Lobar lung resection in elderly patients with non-small cell lung carcinoma: impact of cardiac comorbidity on surgical outcome

PRINCIPLES

The aim of this study was to evaluate the impact of cardiac comorbidity on the perioperative morbidity and mortality after lobar lung resection for lung cancer in patients aged 70 years and older.

METHODS

The medical records of all 68 patients ≥70 years, who underwent lobar lung resection for non-small cell lung cancer (NSCLC) from 2003 to 2011 at our department, were reviewed retrospectively. Twenty-two patients with a mean age of 76.3 years had cardiac comorbidities (Group A) including previous cardiac operations in 4 patients, previous myocardial infarction in 5 patients, previous coronary stent insertion in 3 patients, medically treated coronary artery disease in 10 patients and medically treated valvular heart disease in 2 patients whereas 46 patients (mean age = 74.5 years) had no previous cardiac history (Group B).

RESULTS

There were no significant differences in postoperative morbidity (13.6% in Group A vs. 17.4% in Group B) between both groups. No in-hospital mortality was observed in both groups.

CONCLUSION

In our experience lobar lung resections for NSCLC in elderly patients with cardiac comorbidity seem to be a safe therapy option for this increasing subpopulation. Though, our retrospective data with the small number of study objects require further confirmation in larger prospective trials.

Value and pitfalls of neurophysiological monitoring in thoracic and thoracoabdominal aortic replacement and endovascular repair

BACKGROUND

The aim of our study was to analyze the neurophysiological monitoring method with regard to its potential problems during thoracic and thoracoabdominal aortic open or endovascular repair. Furthermore, preventive strategies to the main pitfalls with this method were developed.

METHODS

Between 11/2000 and 05/2007 in 97 cases open surgery or endovascular stentgraft-implantation was performed on the thoracic or thoracoabdominal aorta. Intraoperatively, neurophysiologic motor- and somatosensory-evoked potentials were monitored.

RESULTS

Our cases were divided into four groups: event-free patients with normal potentials (A, 63 cases), with correlation of modified evoked potentials and neurological outcome (B, 14 cases), false-positive or false-negative results (C, 4 cases), and medication interaction or technical issues (D, 16 cases). We observed a sensitivity of 93 % and a specificity of 96 % for the neurophysiological monitoring.

CONCLUSIONS

Monitoring spinal cord function during surgical and endovascular interventions on the thoracic and thoracoabdominal aorta is necessary. It can be made more effective by precisely analyzing the interference factors of the neurophysiological monitoring method itself. Successful strategies of immediate troubleshooting could be identified.

Development of a Special Balloon Occlusion Device to Prevent Adverse Events in High-Risk Patients during Open Aortic Surgery

OBJECTIVE

To prevent clamp injury that may occur during aortic surgery, we aimed to develop a special balloon occlusion (BO) device to lower the thromboembolic risk in patients with severe atherosclerosis during aortic aneurysm repair.

METHODS

The study comprised two test phases: a laboratory-testing series focussing on flexible artificial aortas, and an experimental series conducted on 10 pigs.

RESULTS

The device proved to be effective during the laboratory tests and the experiments on pigs. No complications such as intraoperative balloon rupture, dislocation, or occlusion leaks occurred. No damage to the aortic vessels was observed in further histological examinations.

CONCLUSIONS

This BO device has the potential to become an alternative to cross-clamping for vascular surgeons in patients with severely atherosclerotic vessels.

Efficacy and Frequency of Cerebrospinal Fluid Drainage in Operative Management of Thoracoabdominal Aortic Aneurysms

BACKGROUND

Paraplegia remains the most dreaded complication following thoracoabdominal aortic repair. We investigated the efficacy of cerebrospinal fluid drainage as a spinal cord-protecting modality. We also evaluated the correlation between the frequency of cerebrospinal fluid drainage and the Crawford classification.

