Starting the first robotic lobectomy program in the Eastern Europe during Coronavirus disease-2019 pandemic

BACKGROUND

We report our experience in starting RATS (robotic-assisted thoracic surgery) lobectomy program during COVID-19 pandemic.

METHODS

Data from 20 consecutive cases undergoing RATS lobectomy between August 2020 and April 2021 were prospectively accumulated into our database.

RESULTS

The mean operational time was 235±69 minutes (median 210, range 175 to 370). Conversion-to-open rate was 5 %. One patient was converted to an open procedure during surgery due to surgical bleeding. One patient (5 %), with sever chronic obstructive pulmonary disease (COPD), had prolonged air leak with chest drainage 11 days and conservative treatment. Morbidity rate was 10 % (2 patients). Estimated costs of RATS lobectomy in our department were $9,590 (range $8,250-$12,730). 30-days mortality was 0%.

CONCLUSIONS

Safe robotic surgery is based not only on improved robotic equipment, but also on good technical skills and medical knowledge. It requires training of the entire operating room team. The learning curve is steep, involving port placement, use of the correct robotic arms, availability of the proper instrumentation, and proper patient positioning (Tab. 2, Ref. 28).

[Thoracic sarcoma, is indication for surgery sensible? case reports]

Sarcomas form a heterogenous group of diseases. They often affect young patients and their prognosis is uncertain. The only hope for curative treatment of these patients is a surgical R0 resection. Chemotherapy is only indicated for certain types of sarcomas and is often only recommended as part of clinical trials. The article describes 4 different case reports of patients with sarcomas and reflects on the justification of indicating surgical treatment. resection.

Pneumonectomy for non-small cell lung cancer: predictors of early mortality and morbidity

BACKGROUND

The aim of this study was to determine independent risk factors affecting postoperative morbidity and mortality after pneumonectomy for non-small cell lung cancer (NSCLC).

METHODS

A review of 329 patients having pneumonectomy for NSCLC between January 1, 1998 and July 31,2012 was undertaken. Factors affecting morbidity and mortality were analyzed by univariate and multivariate analyses.

RESULTS

The overall 30-day mortality rate was 5.1%. Smoking habits, chronic obstructive pulmonary disease (COPD) status, neoadjuvant therapy and obesity had no statistical influence on the short-term outcome. Coronary artery disease and respiratory failure were identified as risk factors for increased 30-day mortality (p < 0.01). Right pneumonectomy and presence of respiratory failure with mechanical ventilation increased the incidence of bronchopleural fistula (p < 0.01).

CONCLUSIONS

Pneumonectomy for NSCLC carries an acceptable operative morbidity and mortality. Coronary artery disease, right pneumonectomy and respiratory failure adversely affect morbidity and mortality after this procedure.

[Reexpansion pulmonary oedema after drainage of a long-term spontaneous pneumothorax - a case report]

Reexpansion pulmonary oedema is a rare but possibly lethal complication of thoracic drainage for pneumothorax. Morbidity and mortality of this complication remains high (up to 20% of lethal cases) and as such deserves our attention. We report a case of ipsilateral left-sided pulmonary oedema following chest tube insertion in a 42-year-old male patient with spontaneous pneumothorax. Pneumothorax can be expected to last for up to 3 weeks (from the first presentation of sudden dyspnoea and chest pain). The pathophysiology of this lung affection has not yet been completely elucidated; the crucial role is probably played by damage to the endothelium which is followed by increased endothelial permeability during ischemia-reperfusion injury in a rapidly reexpanding lung. The main risk factors for the development of RPE are young age (the younger the patient, the higher the risk), the female sex, the degree of lung collapse, a pneumothorax that lasts more than 24 hours, a reexpansion of the lung in less than ten minutes, the use of a suction system, and - in cases of a pleural effusion - an evacuation volume of more than 2000 ml. Although in patients with these risk factors the administration of initial negative pressure should be avoided, this procedure remains common practice in pneumothorax treatment in the Czech Republic. Thoracic surgeons are more likely to use the suction system than pulmonologists (70% versus 52%). RPE manifestation ranges from benign clinical course (patients are free of complaints with only pathological chest radiography findings) to potentially lethal rapid respiratory failure with circulatory shock. Most patients develop RPE within 1 hour of expansion and the ipsilateral lung is affected. Only rarely can pulmonary oedema be bilateral, or in the contra-lateral lung. Treatment of RPE is supportive and depends on the individual patients condition, ranging from mere monitoring to mechanical ventilation for serious cases. Positive pressure mechanical ventilation and the utilization of positive end-expiratory pressure (PEEP) remains the gold standard of treatment.

