Antibiotic therapy of postoperative bronchopneumonia in patients after lung resections - single-site experience

INTRODUCTION

Infectious complications after lung surgery are the most important factor that affects mortality and morbidity, prolongs hospital stays and increases financial costs. According to various sources, 30-day mortality after lung resections reaches 123%. Infectious complications account for 2075% of overall mortality. The infections most often present as postoperative pneumonia (POP), and their treatment is based on empirical and targeted antibiotic therapy. Any time lag in initiating effective antibiotic therapy significantly increases morbidity and mortality. Postoperative pneumonia is defined according to current guidelines of the American Thoracic Society of 2016 as nosocomial or ventilator pneumonia in patients after surgery.

METHODS

Evaluation of risk factors, infectious agents, morbidity and mortality in patients after lung resections at a single site in the period from 1 January 2018 to 31 December 2019.

RESULTS

Of our group of 190 patients, 21 (11.1%) patients had POP which was severe in 6 (33% with POP) patients, and 11 patients with POP required artificial oxygenation for saturation below 92%. Two patients with POP had to be intubated for respiratory failure, and 3 patients required noradrenaline circulatory support. One patient with severe POP died of multiorgan failure after developing refractory sepsis.

CONCLUSION

Early identification of lung infection and early initiation of POP therapy are critical points for reducing morbidity and mortality after lung resections. Advanced antibiotic regimens for POP stratify the risk of mortality and infection with multidrug-resistant bacterial strains. However, the regimes require modification according to the epidemiological situation at the site with individualization of the specific procedure. Other research tasks include identification of valid markers of the initial stages of infection, and targeting of antibiotic therapy according to risk stratification and the relationship with physiological flora.

[Negative Pressure Wound Therapy as a Treatment Option for Extensive Post-Trauma Subcutaneous Emphysema]

Subcutaneous emphysema can be a secondary complication of chest trauma or one of the complications of ruptured bullae in advanced chronic obstructive pulmonary disease. Massive subcutaneous emphysema impairs the respiratory mechanics and affects the venous returns of the head and neck. It can lead to respiratory insufficiency with the need for mechanical ventilation. The treatment should focus on the primary pathology. Nonetheless, in patients with subcutaneous emphysema as the only but serious symptom, the treatment can zero in solely on this complication. The standard procedure consists in the insertion of chest drain which does not necessarily have to lead to successful treatment results. The authors present a case study of a 77-year-old man with major comorbidities, with extensive subcutaneous emphysema after blunt chest wall trauma, in which respiratory insufficiency developed. The chest drain was ineffective. The solution was to apply subfascial negative pressure therapy infraclavicularly to the area of the pectoral muscle, which made the subcutaneous emphysema almost immediately subside and which substantially improved the clinical condition of the patient. Local negative pressure therapy can be used as the method of choice for treating massive subcutaneous emphysema in patients, in whom the standardised treatment by chest drain with active suction mechanism failed and the lung is expanded in the pleural cavity, and for whom surgery is far too risky. Key words: negative pressure wound therapy, subcutaneous emphysema, rib fracture.

Hyperthermic intraoperative intrapleural chemotherapy and surgical cytoreduction as part of multimodal treatment of malignant pleural mesothelioma - case report M. Szkorupa1, D. Klos1, J. Chudacek1, J. Hanuliak1, M. Stasek1, O. Fischer2, R. Lemstrova3

Malignant pleural mesothelioma is one of the most aggressive malignancies with a very poor prognosis. Multimodal treatment consisting of three modalities - chemotherapy, radiotherapy and cytoreductive surgery is optimal. The use of new therapeutic modalities, such as hyperthermic intraoperative intrapleural chemotherapy or photodynamic therapy can improve the current results of mesothelioma treatment. Combined hyperthermic intraoperative chemotherapy and cytoreductive surgery as part of multimodal therapy of malignant mesothelioma has been used since 2017 at the 1st Department of Surgery of University Hospital Olomouc. The authors report the case of a 47-year-old man with malignant epithelioid mesothelioma of the left pleural cavity. Following neoadjuvant chemotherapy, this patient underwent extrapleural pneumonectomy with intraoperative intracavitary hyperthermic chemotherapy. The postoperative period was complicated by circulatory instability and later by tension fluidothorax with signs of heart failure. Currently, 8 months have elapsed from the surgery and the patient remains without any signs of recurrence.

