as a result of the course intervention, the students in the face-to-face course showed significantly higher subjective satisfaction compared to their peers in the online course. CONCLUSION Case-based learning was shown to be a promising concept in thoracic surgery education, although establishing online learning procedures proved to be more challenging than presence-based teaching.
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Affiliation(s)
- Katharina Rathberger
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
| | - Michael Ried
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Hans-Stefan Hofmann
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
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14
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Ried M, Walles T, Hofmann HS. Entwicklung der akademischen Thoraxchirurgie in Deutschland. Zentralbl Chir 2022. [DOI: 10.1055/a-1857-5902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
ZusammenfassungDie Thoraxchirurgie ist in Deutschland vornehmlich an außeruniversitären thoraxchirurgischen Kliniken abgebildet und nur an verhältnismäßig wenigen Universitätskliniken klinisch als
eigenständige Abteilung oder Klinik und wissenschaftlich als W2- oder W3-Professur etabliert. Infolgedessen ist die Gewinnung von fachärztlichem Nachwuchs und insbesondere die
Generierung von akademisch tätigen Thoraxchirurgen als Kontaktpersonen für Forschende aus den unterschiedlichen Bereichen der Lebens- und Ingenieurwissenschaften sowie für die
Weiterentwicklung des Fachgebiets Thoraxchirurgie deutlich schwieriger als in anderen chirurgischen Fächern. In den medizinischen Fakultäten stehen die Lehre, Forschung und
Patientenversorgung gleichberechtigt nebeneinander. Für die Übernahme dieser Aufgaben durch Thoraxchirurgen werden Konzepte zum Ausbau und der Förderung der akademischen
Thoraxchirurgie in der deutschen Hochschulmedizin benötigt. Ein strukturiertes Curriculum Akademische Thoraxchirurgie kann zusätzlich zu Mentorenprogrammen, Fördermöglichkeiten und
zusätzlichen Freiräumen für die Forschung bzw. Lehre die akademische Karriere in der Thoraxchirurgie unterstützen.
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Affiliation(s)
- Michael Ried
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Thorsten Walles
- Klinik für Herz- und Thoraxchirurgie, Abteilung Thoraxchirurgie, Otto-von-Guericke-Universität Magdeburg Medizinische Fakultät, Magdeburg,
Deutschland
| | - Hans-Stefan Hofmann
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
- KH Barmehrzige Brüder Regensburg, Klinik für Thoraxchirurgie, Regensburg, Deutschland
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Hoenicka M, Sabau M, Liebold A, Hofmann HS, Ried M. Preservation of Adrenoceptor and Endothelin Receptor Mediated Vasoconstriction and of Endothelium-Dependent Relaxation after Cold Storage of Explanted Blood Vessels for ex vivo Analyses. J Vasc Res 2022; 59:303-313. [PMID: 35728582 DOI: 10.1159/000524922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/28/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Adrenoceptor and endothelin (ET) receptor-mediated vasoconstriction as well as endothelium-dependent vasodilation of human saphenous veins were compared before and after 20 h of cold storage. METHODS Contractile responses to potassium chloride (KCl), norepinephrine (NE), and ET-1 as well as vasodilator responses to acetylcholine (ACh) were evaluated. RESULTS Storage in HEPES-supplemented Dulbecco's modified Eagle's medium (HDMEM) diminished KCl induced contractile forces to 71% (p = 0.002) and NE induced contractions to 80% (p = 0.037), in contrast to HEPES-supplemented Krebs-Henseleit solution (HKH) and TiProtec solution. KCl-normalized NE contractions were not affected by storage. NE EC50 values were slightly lower (7.1E-8 vs. 7.5E-8, p = 0.019) after storage in HKH, with no changes after storage in the other solutions. Endothelium-dependent responses to ACh were not affected by storage. ET-1 induced contractions were attenuated after storage in HDMEM (77%, p = 0.002), HKH (75%, p = 0.020), and TiProtec (73%, p = 0.010) with no changes in normalized constrictions. ET-1 EC50 values were not affected by storage. CONCLUSION Loss of contractility after storage in HDMEM may reflect the lower content of dextrose. There was no specific attenuation of adrenoceptor, ET-receptor, or ACh receptor mediated signal transduction after storage in any of the media. HKH or TiProtec are equally suitable cold storage solutions for ex vivo measurements.
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Affiliation(s)
- Markus Hoenicka
- Department of Cardiothoracic and Vascular Surgery, Ulm University Medical Center, Ulm, Germany
| | - Marius Sabau
- Department of Cardiothoracic and Vascular Surgery, Ulm University Medical Center, Ulm, Germany
| | - Andreas Liebold
- Department of Cardiothoracic and Vascular Surgery, Ulm University Medical Center, Ulm, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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Markowiak T, Ried M, Großer C, Hofmann HS, Hillejan L, Hecker E, Semik M, Lesser T, Kugler C, Seifert S, Scheubel R. Postoperative outcome after palliative treatment of malignant pleural effusion. Thorac Cancer 2022; 13:2158-2163. [PMID: 35748347 PMCID: PMC9346186 DOI: 10.1111/1759-7714.14534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/23/2022] [Accepted: 05/25/2022] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND The objective of this nationwide, registry-based study was to compare the two most frequently used procedures for the palliative treatment of a malignant pleural effusion (MPE) and to evaluate differentiated indications for these two procedures. METHODS This was a retrospective observational study based on data of the "PLEURATUMOR" registry of the German Society for Thoracic Surgery. Patients who were documented in the period from January 2015 to November 2021 and had video-assisted thoracic surgery (VATS) talc pleurodesis or implantation of an indwelling pleural catheter (IPC) were included. RESULTS A total of 543 patients were evaluated. The majority suffered from secondary pleural carcinomatosis (n = 402; 74%). VATS talc pleurodesis (n = 361; 66.5%) was performed about twice as often as IPC implantation (n = 182; 33.5%). The duration of surgery was significantly shorter in IPC-patients with 30 min compared to VATS talc pleurodesis (38 min; p = 0.000). Postoperative complication rate was 11.8% overall and slightly higher after VATS talc pleurodesis (n = 49; 13.6%) than after IPC implantation (n = 15; 8.2%). After VATS talc pleurodesis patients were hospitalized significantly longer compared to the IPC group (6 vs. 3.5 days; p = 0.000). There was no significant difference in postoperative wound infections between the groups (p = 0.10). The 30-day mortality was 7.9% (n = 41). CONCLUSION The implantation of an IPC can significantly shorten the duration of surgery and the hospital stay. For this reason, the procedure should be matched with the patient's expectations preoperatively and the use of an IPC should be considered not only in the case of a trapped lung.
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Affiliation(s)
- Till Markowiak
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Christian Großer
- Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.,Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Ludger Hillejan
- Department of Thoracic Surgery, Niels-Stensen-Kliniken, Ostercappeln, Germany
| | - Erich Hecker
- Department of Thoracic Surgery, Thoraxzentrum Ruhrgebiet, Academic Hospital, University Duisburg-Essen, Herne, Germany
| | - Michael Semik
- Department of Thoracic Surgery, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Thomas Lesser
- Department of Thoracic and Vascular Surgery, Lung Cancer Center DKG, SRH Wald-Klinikum Gera, Gera, Germany
| | | | - Sven Seifert
- Department of Thorax, Vascular and Endovascular Surgery, Chemnitz Hospital, Chemnitz, Germany
| | - Robert Scheubel
- Clinic of Thoracic Surgery, Waldburg-Zeil Clinic, Wangen im Allgäu, Germany
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Markowiak T, Ried M, Larisch C, Nowak D, Hofmann HS, Rakete S. Exposure to cisplatin in the operating room during hyperthermic intrathoracic chemotherapy. Int Arch Occup Environ Health 2022; 95:399-407. [PMID: 34191089 PMCID: PMC8795016 DOI: 10.1007/s00420-021-01738-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/15/2021] [Indexed: 11/04/2022]
Abstract
PURPOSE Hyperthermic intrathoracic chemotherapy (HITOC) is an additive, intraoperative treatment for selected malignant pleural tumors. To improve local tumor control, the thoracic cavity is perfused with a cisplatin-containing solution after surgical cytoreduction. Since cisplatin is probably carcinogenic to humans, potential contamination of surfaces and pathways of exposure should be systematically investigated to enable risk assessments for medical staff and thus derive specific recommendations for occupational safety. METHODS Wipe sampling was performed at pre-selected locations during and after ten HITOC procedures, including on the surgeon's gloves, for the quantitation of surface contaminations with cisplatin. After extraction of the samples with hydrochloric acid, platinum was determined as a marker for cisplatin by voltammetry. RESULTS High median concentrations of cytostatic drugs were detected on the surgeons' (1.73 pg Cis-Pt/cm2, IQR: 9.36 pg Cis-Pt/cm2) and perfusionists' (0.69 pg Cis-Pt/cm2, IQR: 1.73 pg Cis-Pt/cm2) gloves. The display of the perfusion device showed partially elevated levels of cisplatin up to 4.92 pg Cis-Pt/cm2 and thus could represent an origin of cross-contamination. In contrast, cisplatin levels on the floor surfaces in the area of the surgeon and the perfusion device or in the endobronchial tube were relatively low. CONCLUSION With a correct use of personal protective equipment and careful handling, intraoperative HITOC appears to be safe to perform with a low risk of occupational exposure to cisplatin.