[Lung transplantation]

Lung transplantation is an effective life-saving therapy for the treatment of a variety of end-stage lung diseases. However, the application of lung transplantation is hindered by multiple factors such as the shortage of organ donors, early graft failure, infection, and chronic graft dysfunction. A novel strategy for donor lung preservation--ex-vivo lung perfusion (EVLP)--that keeps the organ at physiological protective conditions, has shown great promise to increase lung utilization by reassessing, treating, and repairing injured donor lungs prior to transplantation. Infections are a major cause of early morbidity and mortality after lung transplantation. Because of the potential association of infections such as respiratory viral infections and gram-negative bacterial infections with bronchiolitis obliterans syndrome, prompt attention to these pathogens is critical. Despite marked improvements in early survival, long-term outcome after lung transplantation is still threatened by bronchiolitis obliterans syndrome. The program of lung transplantation in Czech Republic was started in University Hospital Motol in Prague in 1997. Nowadays in Czech Republic is performed about 20 transplants every year with results comparable to other advanced centers. Until September 2011, 175 transplants were carried out in Czech Republic.

[Timeline trends in surgery of bronchogenic carcinoma]

BACKGROUND

The aim of our study was to determine how patient preoperative status and outcomes of resection have changed over last 12 years.

MATERIAL AND METHODS

This retrospective study of prospective database included 1412 patients operated from January 1,1998 through December 31,2009. Patient characteristics and outcomes were compared for two time periods (1998-2003 and 2004-2009).

RESULTS

We performed 985 lobectomies with 30-days mortality 1.8% and 300 pneumonectomies with 30-days mortality 5.7%. Median of survival of all 1412 patients was 4.3 year and 5-year survival was 45%. The percentage of female patients, lobectomies and adenocarcinoma increased over time, as well as age of our patients. Outcome improved over time, with significant decrease in 30-days mortality after pneumonectomy (8.2% vs. 2.3%, p = 0.029). The overall 3-year survival improved in patients with III. stage (30 % vs. 40%, p = 0.012).

CONCLUSION

Our study identified time trends which are in-line with increased incidence of lung cancer among women and with improvement of preoperative evaluation, preoperative and postoperative care

Time trend in the surgical therapy of lung cancer

BACKGROUND

The purpose of our study was to clarify results of surgery for non-small cell lung cancer (NSCLC) and its time trends.

METHODS

We retrospectively reviewed our prospective database of patients who underwent surgery for NSCLC between 1998 and 2009 in our institution. Patients were divided into two equal 6-year periods according to the year of surgery (1998-2003 and 2004-2009).

RESULTS

One thousand, four hundred and twelve patients underwent operation for NSCLC. We performed 985 lobectomies with 30-days mortality of 1.8 % and 300 pneumonectomies with 30-days mortality of 5.7 %. Median of survival of all 1412 patients was 4.3 year and 5-year survival was 45 %. The percentage of female patients, lobectomies and adenocarcinomas increased over time, as well as the age of our patients. Outcome improved over time, with significant decrease in a 30-days mortality after pneumonectomy (8.2 % vs 2.3 %, p=0.029). The overall 3-year survival improved in patients with stage III (30 % vs 40 %, p=0.012).

CONCLUSION

Outcomes of lung resection for NSCLC improved over time despite a worsening of some elements of preoperative status. The shift in histological distribution was associated with an increasing proportion of patients with stage I, a lower operative mortality and better 3- and 5-year survival. These trends are due to improvement of preoperative evaluation, preoperative and postoperative care (Tab. 1, Fig. 2, Ref. 9). Full Text in free PDF www.bmj.sk.