METHODS

Spinal cord function was monitored during 20 open surgical procedures (group I) and 27 stent-graft implantations (group II). Evoked potentials and intracranial pressure were monitored in each operation. If intracranial pressure exceeded 15 mmHg, cerebrospinal fluid was drained.

RESULTS

Cerebrospinal fluid drainage was necessary in 75 % of patients in group I (Crawford type I: 33 %, type II: 40 %, type III: 20 %, type IV: 7 %) and in 22 % of patients in group II (Crawford type I: 33 %, type II: 66 %). Evoked potential alterations correlated with an increase in intracranial pressure. Timely cerebrospinal fluid drainage reversed these changes in 72 %. Three patients remained paraplegic.

CONCLUSION

Cerebrospinal fluid drainage is a valuable neuroprotective interventional tool to lower the risk of spinal cord ischemia. The combination of neurophysiological monitoring and cerebrospinal fluid drainage optimizes the prevention of paraplegia during aortic repair.

Thoracoabdominal Aortic Aneurysm Repair: Interplay of Spinal Cord Protecting Modalities

BACKGROUND

The purpose of this study was to assess the complementary use of different methods of measuring spinal cord perfusion during thoracoabdominal aortic surgery.

METHODS

The spinal cords of 28 patients undergoing surgery on the thoracoabdominal aorta were monitored with transcranial electrical stimulation (tcMEP) and somatosensory-evoked potentials (SSEP). Available approaches of spinal cord-protection included: Moderate systemic hypothermia, constant cerebrospinal fluid (CSF) drainage and pressure monitoring, reimplantation of segmental arteries, cardiopulmonary bypass (CPB), and staged clamping.

RESULTS

Fourteen of 19 patients (75%) undergoing open surgical treatment (Group I) exhibited loss of tcMEP after proximal aortic clamping. In nine cases (47%), we observed recovery of tcMEP after intraoperative interventions, while two patients subsequently developed paraplegia and three died. Seventeen of 19 patients showed loss of SSEP, with recovery in 12 cases (63%). During stent-graft implantation (Group II), one of nine patients (11%) demonstrated tcMEP loss with intraoperative, intervention-related recovery. The SSEP-recording course remained stable.

CONCLUSIONS

tcMEP/SSEP monitoring has proved to be an excellent means of detecting spinal cord ischaemia during surgery on thoracoabdominal aortic aneurysms. The prognostic value of tcMEP monitoring should be considered superior to that of SSEP measurements, because of its direct and rapid response to spinal malperfusion. Through combined neurophysiological monitoring, vital parameter balancing and intraoperative interventions, spinal cord perfusion improves and recovery of tcMEP and SSEP is achievable, reducing the prevalence of postoperative paraplegia.

Improved Spinal Cord Perfusion during Thoracoabdominal Aortic Repair

OBJECTIVES

The study's aim is to evaluate whether intraoperative neurophysiological monitoring with transcranial motor-evoked potentials (tcMEP) permits early recognition of neuronal lesions, thus making interventions to prevent irreversible spinal cord damage possible.

MATERIAL AND METHODS

TcMEP monitoring was carried out in twelve patients (mean age 60 years) during open surgical thoracoabdominal aortic replacement. Current approaches for corrective, spinal cord-protecting interventions consist of: raising distal perfusion by increasing cardiopulmonary bypass (CPB) flow, catecholamine application, reducing central venous pressure, reimplantation of segmental arteries, and cerebrospinal fluid (CSF) drainage.

RESULTS

Nine patients exhibited loss of tcMEP after segmental aorta clamping. In five patients we observed a recovery of tcMEP through counteractive measures. Three patients died intraoperatively, one patient presented with postoperative paraplegia and loss of tcMEP.

CONCLUSION

TcMEP loss is associated with spinal cord ischaemia, causing postoperative paraplegia. TcMEP monitoring is an excellent method to detect spinal cord ischaemia at an early stage.