Postoperative chylothorax review

The spectrum of causes of chylothorax is wide, including an injury to the thoracic duct in various thoracosurgical procedures, especially in esopha-geal, lung and heart surgery. Late diagnosis or inadequate treatment of chylothorax still has a high rate of morbidity and mortality. This is mainly related to high losses of chyle which is rich in minerals, plasma proteins, fats and lymphocytes. The most serious effects are mineral breakdown, malnutrition and immunodeficiency. Early diagnosis and adequate therapy are essential. The strategy is based on the type of primary operation, the volume of chyle secretion and its duration. The authors present an overview of the issue of chylothorax from its etiology of origin to its anatomy, physiology, pathophysiology, symptomatology, diagnosis and therapy.

[Evolution of Opinions on Chest Wall Stabilisation and Our Experience]

PURPOSE OF THE STUDY Rib fractures represent one of the most common fractures sustained by 10-40% of all patients with blunt chest trauma, their incidence increases with age. In the current literature, however, new indication criteria continue to emerge. The purpose of this study is to assess the indication criteria, the timing of surgery and the use of individual plates in dependence on fracture location in our patients after the chest wall stabilisation in a retrospective analysis. MATERIAL AND METHODS Our group of patients (n = 349) included the patients who were hospitalised in the Trauma Centre of the University Hospital Olomouc from 1 January 2015 to 31 January 2019, of whom 16 patients were indicated for a surgery. In case of polytrauma, spiral CT was performed, while all patients with a more serious wall chest trauma underwent 3D CT chest wall reconstruction. The surgical approach was chosen based on the fracture location, most frequently posterolateral thoracotomy was opted for. The type of plates was chosen based on the location and type of the fracture. The most common was the lateral type of fracture. RESULTS The most common indication for surgery was multiple rib fractures with major chest wall disfiguration with the risk of injury to intrathoracic organs, present hemothorax or pneumothorax. The age of patients ranged from 44 to 92 years. 8 patients sustained a thoracic monotrauma, the remaining patients suffered multiple injuries, mostly craniocerebral trauma, pelvic or long bone fractures or parenchymal organ injury. The patients were indicated for surgery between 1 hour and 7 days after the hospital admission, on average 3 plates per patient were used and the most commonly used type of plate was the newly modified Judet plate made by Medin. All the patients underwent a surgical revision of pleural cavity, in 3 patients diaphragmatic rupture was found despite a negative preoperative CT scan. The duration of mechanical ventilation in polytrauma patients was 16 days, in thoracic monotrauma patients it was 2 days. CONCLUSIONS Prevailing majority of patients with a blunt chest trauma with rib fractures is still treated non-operatively, which is confirmed also by our group of patients. Nonetheless, correctly and early indicated stabilisation of the chest wall based on accurate indication criteria is of a great benefit to the patients. The aim of each and every trauma centre should be to develop a standardised protocol for the management of blunt chest trauma (the so-called "rib fracture protocol"), which comprises precisely defined criteria for patient admission, multimodal analgesia, indications for surgery, comprehensive perioperative and postoperative care and a subsequent rehabilitation of patients. Key words: rib fracture protocol, chest wall stabilisation, flail chest.

Fistuloclysis as a method of nutritional management in a patient with high output enteroatmospheric fistula - a case report

Enteric fistula is a pathological communication between the small intestine and surrounding tissue. In case of communication with body surface it is called an enterocutaneous or enteroatmospheric fistula. There are many causes of enterocutaneous/enteroatmospheric fistula occurrence. A common result is malnutrition and organ dysfunction which leads to increased morbidity and mortality of the patients. Adequate nutritional support is a very important element in the management of patients with enterocutaneous/enteroatmospheric fistulas. One of the options of nutritional support is fistuloclysis which means administration of enteral nutrition formula to the distal fistula. We present the case of 76-year-old patient with a high-localized and high output enteroatmospheric fistula in whom we were able to reach adequate nutritional status using fistuloclysis, followed by closure of the fistula.

[Combined treatment of early tracheobronchopleural fistula after right tracheal sleeve pneumonectomy]

Extended tracheo-bronchoplastic resection for lung cancer with carinal involvement ranks among technically demanding procedures. Despite certain progress in oncological therapy, this type of resection remains the only potentially curative treatment of NSCLC in this localization. However, given the severity of complications postoperative mortality is relatively high (711%). The main cause of death is tracheobronchopleural fistula complicated by thoracic empyema, bronchopneumonia and septic shock. If ARDS (acute respiratory distress syndrome) develops, the mortality rate rises up to 70%. The treatment of tracheobronchopleural fistula is arduous, long-term and essentially multidisciplinary. In this case report, the authors present the case of a 58 years old patient developing the tracheobronchopleural fistula early after carinal resection and sleeve pneumonectomy for a centrally localised squamous cell carcinoma of the right lung. The fistula was primarily sutured and secured using a muscular flap. For recurrence of the fistula, tissue adhesive glue was applied in combination with the introduction of a plastic stent, which resulted in healing of the tracheobronchopleural fistula.Key words: sleeve pulmonectomy carinal resection tracheobronchopleural fistula tracheobronchial stenting.