Risk factor analysis for early mortality and morbidity following pneumonectomy for non-small cell lung cancer

OBJECTIVES

The purpose of this report is to analyze factors affecting morbidity and mortality following pneumonectomy for non-small cell lung cancer (NSCLC).

METHODS

We reviewed our institutional experience with all consecutive patients undergoing pneumonectomy for NSCLC from 1998 to 2010. Patients were analyzed with regard to hospital mortality and morbidity and long-term outcome.

RESULTS

There were 310 patients following pneumonectomy. Overall 30-day mortality rate was 5.5 %. Chronic obstructive pulmonary disease, induction therapy, smoking habits and obesity had no statistical influence on short-term outcome. Coronary artery disease and respiratory failure were identified as risk factors for increased 30-day mortality (p<0.01). Right pneumonectomy and presence of respiratory failure with mechanical ventilation increases the incidence of bronchopleural fistula (p<0.01).

CONCLUSIONS

Patients with right pneumonectomies are at increased risk. Coronary artery disease and respiratory failure adversely affect morbidity and mortality after this procedure (Tab. 3, Ref. 19). Full Text in free PDF www.bmj.sk.

[The surgical repair of thoracic deformities in adult patients]

The authors' experience with the surgical repair of thoracic deformities in 45 adult patients is reported. The most frequent deformity was pectus excavatum (n = 42), the asymmetric form of which was observed in 59 % of our patients. The patients were treated by means of a modified Ravitch method, with the retrosternal introduction of a Jensen strut. The strut was left in place for one year and then was removed via a small incision. With the exception of two cases of postoperative pneumothorax, no other postoperative complications were seen and no patient died. In the follow-up 1 year after removal of the Jensen strut, no recurrent deformities were observed in 36 patients. On the basis of these results, we consider the described technique as the method of choice in the treatment of congenital thoracic deformities in adult patients.

[Impact of neoadjuvant chemotherapy on postoperative complications following pneumonectomy]

BACKGROUND

The risks of complications in patients undergoing pneumonectomy after preoperative chemotherapy for nonsmall cell lung cancer remain controversial. We reviewed a consecutive series of patients having undergone pneumonectomy in a single centre.

MATERIAL AND METHODS

This retrospective study included 292 patients operated from January 1, 1998 through December 31, 2008. Group 1 included patients those who received preoperative chemotherapy and pneumonectmy (57 patients, 19%), and group 2 included patients who underwent pneumonectomy alone (235 patients, 81%). The main objectives were 30-day and 90-day mortality rates, and major postoperative complications.

RESULTS

There was no statistically significant difference in patients' age, gender, cardiovascular co morbidity, histology and side of pneumonectomy between these two groups. Overall 30-days and 90-days mortality rates were 5.5 % and 8.6%, respectively. Postoperative mortality at 30 days was 5.2% in group 1 and 5.6 % in group 2 (p = 0.16), and 10.5% for group 1 and 8.1% in group 2 at 90 days (p = 0.8). Incidence of empyema was 5.2% in group 1 and 3.0% in group 2 (p = 0.12); incidence of bronchopleural fistula was 3.5 % in group 1 and 3.0% in group 2 (p = 0.10); incidence of postoperative respiratory failure was 3.4% in group 1 and 3.0% in group 2 (p = 0.75).

CONCLUSION

Preoperative chemotherapy does not significantly increase postoperative morbidity and early mortality after pneumonectomy in our experience.

[Risk factors of atelectasis following pulmonary lobectomy]

BACKGROUND

The aim our study was to determine incidence and predisposing factors of atelectasis following pulmonary lobectomy.

METHODS AND RESULTS

Retrospective study of our prospective database included 282 patients. Postlobectomy atelectasis (APL) was defined as ipsi- or contralateral atelectasis with whiteout of the involved lobe or segment on the chest radiograph requiring bronchoscopy. Postlobectomy atelectasis occurred in 18 (6.4%) patients. Chronic obstructive pulmonary disease (COPD) remained the only preoperative variable predicted of APL (p < 0.05). Patients undergoing right upper lobectomy (RUL), either alone or in combination with the right middle lobe had a significantly greater incidence of APL when compared with all other types of resections (p < 0.05).