Setup of Neurophysiological Monitoring with tcMEP/SSEP During Thoracoabdominal Aneurysm Repair

OBJECTIVES

The article describes a procedure for the intraoperative neurophysiological placement of electrodes to control the spinal cord function during thoracoabdominal aortic aneurysm repair.

MATERIAL AND METHODS

Intraoperative monitoring is performed by motor-evoked myogenic potentials after transcranial electric stimulation (tcMEP) and somatosensory-evoked potentials (SSEP). In tcMEP, the stimulating percutaneous needle electrodes are placed at C3 and C4 according to the 10 - 20 system for EEG recordings. TcMEP are recorded from the anterior tibial and gastrocnemius muscles on both sides. The SSEP electrodes are placed laterally and caudally onto the malleolus medialis in order to stimulate the tibial nerve. The stimulus is documented via electrodes attached to the scalp within the sensory cortex region.

RESULTS

The application of the electrodes is both easy to learn and can be performed without further difficulties. Once attached, the electrodes provide a quick assessment and interpretation of spinal cord function. The identification of external sources of disturbance during the monitoring (e. g. insufficient impedance, unfavourable electrode positioning, and technical interference caused by medical equipment) enables the supervisor to differentiate between normal and abnormal neurological responses.

CONCLUSIONS

TcMEP and SSEP allow an adequate, direct, and reliable intraoperative assessment of spinal cord function, enabling the surgeon to diagnose an impending ischaemia and act accordingly. This measurement technique provides the surgical team with a means of integrating neurological aspects during thoracoabdominal aneurysm repair.

[Serum IgG concentrations and antibody titer of burn patients after preventive intravenous IgG substitution with a Pseudomonas immunoglobulin]

In a randomized clinical trial 30 patients with burn injury received supportive therapy with a Pseudomonas hyperimmunoglobulin (Psomaglobin N). The control group received no additional therapy. The patients of both groups were between 15 and 60 years of age and had a full-thickness burn of 30-70% of the body surface area with inhalational trauma being optional. The whole trauma was classified and scored with the 'Abbreviated Burn Severity Index' (which allows another extra score point for inhalational trauma). Both groups underwent the same intensive care unit treatment with preference to early wound excision and wound grafting following functional aspects of reconstructive surgery. Bacteriological monitoring was performed on suspicion of wound infection and bacteremia by taking wound swabs and blood cultures. The supportive treatment group received a total of 250 mg/kg hyperimmunoglobulin on days 3, 5, 7, 10, and 13. Of 30 patients in the control group 16 had an additional inhalation trauma, and 8 of those (50%) died (only 1 of 14 patients without inhalation trauma died). In the group receiving supportive treatment, 23 out of 30 patients had an inhalation trauma, and 8 of those (35%) died (1 of 7 patients without inhalation trauma). In both groups with inhalation injury, the patients were at risk of developing bacteremia: 13 of 23 of the immunoglobulin-treated patients and 12 of 16 patients of the control group. Bacteremic controls died at a lower score than bacteremic immunoglobulin-treated patients (8.6 vs. 10.3 points).(ABSTRACT TRUNCATED AT 250 WORDS)

IgG-Serum-Konzentrationen und Antikörpertiter brandverletzter Patienten nach prophylaktischer intravenöser IgG- Substitution mit einem Pseudomonas-Immunglobulin