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Affiliation(s)
- Till Markowiak
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.
| | - Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Christopher Larisch
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Dennis Nowak
- Germany and Comprehensive Pneumology Center Munich, University Hospital, LMU Munich, Institute and Clinic for Occupational, Social and Environmental Medicine, Munich, Germany
- Comprehensive Pneumology Center Munich, German Center for Lung Research, Munich, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
- Department of Thoracic Surgery, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Stefan Rakete
- Germany and Comprehensive Pneumology Center Munich, University Hospital, LMU Munich, Institute and Clinic for Occupational, Social and Environmental Medicine, Munich, Germany
- Comprehensive Pneumology Center Munich, German Center for Lung Research, Munich, Germany
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Mederer T, Elsner F, Robold T, Großer C, Neu R, Ried M, Bleicher S, Schamberger T, Blochberger I, Hofmann HS, Klein CA. EpCAM-positive disseminated cancer cells in bone marrow impact on survival of early-stage NSCLC patients. Lung Cancer 2022; 167:73-77. [DOI: 10.1016/j.lungcan.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/15/2022] [Accepted: 02/18/2022] [Indexed: 10/19/2022]
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Markowiak T, Ansari MKA, Neu R, Schalke B, Marx A, Hofmann HS, Ried M. Evaluation of Surgical Therapy in Advanced Thymic Tumors. Cancers (Basel) 2021; 13:cancers13184516. [PMID: 34572742 PMCID: PMC8471625 DOI: 10.3390/cancers13184516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/01/2021] [Accepted: 09/05/2021] [Indexed: 11/16/2022] Open
Abstract
A complete resection of thymic tumors is known to be the most important prognostic factor, but it is often difficult to perform, especially in advanced stages. In this study, 73 patients with advanced thymic tumors of UICC stages III and IV who underwent radical resection were examined retrospectively. The primary endpoint was defined as the postoperative resection status. Secondary endpoints included postoperative morbidity, mortality, recurrence/progression-free, and overall survival. In total, 31.5% of patients were assigned to stage IIIa, 9.6% to stage IIIb, 47.9% to stage IVa, and 11% to stage IVb. In stages III a R0 resection was achieved in 53.3% of patients. In stages IV a R0/R1 resection was documented in 76.7% of patients. Surgical revision was necessary in 17.8% of patients. In-hospital mortality was 2.7%. Median recurrence/progression-free interval was 43 months (p = 0.19) with an overall survival of 79 months. The 5-year survival rate was 61.3%, respectively. Median survival after R2 resection was 25 months, significantly shorter than after R0 or R1 resection (115 months; p = 0.004). Advanced thymic tumors can be resected with an acceptable risk of complications and low mortality. In stage III as well as in stage IV the promising survival rates are dependent on the resection-status.
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Affiliation(s)
- Till Markowiak
- Department of Thoracic Surgery, University Medical Center Regensburg, 93053 Regensburg, Germany; (T.M.); (M.K.A.A.); (R.N.); (H.-S.H.)
| | - Mohammed Khalid Afeen Ansari
- Department of Thoracic Surgery, University Medical Center Regensburg, 93053 Regensburg, Germany; (T.M.); (M.K.A.A.); (R.N.); (H.-S.H.)
| | - Reiner Neu
- Department of Thoracic Surgery, University Medical Center Regensburg, 93053 Regensburg, Germany; (T.M.); (M.K.A.A.); (R.N.); (H.-S.H.)
| | - Berthold Schalke
- Department of Neurology, University Medical Center Regensburg, 93053 Regensburg, Germany;
| | - Alexander Marx
- Institute of Pathology, University Medical Center Mannheim, University of Heidelberg, 68167 Mannheim, Germany;
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, 93053 Regensburg, Germany; (T.M.); (M.K.A.A.); (R.N.); (H.-S.H.)
- Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, 93049 Regensburg, Germany
| | - Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, 93053 Regensburg, Germany; (T.M.); (M.K.A.A.); (R.N.); (H.-S.H.)
- Correspondence: ; Tel.: +49-941-944-9801
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20
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Ried M, Schmid S, Fischer S, Hohenberger P, Neudecker J, Spillner J, Hofmann HS, Walles T. Nachwuchsakademie der DGT: Förderung von Forschungsnachwuchs in der Thoraxchirurgie. Zentralbl Chir 2021; 146:318. [PMID: 34154017 DOI: 10.1055/s-0037-1599669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Michael Ried
- Universitätsklinikum Regensburg, Abteilung für Thoraxchirurgie
| | - Severin Schmid
- Universitätsklinikum Freiburg, Klinik für Thoraxchirurgie
| | - Stefan Fischer
- Klinikum Ibbenbüren, Klinik für Thoraxchirurgie und Lungenunterstützung
| | - Peter Hohenberger
- Universitätsmedizin Mannheim, Chirurgische Klinik, Spezielle chirurgische Onkologie und Thoraxchirurgie
| | | | - Jan Spillner
- Uniklinik RWTH Aachen, Klinik für Thorax-, Herz- und Gefäßchirurgie, Sektion Thoraxchirurgie und thorakale Organunterstützung
| | | | - Thorsten Walles
- Universitätsmedizin Magdeburg, Klinik für Herz- und Thoraxchirurgie
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Larisch C, Markowiak T, Loch E, Großer C, Bednarski PJ, Mueller K, Hofmann HS, Ried M. Assessment of concentration and penetration depth of cisplatin in human lung tissue after decortication and hyperthermic exposure. Ann Transl Med 2021; 9:953. [PMID: 34350268 PMCID: PMC8263868 DOI: 10.21037/atm-20-6307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 03/08/2021] [Indexed: 12/13/2022]
Abstract
Background Hyperthermic perfusion of the pleural cavity with cisplatin after pleurectomy/decortication is an additional therapeutic option to reduce local relapse of malignant pleural tumours. Although there are data on the clinical effect, only little is known about the local impact on human lung tissue by cisplatin. The objective of this experimental study is to evaluate both the concentration and the penetration depth of cisplatin in human lung tissue after normothermic and hyperthermic exposure under ex-vivo-in-vitro conditions. Methods This study was approved by the local ethics committee. In total, 46 patients underwent elective lobectomy and wedge resections were taken from the resected lobes. A decortication of the visceral pleura was performed under ex-vivo conditions, and the tissue samples were incubated with cisplatin (c =0.05 mg/mL) at 37, 42 or 45 °C for 60 minutes. Then the mass concentration of platinum was measured with flameless atomic absorption spectroscopy and then converted into cisplatin concentration. In addition, the current data were compared with previous data of our working group (42 °C, without decortication). Results The overall maximum penetration depth was 7.5 mm due to limitations of our methods. The functional maximum penetration depth did not vary with temperature (P=0.243) but by decortication (P<0.001). The cisplatin concentration decreased with increasing penetration depth (P<0.001). An increase of temperature showed no effect on the cisplatin concentration in decorticated tissue samples (P=0.985). However, decortication at 42 °C significantly increased the cisplatin concentration in comparison to not decorticated tissue samples (P=0.005). Conclusions Decortication of the visceral pleura increases the cisplatin concentration in the lung tissue. Therefore, it possibly reduces the likelihood of a local relapse. An increase of temperature did not show any effect.
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Affiliation(s)
- Christopher Larisch
- Department for Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Till Markowiak
- Department for Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Elena Loch
- Department for Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Christian Großer
- Department for Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Prüfeninger Str. 86, 93049 Regensburg, Germany
| | - Patrick J Bednarski
- Institute of Pharmacy, University of Greifswald, Friedrich-Ludwig-Jahnstrasse 17, 17489 Greifswald, Germany
| | - Karolina Mueller
- Center for Clinical Studies, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Hans-Stefan Hofmann
- Department for Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany.,Department for Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Prüfeninger Str. 86, 93049 Regensburg, Germany
| | - Michael Ried
- Department for Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
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22
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Markowiak T, Larisch C, Hofmann HS, Ried M. Hyperthermic intrathoracic chemotherapy (HITHOC): narrative review of the current literature, recommendations and future studies. Ann Transl Med 2021; 9:955. [PMID: 34350270 PMCID: PMC8263861 DOI: 10.21037/atm-20-5444] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 02/05/2021] [Indexed: 11/10/2022]
Abstract
Although the method of hyperthermic intrathoracic chemotherapy (HITHOC) after cytoreductive surgery is known for more than 20 years now, the interest of the scientific community has been growing especially in recent years with annually increasing numbers of publications. The feasibility and safety of HITHOC has already been demonstrated. The primary objective now is to reach a consent about the optimal implementation and standardization of the procedure. In the international clinical practice of HITHOC the parameters of temperature, duration, type and number of chemotherapeutic agents vary, making a comparison of the short- and long-term results difficult. For about ten years, the combination of surgical cytoreduction and HITHOC has been performed more routinely in several departments of thoracic surgery in Germany, especially in university hospitals. Recently, a group of experts for thoracic surgery of five departments of thoracic surgery elaborated recommendations for the HITHOC procedure in Germany. These recommendations represent a standardized and consistent implementation of HITHOC. Through this, postoperative complications associated to HITHOC should be reduced and a better comparison of the results should be enabled. This article is intended to give a brief overview of the literature, current recommendations in the implementation of HITHOC and also aims to show future perspectives of this procedure.
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Affiliation(s)
- Till Markowiak
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Christopher Larisch
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.,Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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Migliore M, Ried M, Molins L, Lucchi M, Ambrogi M, Molnar TF, Hofmann HS. Hyperthermic intrathoracic chemotherapy (HITHOC) should be included in the guidelines for malignant pleural mesothelioma. Ann Transl Med 2021; 9:960. [PMID: 34350275 PMCID: PMC8263862 DOI: 10.21037/atm-20-7247] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/17/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Marcello Migliore
- Thoracic Surgery, Department of Cardio-thoracic Surgery, University Hospital of Wales, UK and Department of Surgery and Medical Specialties, University of Catania, Catania, Italy
| | - Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Laureano Molins
- Department of Thoracic Surgery, Catholic University of Barcelona, Barcelona, Spain
| | - Marco Lucchi
- Thoracic Surgery, University of Pisa, Pisa, Italy
| | | | - Tamas F Molnar
- Thoracic Surgery, Department of Operational Medicine, Faculty of Medicine, University of Pécs, Pécs, Hungary
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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Wiesner S, Loch E, Uller W, Gößmann H, Neu R, Hofmann HS, Ried M. Evaluation of treatment options for postoperative and spontaneous chylothorax in adults. Interact Cardiovasc Thorac Surg 2021; 33:527-533. [PMID: 34000033 DOI: 10.1093/icvts/ivab127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 02/20/2021] [Accepted: 03/07/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Both postoperative and spontaneous chylothorax remain therapeutic challenges without recommendations for a standardized treatment approach. Regardless of its aetiology, patients with chylothorax experience prolonged hospitalization and suffer from the associated complications or the invasive therapy administered. METHODS We conducted a retrospective, observational review of adult patients with chylothorax treated between January 2010 and September 2019. The primary end point was successful management with sustained cessation and/or controlled chylous output. Therapy duration, inpatient stay and the incidence of complications were evaluated as secondary end points. RESULTS Of the 36 patients included (22 men; median age 63 years), 24 patients (67%) suffered from a postoperative accumulation of chylous fluid in the pleural space; in the remaining 12 (33%) patients, chylothoraces occurred spontaneously. Initial conservative treatment was successful in 42% (n = 15); in the other 20 cases (56%) additional invasive therapeutic strategies were followed. A complicated course requiring more than 1 treatment was seen in 54% (n = 13) of the postoperative and in 58% (n = 7) of the spontaneous cases. The median length of hospitalization was significantly longer in the postoperative group (37.5 vs 15.5 days; P = 0.016). Serious complications were observed only in the postoperative group (P = 0.28). There were no in-hospital deaths. CONCLUSIONS Basic treatment of both postoperative and spontaneous chylothorax should include dietary measures in all patients. Additional sclerosing radiotherapy and interventional or surgical therapy are often necessary. The choice of therapeutic approach should be indicated, depending on the aetiology and development of the chylothorax. Early, multimodal treatment is recommended.