CONCLUSIONS

Postlobectomy atelectasis is an important postlobectomy complication occurring in 6.4% of all lobectomies. Patients with COPD and undergoing RUL are at the higher risk for APL and prophylactic measures to prevent it are necessary.

[Variations of primary spontaneous pneumothorax management]

OBJECTIVE

The aim of our study was to determine the current practice and variation among pulmonologists, general and thoracic surgeons treating primary spontaneous pneumothorax (PSP) in the Czech Republic.

METHODS

A pneumothorax questionnaire was mailed to 153 chiefs of departments of general surgery, pneumology and to thoracic surgeons (55 pulmonologists, 75 general surgeons, 23 thoracic surgeons). Mail contained the survey questionnaire and cover letter requesting the recipients' participation and explaining the purpose of the research. National survey questionnaire included questions on PSP management, chest tube attachment preferences and its removal management

RESULTS

Ninety seven respondents (63%) answered the survey. This included 28 pulmonologists (28/55, 52%), 48 general surgeons (49/75, 64%) and 20 thoracic surgeons (20/23, 87%). Sixty nine percent of respondents treat first PSP with chest tube, 6% by aspiration. Seventy four percent of respondents insert chest tube in the second intercostal space midclavicular line and 22% in the fourth intercostal space midaxillary line. Nearly 71% of pulmonologists use < 18F chest tube, 85% of thoracic surgeons insert a 20-24F chest tube. Active suction use 56% of respondents. Seventy four percent of physicians clamp chest tube prior its removal. Thirty nine percent of respondents pull out a chest tube at the end of inspirium, and 33% at the end of expirium.

CONCLUSIONS

Marked practice variations exist among physicians treating spontaneous pneumothorax. Variations exist not only between pulmonologists and surgeons, but also in the group of surgeons itself.

Induction Therapy in Lung Transplantation: Initial Single-Center Experience Comparing Daclizumab and Antithymocyte Globulin

Acute and chronic rejection remain unresolved problems after lung transplantation, despite heavy multidrug immunosuppression. Because acute rejection is associated with inferior outcomes in lung transplantation, we have routinely employed antithymocyte globulin (ATG) or daclizumab as adjuncts to reduce the incidence of rejection episodes.

METHODS

We performed a controlled clinical trial of the two therapies to evaluate differences in postoperative rejection, infection, bronchiolitis obliterans syndrome (BOS) and host survival. Twenty-five consecutive lung transplant patients received ATG (n = 12; group 1) or daclizumab (n = 13; group 2) as an induction agent. The groups showed similar demographics and immunosuppression protocols, differ only in induction agent.

RESULTS

No differences were observed in the immediate postoperative outcomes, such as length of hospitalization, ICU stay, or time on ventilator. There were no significant differences in the number of episodes of acute rejection, freedom from BOS, or infections. Freedom from acute rejection was significantly greater with daclizumab than with ATG (P = .037). The 1-year survival for group 1 was 67% and for group 2, 77% (P = .584).

CONCLUSIONS

Daclizumab constitutes a safe and effective form of induction immunosuppressive therapy. Using a two-dose administration schedule, daclizumab prolonged the time without acute rejection compared to ATG. The differences in the incidence of infectious complications, acute rejection, or BOS as well as the short-term or long-term results were not significantly different. The results of the study justify the further use of daclizumab as an induction agent in patients following lung transplantation.

Initial Single-Center Experience With Sirolimus After Lung Transplantation

BACKGROUND

Standard immunosuppression after lung transplantation includes calcineurin inhibitors, mycophenolate mofetil, and steroids. Long-term survivors of lung transplantation are often confronted with chronic kidney disease, by definition related to the intake of calcineurin inhibitors. Sirolimus has been increasingly proposed as an alternative immunosuppressive agent due to its absence of nephrotoxicity, which could be used in selected patients.