[Catamenial pneumothorax - case reports and literature review]

AIM

Catamenial pneumothorax is menstrual cycle dependent and represents the most common form of thoracic endometriosis syndrome. Recurrences are very common even after surgical resection.

DESIGN

Case reports and literature overview.

SETTING

Department of Respiratory Medicine, Department of Surgery I, Department of Obstetrics and Gynecology, University Hospital, Palacky University, Olomouc.

CASE REPORT

Two cases of catamenial pneumothorax are presented with repeated recurrences of right-sided pneumothorax even after surgical treatment. Histopathologic finding of pelvic endometriosis was shown in both patients.

CONCLUSION

Catamenial pneumothorax is usually connected with thoracic endometriosis and also includes catamenial hemothorax, recurrent catamenial hemoptysis, catamenial pleural pain as well as endometriosis lung nodules. Multidisciplinary approach including pneumologist, thoracic surgeon and gynecologist with early postoperative hormonal treatment that deals with the main chronic systemic disease may lead to improved results, mainly reduced recurrence rates of catamenial and/or endometriosis related pneumothorax.

Strategies of treatment of chest wall tumors and our experience

INTRODUCTION

The only curative treatment of tumors of the chest wall (primary or secondary),despite all the progress in oncological therapy, is a surgical radical resection. The goal of the paper is the identification of a complication occurring after chest wall resections for a tumor (evaluation of morbidity and mortality). Furthermore, the tumor type and employed reconstruction method were analyzed.

METHODS

A group of patients who underwent resection of the chest wall for primary or secondary tumors at the 1st Dept. Of Surgery, University Hospital Olomouc, was retrospectively analyzed. Age, diagnosis, procedure, histopathology of the tumor, preoperative and postoperative oncological treatment, preoperative co-morbidities, postoperative complications, the use of artificial lung ventilation and recurrences were recorded for all patients.

RESULTS

57 patients aged 16 to 86 years underwent a chest wall resection, 51% for a primary tumor and 49% for a secondary tumor. Resection of at least one rib or partial resections of the sternum were performed in every patient. Reconstruction with a mesh was employed in 22 patients; in 10 patients the mesh was covered with a muscle flap. Postoperative complications occurred in 10 patients (17.5%).

CONCLUSION

It is necessary to follow the basic principles of treatment of chest wall tumors; therefore surgery of these tumors should be concentrated to specialized centers. Always before surgery, diagnosis should be established by means of a biopsy and generalization of the disease should be excluded, ideally using PET/CT. Most important for successful treatment is experience and interdisciplinary cooperation of the team. This results in a low mortality and morbidity rate, which was confirmed by our results.

KEYWORDS

chest wall tumors chest reconstruction sternum resection - treatment of chest wall tumors chondroma.

[Chest drainage methods. The work is intended for postgraduate medical education]

INTRODUCTION

The mastering of the chest drainage technique should be among the basic skills of any surgeon, pneumologist or critical care specialist. What is essential is the knowledge of the anatomy of the chest, the basic radiologic interpretation of pathological findings in the pleural cavity, and some manual skill. The possibility of complications occurring and the method of their treatment are also important.

OBJECTIVE

The aim of the article is to give an outline of the time aspect of the indication, necessary material equipment, the technique of chest drainage itself, differences in the drainage of pneumothorax, free and circumscribed effusion, caring for the chest drain following drainage and also of possible errors and mistakes that may occur. It also deals with methods of solving the complications.

CONCLUSION

Chest drainage performed by a physician experienced in the chest drainage technique and keeping its basic principles may be considered to be a safe and effective method.

[Chest drainage systems and the complications associated with drainage]

INTRODUCTION

Chest drainage inevitably involves attaching the drain to a chest drainage system. Chest drainage may be related to some specific complications.

OBJECTIVE

The aim of the article is to explain the classification and principles of the individual chest drainage systems. They may be divided into passive ones (valve and water seal) and active chest suction. Balanced chest drainage represents a specific method. Further, the article deals with the most common complications of chest drainage, namely prolonged air leak, multifactorial lung oedemas, atrial fibrillation and empyema of the chest cavity.

CONCLUSION

The choice of a suitable drainage system is an important factor for the success of chest drainage, including the probability of complications occurring. The knowledge of appropriate methods of solving the complications of chest drainage, including the use of less standard techniques, allows us to treat the majority of even considerably complicated conditions.