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Affiliation(s)
- Sigrid Wiesner
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Elena Loch
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Wibke Uller
- Department of Radiology, University Medical Center Regensburg, Regensburg, Germany
| | - Holger Gößmann
- Department of Radiology, University Medical Center Regensburg, Regensburg, Germany
| | - Reiner Neu
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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Markowiak T, Dakkak B, Loch E, Großer C, Klinkhammer-Schalke M, Hofmann HS, Ried M. Video-assisted pulmonary metastectomy is equivalent to thoracotomy regarding resection status and survival. J Cardiothorac Surg 2021; 16:84. [PMID: 33858453 PMCID: PMC8048191 DOI: 10.1186/s13019-021-01460-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 04/05/2021] [Indexed: 12/29/2022] Open
Abstract
Background Surgical resection of pulmonary metastases leads to prolonged survival if strictly indicated. Usually, thoracotomy with manual palpation of the entire lung with lymph node dissection or sampling is performed. The aim of this study was to evaluate the role of video-assisted thoracoscopic surgery (VATS) in pulmonary metastectomy with curative intent. Methods In this study, all patients with suspected pulmonary metastasis (n = 483) who visited the Center for Thoracic Surgery in Regensburg, between January 2009 and December 2017 were analysed retrospectively. Results A total of 251 patients underwent metastectomy with curative intent. VATS was performed in 63 (25.1%) patients, 54 (85.7%) of whom had a solitary metastasis. Wedge resection was the most performed procedure in patients treated with VATS (82.5%, n = 52) and thoracotomy (72.3%, n = 136). Postoperative revisions were necessary in nine patients (4.8%), and one patient died of pulmonary embolism after thoracotomy (0.5%). Patients were discharged significantly faster after VATS than after thoracotomy (p < 0.001). Complete (R0) resection was achieved in 89% of patients. The median recurrence-free survival was 11 months (95% confidence interval 7.9–14.1). During follow-up, eight (12.7%) patients in the VATS group and 42 (22.3%) patients in the thoracotomy group experienced recurrence (p = 0.98). The median overall survival was 61 months (95% confidence interval 46.1–75.9), and there was no significant difference with regard to the surgical method used (p = 0.34). Conclusions VATS metastasectomy can be considered in patients with a solitary lung metastasis. An open surgical approach with palpation of the lung showed no advantage in terms of surgical outcome or survival.
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Affiliation(s)
- Till Markowiak
- Department of Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Beshir Dakkak
- Department of Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Elena Loch
- Department of Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Christian Großer
- Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Monika Klinkhammer-Schalke
- Tumor Center, University Institute of Quality Assurance and Health Services Research, Regensburg, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.,Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
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26
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Englert L, Stadlbauer C, Spaeth M, Hofmann HS, Schneider C, Hatz RA, Preissler G, Michel S, Golovchenko S, Ried M, Hoenicka M. Evaluation of the combination of endothelin receptor antagonists (ERA) and phosphodiesterase-5 inhibitors for the treatment of pulmonary arterial hypertension (PAH) in pathologic human pulmonary arteries in an ex-vivo organ bath model. Pulm Pharmacol Ther 2020; 66:101985. [PMID: 33359621 DOI: 10.1016/j.pupt.2020.101985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/13/2020] [Accepted: 12/09/2020] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- L Englert
- Department of Thoracic Surgery, University Medical Center Regensburg, Germany.
| | - C Stadlbauer
- Department of Thoracic Surgery, University Medical Center Regensburg, Germany
| | - M Spaeth
- Department of Thoracic Surgery, University Medical Center Regensburg, Germany
| | - H S Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, Germany
| | - C Schneider
- Department of Thoracic Surgery, Campus Großhadern, University of Munich, Germany
| | - R A Hatz
- Department of Thoracic Surgery, Campus Großhadern, University of Munich, Germany
| | - G Preissler
- Department of Thoracic Surgery, Hospital Schillerhöhe, Robert-Bosch-Hospital, Gerlingen, Germany
| | - S Michel
- Department of Cardiac Surgery, Campus Großhadern, University of Munich, Germany
| | - S Golovchenko
- Department of Thoracic Surgery, University Medical Center Regensburg, Germany
| | - M Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Germany
| | - M Hoenicka
- Department of Cardiothoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany
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27
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Robold T, Ried M, Neu R, Hofmann HS. [Minimum volumes in surgical treatment of lung cancer : A survey of thoracic surgeons in Germany on the introduction of a minimum volume regulation for surgical treatment of lung cancer]. Chirurg 2020; 91:1053-1061. [PMID: 32382805 PMCID: PMC7716896 DOI: 10.1007/s00104-020-01185-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Federal Joint Committee (G‑BA) is currently discussing the introduction of new minimum volume regulations (MVR) in Germany. The present study examined the current opinions of active thoracic surgeons regarding minimum volumes (MV) for the surgical treatment of lung cancer. METHODS The participating centers for the online survey were identified on the basis of the thoracic surgery departments in the 2017 hospital directory (Federal Statistical Office), lung cancer centers (German Cancer Society), certified centers of excellence for thoracic surgery (German Society for Thoracic Surgery), hospitals with a focus on lung surgery and German university hospitals. They were asked about the potential effects of MVR on the quality of results and quality of care, economic aspects and the structure of care. Furthermore, a recommendation for MV was requested and possible provisions for exemption were evaluated. RESULTS A total of 145 hospitals (response rate 85%) with 454 thoracic surgeons (response rate 54%) were surveyed. The results showed a high degree of approval for MV to improve the quality of results and 78.4% of the surgeons surveyed expected it to result in centralization of surgical care, although this would not lead to a deterioration in care according to 70.1% of the participants. Approximately 46.1% of the participants expected care to become more economical and 83.3% supported the introduction of an MVR, with the average recommended MV being 67 anatomical lung resections per center per year. CONCLUSION An MVR for the surgical treatment of lung cancer met with a high degree of approval among active thoracic surgeons. The MV that was called for (n = 67) was slightly below the prerequisite for primary surgical cases at a certified lung cancer center.
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Affiliation(s)
- Tobias Robold
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß Allee 11, 93053, Regensburg, Deutschland.
| | - Michael Ried
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß Allee 11, 93053, Regensburg, Deutschland
| | - Reiner Neu
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß Allee 11, 93053, Regensburg, Deutschland
| | - Hans-Stefan Hofmann
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß Allee 11, 93053, Regensburg, Deutschland
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Abstract
The appropriate therapy and prognosis of patients with thymic malignancies is decisively influenced by the local extent and dissemination of the tumor. For this reason, a staging system that reflects these factors is essential. Mainly the Masaoka-Koga classification, which was introduced in 1994, has been applied for this purpose. The rarity of thymic malignancies makes it difficult not only to establish internationally standardized diagnostics and treatment, but also to progress staging. Besides, efforts were made to adapt the classification into a tumor-node-metastasis-based (TNM) system for standardization with the staging of other tumor entities. The 2017 published 8th edition of the TNM Classification of Malignant Tumors introduced several adjustments based on a proposal of the International Association for the Study of Lung Cancer (IASLC) and the International Thymic Malignancy Interest Group (ITMIG). Compared to the Masaoka-Koga classification, surgically good resectable tumor involvements like pericardium, mediastinal fat or mediastinal pleura have been shifted to lower stages. Thus, even more than in Masaoka-Koga classification, tumors are basically divided into completely resectable and thus surgically treatable tumors (stage I, II, IIIA) and advanced stages (stage IIIB, IVA and IVB) that require multimodal therapy.
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Affiliation(s)
- Till Markowiak
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.,Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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Abstract
In the treatment of locally advanced thymic tumours, specific diagnostic testing is required, with a multimodal therapeutic approach consisting of surgery, radio- and/or chemotherapy. The complete resection of the tumour represents the most important prognostic factor with regard to recurrence-free and long-term survival. Local invasive growth of malignant thymic tumours into neighbouring mediastinal structures is classified as Masaoka-Koga stage III. Surgical resection can be performed primarily or after induction therapy, depending on the extent of the tumour. However, in some cases these tumours must be classified as non-resectable, so that only palliative radio-/chemotherapy remains as therapeutic option. TNM classification for malignant thymic tumours has been recently introduced. This resembles the established Masaoka-Koga classification in many aspects, but also includes some therapy-relevant changes. A differentiation is made between stages IIIA and IIIB, with the aim of assessing the resectability of advanced thymic tumours in a more differentiated manner and consequent planning of the therapy concept. Besides the thymus, thymoma, perithymic tissue, mediastinal pleura (stage I) or pericardium (stage II), all infiltrated structures should be removed "en bloc", if possible in stage III tumours. While the lung, brachiocephalic vessels or extrapericardial pulmonary vessels can still be resected and reconstructed if necessary, infiltration of the aorta or intrapericardial pulmonary vessels often limits macroscopically complete resection.