METHODS

We prospectively administered sirolimus as an alternative to calcineurin inhibitors in 10 lung transplantation recipients with persistent drug nephrotoxicity. They were switched from tacrolimus to sirolimus. Four patients also had bronchiolitis obliterans syndrome. The conversion scheme consisted of an immediate stop of tacrolimus and an 6 to 8-mg loading dose of sirolimus, followed by 4 mg/d. After 5 days, the sirolimus dose was adjusted to maintain trough levels between 12 and 18 ng/mL or 6 and 12 ng/mL for combined sirolimus and tacrolimus. Patients were monitored for renal and graft function as well as clinical status.

RESULTS

A significant decrease in creatinine was observed after 1 week of treatment (P = .011). Azotemia decreased after 1 month, remaining stable (P < .01). Pulmonary function tests did not show significant modification from before sirolimus, inception in patients with or without bronchiolitis obliterans syndrome. There were seven infections. One patient died of complications related to bronchiolitis obliterans.

CONCLUSION

Sirolimus was a useful alternative immunosuppressant, allowing significant tacrolimus withdrawal in transplant recipients with renal impairment. Sirolimus administration allowed recovery of renal function with low morbidity; it was useful for rescue of chronic renal impairment after lung transplantation.

[Comparison study on the use of tubular and spiral thoracic drains following lung resections. A prospective study]

INTRODUCTION

Purpose of this prospective study was to compare two types of chest drains- standard bore tubes with new concept of flexible spiral drains.

METHODS

From January to March 2005 twenty eight patients after lobectomy or bilobectomy were prospectively randomised. We used two different drains types (flexible spiral- Blake silicon drains, Ethicon) and standard chest drains (Dahlausen GmbH) in all patients. Front drain (diameter 24 Fr) was inserted in the sixth intercostal space anterior axillary line and dorsal one (diameter 28 Fr) in midaxillary line of the sixth intercostal space. Half of the patients had front drain spiral one and second group had a convetional chest tube. Postoperative variables included: tidaling, bubbling, fluid level and its characteristics, wound infection and technical complications of inserted drains.

RESULTS

Mean daily amount of fluid in front drains was 61 ml in spiral drains vs. 78 ml in standard drains. Spiral drains were removed after median of 3.7 days, vs. 4.4 days in standard chest tube group. Mean daily amount of fluid of dorsal drains group was 220 ml in spiral drains group vs. 213 ml in standard drains. Spirals drains were removed after median of 4.5 days vs. 3.6 days in standard chest tube group. There was no significant difference in technical complications between drains.

CONCLUSION

Spiral drains are as safe and effective as conventional tubes after lung surgery. Their only present disadvantage is low cost-effectiveness compare to standard bore tubes.

Cyclosporine-related neurotoxicity in a patient after bilateral lung transplantation for cystic fibrosis

Cyclosporine (CsA) is a widely used immunosuppressant following solid organ transplantation. CsA administration is associated with a number of systemic complications, including neurotoxicity. A 33-year-old man with cystic fibrosis, who underwent bilateral lung transplantation, presented with severe neurotoxic symptoms leading to coma in association with CsA administration combined with high doses of methylprednisolone for treatment of an acute rejection episode. After discontinuation of CsA, a quick resolution of his clinical status was observed, as well as of the pathological findings on magnetic resonance imaging (MRI). CsA was replaced with tacrolimus leading to an uneventful course.

[Resection of the trachea with extracorporeal circulation as a simultaneous procedure during coronary artery bypass grafting--a case report]

The authors describe their surgical management of a female patient with a symptomatic coronary artery disease, who had developed a postintubation stenosis of the trachea. The patient sufferred from a rest dyspnoea with stridor. The unusual combination of the both cardiac and tracheal disorders were managed employing a one-step cardio-thoracic surgical procedure. The tracheal resection was conducted in the extracorporeal circulation condition together with the myocardial revascularization. The case shows how, in indicated cases, availability of the extracorporeal circulation can widen a spectrum and limits of the standard chest surgery.

[Transplantation of the lung lobe]

Absolute deficiency of suitable donors and disproportions in the implant size and the pleural cavity size, limit the lung transplantation numbers and result in high mortality rates on lists. The waiting lobar lung lobes transplantation technique may help to resolve the problem of increasing the rate of satisfied patients. This work presents a case of the first lobar lung transplantation in the Czech Republic in the patient with exogenous allergic alveolitis.