In einer randomisierten klinischen Studie erhielten 30 schwerverbrannte Patienten, die fakultativ ein Inhalationstrauma hatten, entweder nur eine standardisierte intensivmedizinische Behandlung oder an den Behandlungstagen 3, 5,7,10 und 13 zusätzlich 250 mg/kg Pseudomonas-Immunglobulin. Das Verbrennungstrauma wurde nach dem «Abbreviated Burn Severity Index» klassifiziert. Erstes Ziel der Untersuchung war die Häufigkeit von Bakteriämien in den Untergruppen mit einem Inhalationstrauma, der Verbrennungsindex dieser Untergruppen und der Vergleich verstorbener und überlebender Patienten. Als Ergebnis war der Verbrennungs-Score der verstorbenen Patienten der mit Pseudomonas-Immunglobulin behandelten Patienten mit einem Inhalationstrauma und/oder einer Bakteriämie mehr als 1 Punkt höher als in der Kontrollgruppe. Zweites Ziel der Untersuchung waren die IgG-Serumkon-zentrationen und die spezifischen Antikörpertiter gegen die Fisher-Immuntypen 1 und 4 in diesen Untergruppen. Ungeachtet der Substitution mit IgG waren die IgG-Serumkonzentrationen der Patienten mit einer Bakteriämie und/oder mit einem Inhalationstrauma, die an den Folgen der Verbrennungsverletzungen verstarben, am 10. und 13. Behandlungstag niedriger als bei überlebenden Patienten. Dies gilt auch für den Fisher-Immuntyp 1, nicht aber für den Immuntyp 4. Zusammenfassend wurde unter Berücksichtigung der Verletzungsschwere das Letalitätsrisiko bei den mit Pseudomonas-Immunglobulin behandelten Patienten gesenkt. Der erneute Abfall der Immuntyp-1-Antikörper und der IgG-Serumkonzentration ist bei sterbenden Patienten eventuell ein Hinweis auf die irreversible Schädigung der körpereigenen Abwehr von schwerverbrannten Patienten.

[Pseudomonas immunoglobulin prophylaxis in patients with burn injuries]

Pseudomonas aeruginosa belongs to the most frequent pathogens isolated from patients with burns. In a mouse model for artificial burns it was found that prophylactic administration of a hyperimmune globulin with antibody titres against P. aeruginosa (Fisher immunotypes 1, 2, 4 and 6) reduced mortality. Therefore, the prophylactic administration of Pseudomonas immunoglobulin was examined in a prospective randomized study in two groups of 13 patients each. Severely burned patients with at least second degree burns over 30% to 70% of the total body surface area received 250 mg Pseudomonas immunoglobulin/kg body weight by the intravenous route between days 3 and 13. After treatment, plasma IgG levels were significantly raised between days 7 and 16 as compared to the controls, yet the incidence of infections caused by P. aeruginosa was not reduced. However, only two of the six infected patients, developed septicaemia, whereas in the control group, local Pseudomonas infection led to septicaemia in five out of seven patients. The number of septicaemic Staphylococcus aureus infections was also lower in patients on immunoglobulin prophylaxis, with two cases compared to four cases in the control group. Due to the limited number of cases studied, statistically significant results could not be obtained, however, there was a positive trend in favour of Pseudomonas immunoglobulin treatment.

[Prevention using a Pseudomonas immunoglobulin in burn patients]

Pseudomonas aeruginosa belongs to the most frequent pathogens isolated from patients with burns. In a mouse model for artificial burns it was found that prophylactic administration of a hyperimmune globulin with antibody titres against P. aeruginosa (Fisher immunotypes 1, 2, 4 and 6) reduced mortality. Therefore, the prophylactic administration of Pseudomonas immunoglobulin was examined in a prospective randomized study in two groups of 13 patients each. Severely burned patients with at least second degree burns over 30% to 70% of the total body surface area received 250 mg Pseudomonas immunoglobulin/kg body weight by the intravenous route between days 3 and 13. After treatment, plasma IgG levels were significantly raised between days 7 and 16 as compared to the controls, yet the incidence of infections caused by P. aeruginosa was not reduced. However, only two of the six infected patients, developed septicaemia, whereas in the control group, local Pseudomonas infection led to septicaemia in five out of seven patients. The number of septicaemic Staphylococcus aureus infections was also lower in patients on immunoglobulin prophylaxis, with two cases compared to four cases in the control group. Due to the limited number of cases studied, statistically significant results could not be obtained, however, there was a positive trend in favour of Pseudomonas immunoglobulin treatment.