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Affiliation(s)
- Till Markowiak
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Deutschland
| | - Hans-Stefan Hofmann
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Deutschland.,Klinik für Thoraxchirurgie, Krankenhaus Barmherzige Brüder Regensburg, Deutschland
| | - Michael Ried
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Deutschland
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Abstract
INTRODUCTION Objective of the 'German hyperthermic intrathoracic chemotherapy (HITOC) study' is to evaluate the HITOC as additional treatment after surgical cytoreduction for malignant pleural tumours. Even though HITOC is applied with increasing frequency, there is no standardised therapy protocol concerning the technique of HITOC, the selection as well as dosage of chemotherapeutic agents and perioperative management in order to provide a safe and comparable, standardised treatment regime. METHODS AND ANALYSIS This trial is a retrospective, multicentre observational study, which is funded by the German Research Foundation. Approximately 300 patients will be included. Four departments of thoracic surgery, which are performing the most HITOC procedures in Germany, are contributing to this study: Center for Thoracic Surgery at the University Hospital Regensburg, Thoracic Clinic Heidelberg of the University of Heidelberg, Center for Thoracic Surgery of the Hospital University of Munich and the Department of Thoracic Surgery at the University Hospital Freiburg. All patients who underwent surgical cytoreduction and subsequent HITOC at one of the four centres between starting the HITOC programme in 2008 and December 2019 will be included. Information on the performed HITOC will be obtained, focusing on the technique as well as the applied perfusion solution including the chemotherapeutic agent. Furthermore, parameters of the patient's postoperative recovery will be analysed to determine 30-day morbidity and mortality. ETHICS AND DISSEMINATION The approvals by the local ethics committee of the respective clinic and the three participating clinics have been obtained. The results will be presented in conferences and published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER German Clinical Trials Registry (DRKS00015012; Pre-results).
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Affiliation(s)
- Till Markowiak
- Department of Thoracic Surgery, Universitätsklinikum Regensburg, Regensburg, Bayern, Germany
| | - Michael Koller
- Center for Clinical Studies, Universitätsklinikum Regensburg, Regensburg, Bayern, Germany
| | - Florian Zeman
- Center for Clinical Studies, Universitätsklinikum Regensburg, Regensburg, Bayern, Germany
| | - Gunnar Huppertz
- Center for Clinical Studies, Universitätsklinikum Regensburg, Regensburg, Bayern, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, Universitätsklinikum Regensburg, Regensburg, Bayern, Germany
| | - Michael Ried
- Department of Thoracic Surgery, Universitätsklinikum Regensburg, Regensburg, Bayern, Germany
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Robold T, Neumeier J, Ried M, Neu R, Sziklavari Z, Grosser C, Klinkhammer-Schalke M, Hofmann HS. [Surgical Treatment of Lung Cancer: How Has the Introduction of the 8th Edition of the TNM Classification Affected Guideline-Based Therapy?]. Zentralbl Chir 2020; 145:589-596. [PMID: 32629508 DOI: 10.1055/a-1164-7058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
STUDY AIM The 8th edition of the TNM classification combined with the latest update of the S3-guideline (by AWMF/Scientific Medical Societies in Germany) on prevention, diagnosis, therapy and follow-up of lung cancer led to several changes in staging and treatment of lung cancer. The aim of this study was to identify differences in the distribution of patients due to changes from the 7th to the 8th edition that affected staging. The influence on surgical therapy will be discussed by using the recommendations of the latest S3 guideline. METHODS Prospective analysis of all primary cases at two thoracic surgical centres in the year 2016 and follow-up in March 2019. Comparison of the 7th edition of tumour classification for lung cancer with the 8th edition, focused on changes in tumour staging and its effects on the appropriate surgical therapy according to the latest S3 guideline. RESULTS A total of 432 primary cases comprised the study population. According to the 8th edition, 82 patients (7th edition: n = 85) in stage I, 43 (n = 49) patients in stage II, 100 (n = 91) patients in stage III and 207 (n = 207) patients are assigned to stage IV. 81 changes (18.7%) were detected (77 upgrades vs. 4 downgrades). 63 patients (14.6%) exhibited a different graduation within the stages. 18 patients (4.1%) were classified in different tumour stages. As a result, fewer patients (n = 12; 2.8%) should have surgery according to the latest S3 guidelines. 290 patients (67.1%) were classified to new subgroups (IA1-3, IIIC and IVA/B). Two-year survival was significantly higher in IVA (25.2%) vs. IVB (13.0%) patients (p < 0.05). CONCLUSION The 8th edition of the TNM-classification affords a higher level of differentiation. In this study, the new TNM classification led to a shift in the distribution, with a tendency to increase the tumour stage. This is mainly caused by changes in the T-descriptor and stage grouping. As a result, fewer patients in stage I - IIIA should have surgery according to the latest S3 guidelines. A significantly higher two-year survival rate was detected in stage IVA (M1a and M1b) compared to IVB and justifies the new differentiation due to the metastatic pattern.
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Affiliation(s)
- Tobias Robold
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Jakob Neumeier
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Michael Ried
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Reiner Neu
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Zsolt Sziklavari
- Klinik für Thoraxchirurgie, regioMed-Kliniken GmbH, Coburg, Deutschland
| | - Christian Grosser
- Klinik für Thoraxchirurgie, Krankenhaus Barmherzige Brüder Regensburg, Deutschland
| | - Monika Klinkhammer-Schalke
- Institut für Qualitätssicherung und Versorgungsforschung der Universität Regensburg, Tumorzentrum Regensburg, Deutschland
| | - Hans-Stefan Hofmann
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland.,Klinik für Thoraxchirurgie, Krankenhaus Barmherzige Brüder Regensburg, Deutschland
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Markowiak T, Hofmann HS, Ried M. [Five Years PLEURATUMOR Register of the German Society of Thoracic Surgery]. Zentralbl Chir 2020; 146:321-328. [PMID: 32629507 DOI: 10.1055/a-1178-1355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Since 01.01.2015, the nationwide "PLEURATUMOR Register of the German Society of Thoracic Surgery (DGT)" has documented the most relevant parameters of patients with primary and secondary malignant pleural diseases receiving thoracic surgery in Germany. This online database is intended to record both primary and recurrent diseases. In particular, the registry focuses on the documentation of patients with pleural carcinosis, malignant pleural mesothelioma and tumours of the thymus with pleural dissemination. METHODS A structured evaluation of all patients documented up to and including December 2019 was carried out. RESULTS At this time, 33 departments participated in the PLEURATUMOR Register and 670 patients have been recorded. Of these patients, 522 data sets were complete and 516 patients received surgical treatment. Most patients were documented in 2017 (n = 135; 26.2%), and in 2019 (n = 72; 14%). With 317 listed patients (61.4%), pleural carcinosis was the most frequently reported pleural tumour, followed by malignant pleural mesothelioma (n = 175; 33.9%) and thymoma/thymic carcinoma with pleural metastases (n = 11; 2.1%). The majority of patients (n = 499; 96.7%) were treated because of an initial manifestation. The most frequently documented procedure was VATS-talcum pleurodesis (n = 204; 39.5%). In 69 patients (13.4%) hyperthermic intrathoracic chemotherapy was performed after cytoreductive surgery. Postoperative complications occurred in 107 patients (20.7%); in 35 cases (6.8%) surgical revision was necessary. The overall 30-day mortality was 8.3% (n = 43). CONCLUSION Due to the consistent data entry of the participating clinics, a representative dataset of pleural tumour diseases could be recorded. In the future, we hope for consistent continuation of data entry and the initiation of register-based studies.
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Affiliation(s)
- Till Markowiak
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Deutschland
| | - Hans-Stefan Hofmann
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Deutschland.,Klinik für Thoraxchirurgie, KH Barmherzige Brüder Regensburg, Deutschland
| | - Michael Ried
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Deutschland
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Wiesner S, Uller W, Hofmann HS, Ried M. Complicated chylous pericardial and thoracic effusion as the first clinical manifestation of thoracic lymphatic malformation. Interact Cardiovasc Thorac Surg 2020; 30:654-655. [PMID: 31886872 DOI: 10.1093/icvts/ivz301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 11/11/2019] [Accepted: 11/17/2019] [Indexed: 11/14/2022] Open
Abstract
Lymphatic malformations are benign focal proliferations of lymphatic vessels with a congenital origin. We present a case of an 18-year-old patient with post-traumatic chylopericardium and recurrent left-sided chylothorax, who was unresponsive to a variety of therapeutic measures until he was diagnosed with a complicated thoracic lymphatic malformation.
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Affiliation(s)
- Sigrid Wiesner
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Wibke Uller
- Department of Radiology, University Medical Center Regensburg, Regensburg, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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Sterz J, Adili F, Bender M, Dahmen U, Heinemann MK, Hofmann HS, König S, Obertacke U, Rüsseler M, Stefanescu C, Voß SH, Walcher F, Kadmon M. [National Learning Objectives Catalogue in Surgery - General Part Defining Competences of Medical School Graduates in Surgery]. Zentralbl Chir 2019; 144:573-579. [PMID: 31842239 DOI: 10.1055/a-1033-7769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Competency-based medical education is needed in order to meet the requirements of medical care currently and in the future. The basis of this are activity-based learning objectives that are merged in competency-based catalogues. A basis for a core curriculum of undergraduate medical training is the National Catalogue of Learning Objectives for Undergraduate Medical Education (NKLM). Already in 2013, for surgery, the competencies which medical students should have achieved after completing the practical year (PJ) in relation to surgical diseases were defined in the special part of the National Catalogue of Learning Objectives in Surgery (NKLC). In the now amended general part of the NKLC, interdisciplinary competencies were defined and consented from all surgical disciplines, that are relevant for all surgical disciplines and that all representatives from the different surgical disciplines should incorporate in their surgical training. The complete NKLC is now available for faculties, teachers and students for trial (available online: https://www.dgch.de/index.php?id=190&L=528). The guiding principle for the entire development process was to make sure that students gain all competencies they need when starting to work as a medical doctor and therefor to increase patient safety.