[Pulmonary resections and prolonged air leak]

BACKGROUND

The aim of our study was to determine risk factors for prolonged air leak after pulmonary resections.

METHODS AND RESULTS

Two hundred and five patients were operated at our department between January 2003 and March 2004. Prolonged air leak (PAL) was defined as an air leak lasting 7 days or more of postoperative chest tube drainage. PAL occurred in 17 (8.3%) patients and it lasted 10.1+/-3.5 days. COPD remained the only variable predicted for PAL (p<0.05). This complication significantly prolongs the length of hospitalization (p<0.01).

CONCLUSIONS

COPD patients have significantly higher risk for PAL following pulmonary resection. Intraoperative prevention of the air leak requires meticulous surgical technique, stapler use and application of pericardial bovine strips.

[Lung transplantation for primary pulmonary hypertension]

Significant advances in the treatment of primary pulmonary hypertension (PPH) have been achieved in the past decade. Continuous intravenous prostacyclin and lung transplantation are complex and effective approaches in the therapy of PPH. Indication, technique, postoperative care and results of lung transplantation for PPH are discussed.

[Specific features of lung collection from a donor with a beating heart: criteria and technique]

Lung transplantations remain the latest organ transplantation gaining a broad spectrum of clinical applications. It has become an approved treatment method for patients suffering from lung disorders in the terminal phase. The number of transplantations is limited by a lack of suitable organs, increasing patients waiting lists mortality rates. This article provides information on criteria required for the lung collections to be accepted, and also, a detailed description of the combined lung and heart collection technique for unilateral of bilateral lung transplantations. The above technique has been used routinely, undergoing several modifications, in the Czech Republic since 1997, when the lung transplantation programme commenced. 60 lung collections from exited donors were performed until the end of 2003. The aim of the information provided in this article, is to aid mutual cooperation with M.D.s caring for the donor and cooperation of surgeons of all teams, participating in the multiorgan transplantation, which will finally allow the number and quality of the collected organs to be increased.

[Is a scalpel required to perform a thoracotomy?]]

The purpose of this prospective study was to determine whether electrocautery as a means of creating thoracic wound result in increased wound infection rates. Seventy-three patients were randomized prospectively into two groups. Group A-coagulation, where the first half of the incision was done with scalpel and the second half with coagulation-fulgurate. Group B-cut mode, where half of incision was done with scalpel and half with blend cut mode. All wound complications were recorded and divided into infectious (grade 1: induration and erythema with no secretion, grade 2: grade 1 and serous secretion, grade 3: contaminated wound with pus formation) and non-infectious complications (haematoma with its evacuation). Scalpel and electrosurgical thoracotomy incision in elective surgery are similar in terms of early and late wound complications when used to perform anterolateral thoracotomy. Therefore, the choice of which method to use remains only a matter of surgeon preference.

[Computer tomography and staging of bronchogenic carcinoma. Prospective study]

BACKGROUND

The aim of our study was to determine validity of computed tomography in staging of non-small cell lung cancer.

METHODS AND RESULTS

Sixty-two patients with NSCLC were operated at our department between March and September 2003. Lymph nodes with the shortest diameter over 10 mm on CT were considered abnormal. Primary tumor was correctly determined by CT scans in 77 % of cases, lymph nodes involvement in 63 %. Stage of NSCLC was correct in 53% of all patients. Negative predictive value for N1 and N2 was 80 %, resp. 88 %.

CONCLUSIONS

Even with improvement in CT technology, validity of CT in staging of NSCLC remains low. We consider that mediastinoscopy can be avoided in the presence of normal mediastinal CT findings due to high negative predicative value of nodal improvement.

[Benign clear cell tumors of the lung--sugar tumors]

The authors present the case reports of rare benign clear cells tumors of the lung (CCLT) and drawn attention, that examination from frozen sections can be misleading and definitive histological verification can be done on basis of immunohistochemical analysis and can be different from frozen sections examination.