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Affiliation(s)
- Jasmina Sterz
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt, Goethe-Universität, Frankfurt am Main, Deutschland
| | - Farzin Adili
- Klinik für Gefäßmedizin-Gefäß- und Endovascularchirurgie, Klinikum Darmstadt, Deutschland
| | - Michael Bender
- Klinik für Innere Medizin 1, Klinikum Frankfurt Höchst GmbH, Frankfurt am Main, Deutschland
| | - Uta Dahmen
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Experimentelle Transplantationschirurgie, Universitätsklinikum Jena, Deutschland
| | - Markus K Heinemann
- Klinik und Poliklinik für Herz-, Thorax und Gefäß-Chirurgie, Universitätsmedizin Mainz, Deutschland
| | | | - Sarah König
- Institut für Medizinische Lehre und Ausbildungsforschung, Universitätsklinikum Würzburg, Deutschland
| | - Udo Obertacke
- Orthopädisch-Unfallchirurgisches Zentrum, Universitätsklinikum Mannheim, Deutschland
| | - Miriam Rüsseler
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt, Goethe-Universität, Frankfurt am Main, Deutschland
| | - Christina Stefanescu
- Klinik für Kinderchirurgie und Kinderurologie, Universitätsklinikum Frankfurt, Goethe-Universität, Frankfurt am Main, Deutschland
| | | | - Felix Walcher
- Klinik für Unfallchirurgie, Universitätsklinikum Magdeburg, Deutschland
| | - Martina Kadmon
- Gründungsdekanat, Medizinische Fakultät der Universität Augsburg, Deutschland
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Markowiak T, Neu R, Ansari MKA, Großer C, Klinkhammer-Schalke M, Hofmann HS, Ried M. Surgical Cytoreduction and HITOC for Thymic Malignancies with Pleural Dissemination. Thorac Cardiovasc Surg 2019; 69:157-164. [PMID: 31731316 DOI: 10.1055/s-0039-1700883] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Objective of this study was to assess postoperative morbidity and mortality as well as recurrence-free and overall survival in patients with thymic malignancies and pleural dissemination undergoing surgical cytoreduction and hyperthermic intrathoracic chemotherapy (HITOC). METHODS Retrospective study between September 2008 and December 2017 with follow-up analysis in May 2018. RESULTS A total of 29 patients (male: n = 17) with thymic malignancies and pleural spread (primary stage IVa: n = 11; pleural recurrence: n = 18) were included. Surgical cytoreduction was performed via pleurectomy/decortication (P/D; n = 11), extended P/D (n = 15), and extrapleural pneumonectomy (EPP; n = 3). These procedures resulted in 25 (86%) patients with macroscopically complete (R0/R1) resection. Intraoperative HITOC was performed for 60 minutes at 42°C either with cisplatin (100 mg/m2 body surface area [BSA] n = 8; 150 mg/m2 BSA n = 6; 175 mg/m2 BSA n = 1) or with a combination of cisplatin (175 mg/m2 BSA)/doxorubicin (65 mg; n = 14). Postoperative complications occurred in nine patients (31%). Cytoprotective therapy resulted in lower postoperative creatinine levels (p = 0.036), and there was no need for temporary dialysis in these patients. The 90-day mortality rate was 3.4%, as one patient developed multiple organ failure. While recurrence-free 5-year survival was 54%, an overall 5-year survival rate of 80.1% was observed. Survival depended on histological subtype (p = 0.01). CONCLUSION Surgical cytoreduction with HITOC is feasible in selected patients and offers encouraging survival rates. The application of cytoprotective agents appears to be effective for the prevention of postoperative renal insufficiency.
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Affiliation(s)
- Till Markowiak
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Reiner Neu
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | | | - Christian Großer
- Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Monika Klinkhammer-Schalke
- Tumor Center, University Institute of Quality Assurance and Health Services Research, Regensburg, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.,Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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Möller T, Egberts JH, Eichhorn M, Hofmann HS, Krüger I, Rückert JC, Sandhaus T, Steinert M. Current status and evolution of robotic-assisted thoracic surgery in Germany-results from a nationwide survey. J Thorac Dis 2019; 11:4807-4815. [PMID: 31903271 DOI: 10.21037/jtd.2019.10.48] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Robot-assisted surgery has made a significant entry into surgical practice within Germany, including thoracic surgery. As no published data exists regarding robotic-assisted thoracic surgery (RATS), we conducted a survey to investigate its current status. Methods We performed a nationwide survey of all centers active in RATS, using a standardized questionnaire. The annual number of operations, mean duration of surgery, docking time, length of hospital stay(s), conversions, chest tube duration, the RATS program start date, robot system used, operating room capacity, and staplers and instruments used were recorded. Results Of the 22 centers contacted, 14 responded. In total, 786 RATS interventions were recorded. Most were anatomical lung resections, comprising 372 (bi-) lobectomies and 80 segmentectomies. During the study period, eight bronchoplastic procedures were performed robotically. There were 93 wedge lung resections, 148 thymectomies, 26 sympathectomies, and 59 other RATS procedures, and a single-center series of around 1,000 RATS thymectomies (excluded from statistical analysis). The average incision-suture time of the RATS lobectomy was 245 (range, 80-419) minutes, average residence time seven days. The conversion rate was 6.7% across all interventions, with significant inter-intervention differences. All surveyed centers plan to further expand RATS, with OR capacity being a frequent impediment. Five RATS interventions were performed in Germany in 2013, versus 320 in 2018. Conclusions Overall, RATS is becoming more established in everyday clinical practice in Germany. The number of operations, active centers, and trained RATS surgeons has increased steadily since 2013. A German-speaking operation course for entry into RATS already exists. Even extended resections can be carried out safely, and RATS has become standard procedure in some centers.
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Affiliation(s)
- Thorben Möller
- Department for General, Visceral-, Thoracic-, Transplantation-, and Pediatric Surgery, University Hospital Schleswig Holstein, Campus Kiel, Germany
| | - Jan-Hendrik Egberts
- Department for General, Visceral-, Thoracic-, Transplantation-, and Pediatric Surgery, University Hospital Schleswig Holstein, Campus Kiel, Germany
| | - Martin Eichhorn
- Department of Thoracic Surgery, Thoraxklinik, Heidelberg University, Heidelberg, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University of Regensburg Medical Center, Regensburg, Germany
| | - Ingo Krüger
- Department of Vascular and Thoracic Surgery, Rhein-Maas Klinikum, Würselen, Germany
| | - Jens-C Rückert
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital, Berlin, Germany
| | - Tim Sandhaus
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
| | - Matthias Steinert
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
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Markowiak T, Kerner N, Neu R, Potzger T, Großer C, Zeman F, Hofmann HS, Ried M. Adequate nephroprotection reduces renal complications after hyperthermic intrathoracic chemotherapy. J Surg Oncol 2019; 120:1220-1226. [PMID: 31602673 DOI: 10.1002/jso.25726] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 09/27/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND OBJECTIVES Hyperthermic intrathoracic chemotherapy (HITOC) is used for the treatment of malignant pleural tumors. Although HITOC proved to be safe, postoperative renal failure due to nephrotoxicity of intrapleural cisplatin remains a concern. METHODS This single-center study was performed retrospectively in patients who underwent pleural tumor resection and HITOC between September 2008 and December 2018. RESULTS A total of 84 patients (female n = 33; 39.3%) with malignant pleural tumors underwent surgical cytoreduction with subsequent HITOC (60 minutes; 42°C). During the study period, we gradually increased the dosage of cisplatin (100-150 mg/m2 BSA n = 36; 175 mg/m2 BSA n = 2) and finally added doxorubicin (cisplatin 175 mg/m2 BSA/doxorubicin 65 mg; n = 46). All patients had perioperative fluid balancing. The last 54 (64.3%) patients also received perioperative cytoprotection. Overall 29 patients (34.5%) experienced renal insufficiency. Despite higher cisplatin concentrations, patients with cytoprotection showed significantly lower postoperative serum creatinine levels after 1 week (P = .006) and at discharge (P = .020). Also, they showed less intermediate and severe renal insufficiencies (5.6% vs 13.3%). CONCLUSIONS Adequate perioperative fluid management and cytoprotection seem to be effective in protecting renal function. This allows the administration of higher intracavitary cisplatin doses without raising the rate of renal insufficiencies.
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Affiliation(s)
- Till Markowiak
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Nadine Kerner
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Reiner Neu
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Tobias Potzger
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Christian Großer
- Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center Regensburg, Regensburg, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.,Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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Ried M, Eichhorn M, Winter H, Grützner U, Lindner M, Hatz RA, Haager B, Passlick B, Galetin T, Lopez-Pastorini A, Stoelben E, Hofmann HS. [Expert Recommendation for the Implementation of Hyperthermic Intrathoracic Chemotherapy (HITOC) in Germany]. Zentralbl Chir 2019; 145:89-98. [PMID: 31291667 DOI: 10.1055/a-0934-7806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION During the last few years, hyperthermic intrathoracic chemotherapy (HITOC) has been performed in several departments for thoracic surgery in Germany. The objective of this expert recommendation is to provide elementary recommendations for a standardised HITOC treatment, which are based on clinical experiences and research data. METHODS Between October and December 2018, a group of experts for thoracic surgery in five departments of thoracic surgery developed recommendations for the HITOC procedure in Germany. These experts were selected by the latest national survey for HITOC and had the most clinical experience with HITOC. All recommendations are based on clinical experience, the experts' research data and recent literature. RESULTS All recommendations were evaluated by all participating departments in one consensus survey. Finally, a total of six main conclusions including a total of 17 recommendations were developed. For each recommendation, the strength of the consensus is presented in percentages. 100% agreement was established for nomenclature, technique, the chemotherapeutic agent, the perioperative management, the safety measures and the indications for HITOC. All experts recommended cisplatin as the first choice chemotherapeutic agent for HITOC. The dosage of cisplatin is specified in mg/m2 body surface area (BSA) and should be between 150 and 175 mg/m2 BSA. The volume of the perfusion fluid (approximately 4 - 5 l) seems to play a role for the concentration gradient of cisplatin and should therefore also be taken into account. CONCLUSIONS These expert recommendations provide a standardised and consistent implementation of the HITOC procedure. On this basis, postoperative complications associated to HITOC should be reduced and comparison of the results should be improved.
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Affiliation(s)
- Michael Ried
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Deutschland
| | - Martin Eichhorn
- Chirurgische Abteilung, Thoraxklinik am Universitätsklinikum Heidelberg, Deutschland
| | - Hauke Winter
- Chirurgische Abteilung, Thoraxklinik am Universitätsklinikum Heidelberg, Deutschland
| | - Uwe Grützner
- Thoraxchirurgisches Zentrum München, Klinikum der Universität München, Deutschland
| | - Michael Lindner
- Asklepios Fachkliniken München-Gauting, Klinikum der Universität München, Thoraxchirurgisches Zentrum München, Deutschland
| | - Rudolf A Hatz
- Thoraxchirurgisches Zentrum München, Klinikum der Universität München, Deutschland
| | - Benedikt Haager
- Klinik für Thoraxchirurgie, Universitätsklinikum Freiburg, Deutschland
| | - Bernward Passlick
- Klinik für Thoraxchirurgie, Universitätsklinikum Freiburg, Deutschland
| | - Thomas Galetin
- Lungenklinik, Lehrstuhl für Thoraxchirurgie, Private Universität Witten Herdecke, Kliniken der Stadt Köln gGmbH, Deutschland
| | - Alberto Lopez-Pastorini
- Lungenklinik, Lehrstuhl für Thoraxchirurgie, Private Universität Witten Herdecke, Kliniken der Stadt Köln gGmbH, Deutschland
| | - Erich Stoelben
- Lungenklinik, Lehrstuhl für Thoraxchirurgie, Private Universität Witten Herdecke, Kliniken der Stadt Köln gGmbH, Deutschland
| | - Hans-Stefan Hofmann
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Deutschland.,KH Barmherzige Brüder Regensburg, Klinik für Thoraxchirurgie, Deutschland
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Markowiak T, Holzamer A, Hilker M, Pregler B, Debl K, Hofmann HS, Ried M. Incidental thoracic findings in computed tomography scans before transcatheter aortic valve implantation. Interact Cardiovasc Thorac Surg 2019; 28:559-565. [PMID: 30380069 DOI: 10.1093/icvts/ivy299] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/10/2018] [Accepted: 09/16/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Preoperative computed tomography (CT) scans for transcatheter aortic valve implantation (TAVI) are used routinely. In elderly high-risk patients, incidental radiographic findings are frequently reported. The aim of this study was to investigate the impact of auxiliary findings on the patients' mid-term survival, which might affect the treatment strategy. METHODS Between March 2011 and April 2016, all radiological reports of contrast-enhanced CT scans of 976 patients scheduled for TAVI were analysed retrospectively for incidental thoracic findings including solitary pulmonary nodules (SPN) and thoracic lymphadenopathy (LAP). The minimum follow-up period was 1 year after TAVI. RESULTS The median age of all patients was 79 years; 51.9% (n = 507) were women. Approximately 37% (n = 361) of patients showed 1 of the determined findings. An SPN ≥5 mm was diagnosed in 16.4% (n = 160) of patients. Four of them developed lung cancer and 2 nodules were identified as metastases during follow-up. In addition, 12% (n = 117) of the patients had thoracic LAP. Whereas SPN had no significant effect on the overall survival rate, evidence of LAP turned out to be a statistically significant factor regarding 4-year survival (P = 0.001; hazard ratio 1.66; 95% confidence internal 1.19-2.31). CONCLUSIONS SPN ≥5 mm were detected in 16.4% of patients scheduled for TAVI. Nevertheless, the incidence of lung cancer was low and the effect on survival in this high-risk group of patients was statistically not significant. In contrast, thoracic LAP had a significant negative effect on survival. It needs to be proven if the outcome of this cohort can be enhanced by further diagnostics and therapy.
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Affiliation(s)
- Till Markowiak
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Andreas Holzamer
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Michael Hilker
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Benedikt Pregler
- Department of Radiology, University Medical Center Regensburg, Regensburg, Germany
| | - Kurt Debl
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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Hoenicka M, Golovchenko S, Englert L, Spaeth M, Shoshiashvili L, Großer C, Hofmann HS, Ried M. Combination Therapy of Pulmonary Arterial Hypertension with Vardenafil and Macitentan Assessed in a Human Ex Vivo Model. Cardiovasc Drugs Ther 2019; 33:287-295. [DOI: 10.1007/s10557-019-06868-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Sommerauer L, Philipp A, Lubnow M, Müller T, Lunz D, Hofmann HS, Ried M. [Non-Elective Thoracic Surgery in Patients with Respiratory Insufficiency During Support with Veno-Venous Extracorporeal Membrane Oxygenation]. Zentralbl Chir 2018; 144:93-99. [PMID: 30321882 DOI: 10.1055/a-0721-1983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Patients with severe respiratory failure and veno-venous extracorporeal membrane oxygenation (vv-ECMO) often require diagnostic or therapeutic thoracic surgery. METHODS Retrospective analysis of prospectively collected data (Regensburg ECMO Registry) on all patients requiring vv-ECMO between December 2010 and December 2016 due to acute lung failure (ALF) with diagnostic or therapeutic thoracic surgery. Endpoints were the indications for thoracic surgery as well as postoperative morbidity and in-hospital mortality. RESULTS A total of 418 patients (male n = 285, 68%, mean age 50.0 ± 16.5 years) with severe respiratory insufficiency refractory to conventional therapy required vv-ECMO. Indications for vv-ECMO were ALF due to pneumonia (59.8%), postoperative (18.7%), posttraumatic (9.8%), after chemotherapy (2.8%) and others (8.9%). Overall, in 24.4% (n = 102) of patients with vv-ECMO surgery was performed. Of these, 28.4% (n = 29) of patients required thoracic surgery. Primary indications for thoracic surgery were most frequently therapeutic due to hemothorax (n = 13; 44.8%), followed by carnifying pneumonia/pulmonary abscess (n = 5; 17.2%), pleural empyema (n = 3; 10.3%) and others (n = 3; 10.3%). In patients with interstitial lung disease of unknown origin (n = 5; 17.2%), diagnostic pulmonary biopsy was performed. For initial thoracic intervention thoracotomy was carried out in 93.1% (n = 27) of patients, whereas only two patients (6.9%) received thoracoscopy. At least one repeated thoracotomy was performed in 15 patients (51.7%) and nine patients (31.0%) underwent more than two surgeries. In-hospital mortality of patients with thoracic surgery (44.8%) was higher than in patients without thoracic surgery (35.7%; p = 0.326). CONCLUSION Thoracic surgery in patients with vv-ECMO warrants strict indications, because postoperative complications are common and surgical revision (58,6%) is often required. Therefore, ECMO therapy should only be carried out in specialised centers with thoracic surgery.
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Affiliation(s)
- Laura Sommerauer
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Regensburg
| | - Alois Philipp
- Fachbereich Kardiotechnik, Universitätsklinikum Regensburg, Regensburg
| | - Matthias Lubnow
- Innere Medizin II, Universitätsklinikum Regensburg, Regensburg
| | - Thomas Müller
- Innere Medizin II, Universitätsklinikum Regensburg, Regensburg
| | - Dirk Lunz
- Anästhesiologie, Universitätsklinikum Regensburg, Regensburg
| | - Hans-Stefan Hofmann
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Regensburg.,KH Barmherzige Brüder Regensburg, Klinik für Thoraxchirurgie, Regensburg
| | - Michael Ried
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Regensburg
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Ried M, Sommerauer L, Lubnow M, Müller T, Philipp A, Lunz D, Hofmann HS. Thoracic Bleeding Complications in Patients With Venovenous Extracorporeal Membrane Oxygenation. Ann Thorac Surg 2018; 106:1668-1674. [PMID: 30193999 DOI: 10.1016/j.athoracsur.2018.07.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 06/11/2018] [Accepted: 07/09/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients with respiratory failure are treated more frequently with venovenous extracorporeal membrane oxygenation (vv-ECMO). These patients are at risk for bleeding due to complex multifactorial coagulation disorders resulting from the extracorporeal circulation. METHODS A retrospective analysis was conducted of prospectively collected data on all patients requiring vv-ECMO between December 2010 and December 2016. End points were the incidence, consequence, and in-hospital mortality of patients with thoracic bleeding complications. RESULTS The study included 418 patients (aged 50 ± 16.5 years) requiring vv-ECMO. In 23.2% (n = 97) of patients, relevant hemorrhage was documented. Thoracic bleeding developed in 40 patients (41.2%), followed by diffuse (21.6%), cerebral (14.4%), gastrointestinal (6.2%), cannulation site (6.2%), and other bleeding locations. Thoracic bleeding complications occurred spontaneously (40%), postoperatively (37.5%), after interventions (20%), and after trauma (2.5%). A thoracic operation was performed in 60% (n = 24) of these patients, and a repeated operation due to bleeding was necessary in 45.8%. Mean ECMO duration (18.6 ± 16.8 days; p = 0.035) and hospital length of stay (58 ± 50 days; p = 0.002) were significantly longer than that in patients without bleeding. In-hospital mortality was significantly higher in patients with thoracic bleeding complications (52.5%) than in patients without bleeding complications (32.7%; p = 0.013). CONCLUSIONS Thoracic bleeding complications were observed in 9.6% of patients and represented the most frequent bleeding complication during vv-ECMO treatment. Almost 60% of patients required surgical revision, and nearly half of these patients underwent a repeated operation. Because mortality is high in these patients, vv-ECMO should be performed in only centers experienced with thoracic surgery.