[Lung transplantation--present status worldwide and in the Czech Republic]

Lung transplantation has evolved to a standard treatment modality for patients suffering from end-stage lung diseases and it provides very good short- and satisfactory long-term survival. Accepted indications for lung transplantation include chronic obstructive pulmonary disease (COPD) and other causes of emphysema (i.e., alpha-1-antitrypsin deficiency), parenchymal diseases (i.e., idiopathic pulmonary fibrosis), genetic disorders such as cystic fibrosis, vascular diseases (i.e., primary pulmonary hypertension), chronic infectious diseases (i.e., bronchiectasis), as well as rare indications such as lymphangioleiomyomatosis or sarcoidosis. Presented article reviews the current strategies in the treatment of lung transplant recipients, surgical techniques, limitations of and effects of lung transplantation.

[Bouveret's syndrome: biliary ileus manifested by acute upper gastrointestinal hemorrhage and impaired gastric emptying]

The authors present a very rare case of impaired gastric evacuation, known as Bouveret's syndrome, caused by a large biliary concrement wedged in the duodenum as a result of the development of a cholecystoduodenal fistula in a 77-year-old man. The condition was manifested clinically by developed high ileus and subsequent haemorrhage into the upper GIT. The diagnosis was established on the background of the clinical picture, passage through the upper GIT and endoscopy. As the attempt to remove the concrement endoscopically failed, laparotomy had to be used. In the conclusion of this case-record the authors discuss the method of assessment of the correct diagnosis endoscopically and possibilities of therapeutic strategy.

[Complications of endoscopic extraction of foreign bodies and their treatment]

Endoscopic extraction of foreign bodies from the upper part of the digestive tract has become recently the method of choice. As this method can be associated with very serious complications which cannot be resolved endoscopically and which may have permanent sequelae, it is important to consider the indication of endoscopic extraction of foreign bodies from the oesophagus or stomach very carefully. Fore illustration the authors present the case of a young female patient who swallowed by mistake a fork During its extraction a serious injury of the oesophagus occurred which had to be treated surgically. In the discussion pros and cons of endoscopic extraction are considered, the main principle being primum non nocere.

Lung transplantation for cystic fibrosis: immune system and autoimmunity

BACKGROUND

In the current study we focused on changes in the immune parameters of patients with CF after lung transplantation (Tx), with particular emphasis on the interaction of the immune system, infection, the autoimmune phenomenon observed in some CF patients, and immunosuppression.

MATERIAL AND METHODS

Seven transplant patients with CF were investigated, 3 men and 4 women; the average age at Tx was 24.2 years (20.2-32.3). The parameters of both humoral immunity (immunoglobulins, complement, CRP, antinuclear and antineutrophil cytoplasmic antibodies) and cellular immunity (T and B lymphocytes, NK cells) were traced.

RESULTS

We observed marked initial hyperimmunoglobulinemia, with a sharp drop in immunoglobulin levels within 1 month after Tx. Positivity for antineutrophil cytoplasmic antibodies (ANCA) was found in 3 patients before Tx. A strong ANCA positivity persisted 2 months after Tx despite deep introductory immunosuppression. In one patient ANCA positivity, after a transient negative result at months 2 and 12 after Tx, reappeared one year after Tx. The Burkholderia cepacia infections found in 2 patients proved to be lethal.

CONCLUSIONS

In our series of CF lung transplant recipients, we found Burkholderia cepacia infection to be a risk factor. The robust appearance of autoantibodies and their persistent positivity for many months despite deep immunosuppression is a remarkable feature observed in some CF patients.

[Bronchial anastomoses in lung transplantation]

Bronchial anastomosis is as to the number of complications the most risky anastomosis of transplanted lungs. The most suitable of hitherto used techniques is simple suture with continuous stitches or individual absorbable stitches. The authors prefer the latter technique. They performed a total of 34 bronchial anastomoses. In none dehiscence or stenosis of the anastomosis was occurred. In case of complication of the anastomosis, surgeons often consider the cause of the failure to be ischaemia of the border of the tissue at the time of suture of the anastomosis, corticoid treatment or a poor nutritional status of the patient. The authors cannot confirm the above statements from their own experience, similarly as other authors. They are however aware of the fact that their group of anastomoses is small.