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Affiliation(s)
- Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.
| | - Laura Sommerauer
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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Schnell J, Beer M, Eggeling S, Gesierich W, Gottlieb J, Herth F, Hofmann HS, Jany B, Kreuter M, Ley-Zaporozhan J, Scheubel R, Walles T, Wiesemann S, Worth H, Stoelben E. Management of Spontaneous Pneumothorax and Postinterventional Pneumothorax: German S3-Guideline. Zentralbl Chir 2018; 143:S12-S43. [PMID: 30041262 DOI: 10.1055/a-0588-4444] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
In Germany, 10,000 cases of spontaneous pneumothorax are treated inpatient every year. The German Society for Thoracic Surgery (DGT), in co-operation with the German Society for Pulmonology (DGP), the German Radiological Society (DRG) and the German Society of Internal Medicine (DGIM) has developed an S3 guideline on spontaneous pneumothorax and postinterventional pneumothorax moderated by the German Association of Scientific Medical Societies (AWMF). METHOD Based on the source guideline of the British Thoracic Society (BTS2010) for spontaneous pneumothorax, a literature search on spontaneous pneumothorax was carried out from 2008 onwards, for post-interventional pneumothorax from 1960 onwards. Evidence levels according to the Oxford Center for Evidence-Based Medicine (2011) were assigned to the relevant studies found. Recommendations according to GRADE (A: "we recommend"/"we do not recommend", B: "we suggest"/"we do not suggest") were determined in three consensus conferences by the nominal group process. RESULTS The algorithms for primary and secondary pneumothorax differ in the indication for CT scan as well as in the indication for chest drainage application and video-assisted thoracic surgery (VATS). Indication for surgery is recommended individually taking into account the risk of recurrence, life circumstances, patient preferences and procedure risks. For some forms of secondary pneumothorax, a reserved indication for surgery is recommended. Therapy of postinterventional spontaneous pneumothorax is similar to that of primary spontaneous pneumothorax. DISCUSSION The recommendations of the S3 Guideline provide assistance in managing spontaneous pneumothorax and post-interventional pneumothorax. Whether this will affect existing deviant diagnostic and therapeutic measures will be demonstrated by future epidemiological studies.
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Affiliation(s)
- Jost Schnell
- Lungenklinik Köln-Merheim, Lehrstuhl Thoraxchirurgie der Universität Witten-Herdecke
| | - Meinrad Beer
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Ulm
| | | | | | - Jens Gottlieb
- Klinik für Pneumologie, Medizinische Hochschule Hannover
| | - Felix Herth
- Abteilung für Pneumologie und Beatmungsmedizin, Thoraxklinik Universitätsklinikum Heidelberg
| | | | - Berthold Jany
- Medizinische Klinik - Schwerpunkt Pneumologie und Beatmungsmedizin, KWM Missioklinik Würzburg
| | - Michael Kreuter
- Abteilung für Pneumologie und Beatmungsmedizin, Thoraxklinik Universitätsklinikum Heidelberg
| | - Julia Ley-Zaporozhan
- Klinik und Poliklinik für Radiologie, Klinikum der Ludwig-Maximilans-Universität München
| | | | - Thorsten Walles
- Abteilung Thoraxchirurgie, Universitätsklinik für Herz- und Thoraxchirurgie Magdeburg
| | | | | | - Erich Stoelben
- Lungenklinik Köln-Merheim, Lehrstuhl Thoraxchirurgie der Universität Witten-Herdecke
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Schnell J, Beer M, Eggeling S, Gesierich W, Gottlieb J, Herth FJF, Hofmann HS, Jany B, Kreuter M, Ley-Zaporozhan J, Scheubel R, Walles T, Wiesemann S, Worth H, Stoelben E. Management of Spontaneous Pneumothorax and Post-Interventional Pneumothorax: German S3 Guideline. Respiration 2018; 97:370-402. [PMID: 30041191 DOI: 10.1159/000490179] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 05/18/2018] [Indexed: 11/19/2022] Open
Abstract
In Germany, 10,000 cases of spontaneous pneumothorax are treated inpatient every year. The German Society for Thoracic Surgery, in co-operation with the German Society for Pulmonology, the German Radiological Society, and the German Society of Internal Medicine has developed an S3 guideline on spontaneous pneumothorax and post-interventional pneumothorax moderated by the German Association of Scientific Medical Societies. METHOD Based on the source guideline of the British Thoracic Society (2010) for spontaneous pneumothorax, a literature search on spontaneous pneumothorax was carried out from 2008 onwards, for post-interventional pneumothorax from 1960 onwards. Evidence levels according to the Oxford Center for Evidence-Based Medicine (2011) were assigned to the relevant studies found. Recommendations according to grade (A: "we recommend"/"we do not recommend," B: "we suggest"/"we do not suggest") were determined in 3 consensus conferences by the nominal group process. RESULTS The algorithms for primary and secondary pneumothorax differ in the indication for CT scan as well as in the indication for chest drainage application and video-assisted thoracic surgery. Indication for surgery is recommended individually taking into account the risk of recurrence, life circumstances, patient preferences, and procedure risks. For some forms of secondary pneumothorax, a reserved indication for surgery is recommended. Therapy of post-interventional spontaneous pneumothorax is similar to that of primary spontaneous pneumothorax. DISCUSSION The recommendations of the S3 Guideline provide assistance in managing spontaneous pneumothorax and post-interventional pneumothorax. Whether this will affect existing deviant diagnostic and therapeutic measures will be demonstrated by future epidemiological studies.
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Affiliation(s)
- Jost Schnell
- Lungenklinik Köln-Merheim, Lehrstuhl Thoraxchirurgie der Universität Witten-Herdecke, Witten-Herdecke, Germany,
| | - Meinrad Beer
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Ulm, Ulm, Germany
| | - Stephan Eggeling
- Klinik für Thoraxchirurgie, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Wolfgang Gesierich
- Klinik für Pneumologie, Asklepios-Fachkliniken München Gauting, München Gauting, Germany
| | - Jens Gottlieb
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Felix J F Herth
- Abteilung für Pneumologie und Beatmungsmedizin, Thoraxklinik Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Hans-Stefan Hofmann
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Regensburg, Germany
| | - Berthold Jany
- Medizinische Klinik - Schwerpunkt Pneumologie und Beatmungsmedizin, KWM Missioklinik, Würzburg, Germany
| | - Michael Kreuter
- Klinik und Poliklinik für Radiologie, Klinikum der Ludwig-Maximilans-Universität München, München, Germany
| | - Julia Ley-Zaporozhan
- Abteilung für Pneumologie und Beatmungsmedizin, Thoraxklinik Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Robert Scheubel
- Klinik für Thoraxchirurgie, Fachkliniken Wangen, Wangen, Germany
| | - Thorsten Walles
- Abteilung Thoraxchirurgie, Universitätsklinik für Herz- und Thoraxchirurgie Magdeburg, Magdeburg, Germany
| | - Sebastian Wiesemann
- Klinik für Thoraxchirurgie, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Heinrich Worth
- Pneumologische und kardiologische Praxis Fürth, Fürth, Germany
| | - Erich Stoelben
- Lungenklinik Köln-Merheim, Lehrstuhl Thoraxchirurgie der Universität Witten-Herdecke, Witten-Herdecke, Germany
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Hofmann HS, Braess J, Leipelt S, Allgäuer M, Klinkhammer-Schalke M, Szoeke T, Grosser C, Pfeifer M, Ried M. Multimodality therapy in subclassified stage IIIA-N2 non-small cell lung cancer patients according to the Robinson classification: heterogeneity and management. J Thorac Dis 2018; 10:3585-3594. [PMID: 30069356 DOI: 10.21037/jtd.2018.05.203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Non-small cell lung cancer (NSCLC) with mediastinal lymph node involvement (N2) is a heterogeneous entity. The objective of this analysis is to investigate the results of treatment strategies for N2-positive patients. Methods Retrospective study (2009-2014) of 104 consecutive patients with stage IIIA-N2 NSCLC classified according to the Robinson classification (IIIA1-IIIA4) and treated within a multimodality treatment regime. Results The Robinson subgroups were: IIIA1 (n=27), IIIA3 (n=60) and IIIA4 (n=17). We had no stage IIIA2 samples because we did not perform an intraoperative frozen section of lymph nodes. Surgical resection with systematic lymph node dissection was performed in all patients with stage IIIA1 (n=27). After chemotherapy or chemo-/radiotherapy, 53.3% of patients in stage IIIA3 (n=32) and 11.7% of patients in stage IIIA4 (n=2) underwent surgery with curative intention. R0 was achieved in 92.6% in stage IIIA1, 93.8% in stage IIIA3 and 100% in stage IIIA4. The 30-day mortality was 3.2%. The overall median survival was 31.7 months (5-year survival was 30.5%). There were no significant differences (P=0.583) in survival regarding the Robinson subgroups. Patients who underwent tumour resection had significantly better median survival (39.8 vs. 19.6 months; P=0.014) compared to patients treated conservatively. Deviation from the interdisciplinary recommended therapy (12%) led to a reduced median survival (11.4 vs. 31.8 months; P=0.137). Conclusions N2-patients should be subclassified according to the Robinson classification and discussed in the tumour board. Surgical resection should be recommended in specific cases of N2-disease (non-bulky, sensitivity to systemic treatment).
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Affiliation(s)
- Hans-Stefan Hofmann
- Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Prüfeninger Straße 86, 93049 Regensburg, Germany.,Department of Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Jan Braess
- Department of Oncology and Hematology, Hospital Barmherzige Brüder Regensburg, Prüfeninger Straße 86, 93049 Regensburg, Germany
| | - Susanne Leipelt
- Department of Oncology and Hematology, Hospital Barmherzige Brüder Regensburg, Prüfeninger Straße 86, 93049 Regensburg, Germany
| | - Michael Allgäuer
- Department of Radiotherapy, Hospital Barmherzige Brüder Regensburg, Prüfeninger Straße 86, 93049 Regensburg, Germany
| | | | - Tamas Szoeke
- Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Prüfeninger Straße 86, 93049 Regensburg, Germany
| | - Christian Grosser
- Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Prüfeninger Straße 86, 93049 Regensburg, Germany
| | - Michael Pfeifer
- Department of Pneumology, Hospital Barmherzige Brüder Regensburg, Prüfeninger Straße 86, 93049 Regensburg, Germany
| | - Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
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Ried M, Eicher MM, Neu R, Kraus D, Inderhees S, Marx A, Hofmann HS. [Comparison of the Masaoka-Koga Classification with the New TNM Staging of the IASLC/ITMIG for Thymoma and Thymic Carcinoma]. Zentralbl Chir 2018; 143:S44-S50. [PMID: 29775980 DOI: 10.1055/a-0606-5603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND The Masaoka-Koga classification describes the extent and spread of thymic epithelial malignancies. The objective of this study was to evaluate the Masaoka-Koga and the new TNM-staging system regarding differences in stage distributions, clinical implementation and therapeutic consequences. METHODS Retrospective analysis of all patients who underwent surgery between January 2005 and December 2015 for thymoma/thymic carcinoma in two centres for thoracic surgery. The final tumour stages were determined on the basis of preoperative imaging, surgical reports and histological findings. RESULTS A total of 118 patients (male 51%) with a mean age of 56 ± 14.8 years were included. Indications for surgery were primary mediastinal tumour (n = 97), pleura dissemination (n = 15) or mediastinal recurrence (n = 7). Radical tumour resection was performed in 92% of patients (n = 109) within one operation, whereas 8% of patients (n = 9) underwent two operations. Surgical revision was necessary in 12 patients (10.1%) and in-hospital mortality was 1.7% (n = 2). Early Masaoka-Koga stages I (n = 34) and II (n = 16) shifted to the new UICC stage I (T1: n = 58). Locally advanced stages (Masaoka-Koga stage III n = 22 vs. UICC stage IIIA + IIIB n = 20) and metastasised stages (Masaoka-Koga stage IV n = 36 vs. UICC stage IV n = 39) remained very similar. CONCLUSIONS The new TNM staging system gave rise to changes, especially in early stages (downstaging), but these had no therapeutic implications. Although advanced stages were very similar, the new TNM staging provides more clinically relevant differentiation.
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Affiliation(s)
- Michael Ried
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Deutschland
| | | | - Reiner Neu
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Deutschland
| | - Dietmar Kraus
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Klinikum Nürnberg, Universitätsklinik der Paracelsus Medizinischen Privatuniversität, Nürnberg, Deutschland
| | - Sebastian Inderhees
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Klinikum Nürnberg, Universitätsklinik der Paracelsus Medizinischen Privatuniversität, Nürnberg, Deutschland
| | - Alexander Marx
- Pathologisches Institut Mannheim, Universitätsklinikum Mannheim, Deutschland
| | - Hans-Stefan Hofmann
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Deutschland.,Klinik für Thoraxchirurgie, Krankenhaus Barmherzige Brüder Regensburg, Deutschland
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Abstract
INTRODUCTION For several years, hyperthermic intrathoracic chemotherapy (HITHOC) has been performed in a few departments for thoracic surgery in a multimodality treatment regime in addition to surgical cytoreduction. Specific data about HITHOC in Germany are still lacking. METHODS Survey in written form to all departments of thoracic surgery in Germany. The objective is the evaluation of HITHOC with respect to number, indications, technique, perioperative protection measure and complications. RESULTS A total of 116 departments of thoracic surgery were contacted, with a return rate of 43% (n = 50). HITHOC was not performed in 33 departments, due to lack of resources or experience (n = 17), missing efficacy of the procedure (n = 8) and fear of excessive complication rates (n = 3). Since 2008, a total of 343 HITHOC procedures have been performed in 17 departments. Eight departments have their own perfusion machine, whereas the remaining departments borrow the perfusion machine. Indications were malignant pleural mesothelioma in all departments (n = 17), thymoma with pleural spread (n = 11) and secondary pleural carcinosis (n = 7). The HITHOC was performed in nearly all departments after closing the chest (n = 16), with a temperature of 42 °C (n = 12) and for 60 minutes (n = 15). Cisplatin was always used, either alone (n = 9) or in combination (n = 8). In all the participating departments, the aims of the HITHOC were improvement in local tumor control and prolonged recurrence-free and overall survival. Relevant HITHOC-associated complications were low. CONCLUSIONS HITHOC is performed in at least 17 departments of thoracic surgery in Germany, and is widely standardised with protective measures and a low rate of complications. The aims of the HITHOC are improvement in local tumor control in pleural malignancies combined with prolonged overall survival and better quality of life.
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Affiliation(s)
- Michael Ried
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Deutschland
| | - Hans-Stefan Hofmann
- Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Deutschland.,Krankenhaus Barmherzige Brüder Regensburg, Klinik für Thoraxchirurgie, Deutschland
| | | | - Martin Eichhorn
- Thoraxklinik, Thoraxchirurgie, Universität Heidelberg, Deutschland
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Markowiak T, Ried M, Holzamer A, Hilker M, Hamer O, Hofmann HS. Incidental thoracic findings in CT-scans before Transcatheter Aortic Valve Implantation (TAVI). Pneumologie 2018. [DOI: 10.1055/s-0037-1619148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- T Markowiak
- Abteilung für Thoraxchirurgie, Klinik und Poliklinik für Herz-, Thorax- und Herznahe Gefäßchirurgie, Universitätsklinikum Regensburg
| | - M Ried
- Abteilung für Thoraxchirurgie, Klinik und Poliklinik für Herz-, Thorax- und Herznahe Gefäßchirurgie, Universitätsklinikum Regensburg
| | - A Holzamer
- Abteilung für Thoraxchirurgie, Klinik und Poliklinik für Herz-, Thorax- und Herznahe Gefäßchirurgie, Universitätsklinikum Regensburg
| | - M Hilker
- Abteilung für Thoraxchirurgie, Klinik und Poliklinik für Herz-, Thorax- und Herznahe Gefäßchirurgie, Universitätsklinikum Regensburg
| | - O Hamer
- Institut für Röntgendiagnostik, Universitätsklinikum Regensburg
| | - HS Hofmann
- Abteilung für Thoraxchirurgie, Klinik und Poliklinik für Herz-, Thorax- und Herznahe Gefäßchirurgie, Universitätsklinikum Regensburg
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Hofmann HS, Suttner T, Neu R, Potzger T, Szöke T, Grosser C, Ried M. Burden between Undersupply and Overtreatment in the Care of Primary Spontaneous Pneumothorax. Thorac Cardiovasc Surg 2017; 66:575-582. [PMID: 29290080 DOI: 10.1055/s-0037-1609011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The optimal treatment of primary spontaneous pneumothorax (PSP) is still controversial. The purpose of this study was to analyze the incidence of recurrence, the recurrence-free time, and to identify risk factors for recurrence after PSP. METHODS We performed a retrospective analysis of 135 patients with PSP who were treated either conservatively with a chest tube (n = 87) or surgically with video-assisted thoracoscopic surgery (VATS; n = 48) from January 2008 through December 2012. RESULTS In this study, 101 (74.8%) male and 34 (25.2%) female patients were included with a mean age of 35.7 years. The indications for surgery included blebs/bullae in the radiological images (n = 20), persistent air leaks (n = 15), or the occupations/wishes of the patients (n = 13). A first ipsilateral recurrent pneumothorax (true recurrence) was observed in 31.1% of all patients (VATS: 6.25%, conservative: 44.8%). Including contralateral recurrence, the overall first recurrence rate was 41.3% (VATS: 14.6%, conservative: 57.5%). The recurrence-free time did not differ significantly between the treatment groups (p = 0.51), and most recurrences were observed within the first 6 months after PSP. Independent risk factors identified for the first recurrence were conservative therapy (p = 0.0001), the size of the PSP (conservative; p = 0.016), and a body mass index <17 (VATS; 0.022). The risk for second and third recurrences of PSP was 17.5 and 70%, respectively, for both treatment groups, but it was 100% after conservative therapy. CONCLUSION Surgery for PSP should be selected based on the risk factors and the patient's wishes to prevent first recurrences but also to avoid overtreatment. The treatment of first and subsequent PSP recurrences should be with surgery since conservative treatment is associated with a 100% recurrence rate.
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Affiliation(s)
- Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.,Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Tobias Suttner
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Reiner Neu
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Tobias Potzger
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Tamas Szöke
- Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Christian Grosser
- Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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Ried M, Neu R, Lehle K, Großer C, Szöke T, Lang G, Hofmann HS, Hoenicka M. Superior vasodilation of human pulmonary vessels by vardenafil compared with tadalafil and sildenafil: additive effects of bosentan. Interact Cardiovasc Thorac Surg 2017; 25:254-259. [PMID: 28486684 DOI: 10.1093/icvts/ivx108] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 03/06/2017] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVES Pulmonary arterial hypertension is characterized by pulmonary vascular proliferation and remodelling, leading to a progressive increase in pulmonary arterial resistance. Vasodilator properties of 3 different phosphodiesterase (PDE)-5 inhibitors alone and in combination with an endothelin (ET) receptor antagonist were compared in an ex vivo model. METHODS Segments of human pulmonary arteries (PAs) and pulmonary veins (PVs) were harvested from lobectomy specimens. Contractile forces were determined in an organ bath. Vessels were constricted with norepinephrine (NE) to determine the effects of sildenafil, tadalafil and vardenafil and with ET-1 to assess the effects of bosentan. RESULTS All 3 PDE-5 inhibitors had no relevant effect on the basal tone of the vessels. Both sildenafil and vardenafil significantly (P < 0.0001) reduced the responses of the vessels to NE, whereas tadalafil was effective only in PA (P = 0.0009) but not in PV (P = 0.097). Sildenafil relaxed NE-preconstricted PV (P < 0.0001) but not PA (P = 0.143). Both tadalafil and vardenafil relaxed PA and PV significantly. Vardenafil appears to be the most potent of the PDE-5 inhibitors tested. Furthermore, we analysed the combination of bosentan and vardenafil in PA. Bosentan and vardenafil reduced ET-1 and NE induced vasoconstriction stronger than vardenafil alone (P ≤ 0.049). CONCLUSIONS Vardenafil caused the most consistent antihypertensive response in this ex vivo model. However, ET receptor antagonism appears to be an even more potent mechanism. A combination therapy using vardenafil and bosentan turned out to be an effective combination to lower vessel tension in PA.
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Affiliation(s)
- Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Reiner Neu
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Karla Lehle
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Christian Großer
- Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Tamas Szöke
- Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Gunter Lang
- Department of Cardiothoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.,Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Markus Hoenicka
- Department of Cardiothoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany
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