[Chest drainage--physiological and pathophysiological aspects and indications]

INTRODUCTION

Interventions in the chest region still remain a source of concern for the medical community. Surgeons in particular, however, should be well familiar with this technique as it is them who perform the majority of these drainages.

OBJECTIVE

The aim of the article is to give an outline of the physiology and pathophysiology of respiration in relation to the chest drainage indication, and to discuss the different indications for this type of drainage.

CONCLUSION

Chest drainage is, in case of correct indication and performance, a safe method of therapy for a number of pleural pathologies. It is necessary to consider its employment on a case-by-case basis because it is always essential to assess its benefits versus risks.

[Surgery of the pulmonary metastases]

INTRODUCTION

Surgical resection of lung metastases of epithelial and mesenchymal tumors has an irreplaceable position in the complex treatment of advanced stages of these malignancies. Among the most significant prognostic factors affecting longterm survival of these patients are: parameter of complete resection, number and size of metastases, histological type of primary tumor, lymph node involvement, DFI (Disease Free Interval) and biological aggressiveness of the tumor or TDT (Tumor Doubling Time).

AIM

retrospective analysis of patients with lung metastases of epithelial and mesenchymal tumors operated on at the I. Department of Surgery from 2005 to 2011.

MATERIAL AND METHODS

The authors present a set of 50 patients and evaluation of their age, gender, type of primary tumor, number of metastases, occurrence of bilateral metastases, repeat metastasectomies, duration of DFI, type of operation and selected approach and performance of mediastinal lymphadenectomy. The probability of five-year survival, relationship between survival on DFI, difference in survival between metastases of colorectal cancer versus renal cancer and the influence of repeated metastasectomies and number of metastases on survival were statistically analyzed.

RESULTS

Sixty operations were performed on a set of 50 patients (average age 61.2 years). Forty-two procedures were performed by thoracotomic approach. A solitary metastasis was discovered in 43 patients; in 8 patients, more than 3 metastases were resected. Repeated metastasectomies were performed 10 times. Mediastinal lymphadenectomy was performed in 21 cases. The most frequent procedure was extraanatomic resection (28×). Fourteen patients had DFI < 12 months, 19 patients had DFI 12-36 months and 17 patients had DFI > 36 months. Average survival was 66.9 months; the probability of five-year survival was 0.549 (54.9%). A relationship between DFI and survival was not discovered. There was no statistically significant difference in survival after metastasectomy for colorectal cancer and renal cancer. A relationship between survival interval and number of metastases and repeated metastasectomies was not discovered.

CONCLUSION

Surgical resection of lung metastases plays an important role in multidisciplinary care, assuming a precise selection of patients indicated for this treatment. When properly adhering to the indication criteria, very positive results of long-term survival may be expected.

[History of thoracic surgery: since the early 20th century to the sixties]

The authors give an outline of the history of chest surgery during the 20th century. It was the period when methodology of the procedures for treatment of the respiratory system was mastered. The authors point out the issue of development of the particular procedures which have become a part of daily surgical practice despite all the initial troubles.

[Systematic mediastinal lymphadenectomy in surgery for sarcomatous pulmonary metastases]

PURPOSE OF THE STUDY

Systematic lymph node dissection is performed as standard curative resection for non-small cell lung cancer. Its role in lung metastasectomy is unknown. The aim of our study was to find out the frequency of lymph node metastases, the survival of patients with and without lymph node involvement, and to consider if routine lymph node dissection should be recommended.

MATERIAL AND METHODS

The study was undertaken at three departments of surgery and included 14 patients undergoing lung metastasectomy between July 2008 and December 2011. In all patients systematic lymph node dissection was also performed. When wedge resection was done, N1 nodes were removed only as part of a local procedure at that anatomical site. Patients with mediastinal lymph node involvement detected by pre-operative CT or PET scans were not included in the study.

RESULTS

Lung metastasectomy for metastatic sarcoma was performed in 14 patients. Nine patients had bilateral lung metastases. Solitary lung metastasis was found in only one case. The mean number of removed mediastinal lymph nodes was 14.8 (7-32). Mediastinal lymph node metastases were found in two patients (14.3%). The average disease free interval (DFI) was 79.6 months (median, 25.5 months). Using the Kaplan-Meier method, the 3-year survival rate was 46% (0.46±0.15). The Cox-Mantel test for comparing the survival curves showed, at a 0.05 level of significance, better survival rates for the patients with no metastatic lymph node involvement (p=0.01).

DISCUSSION

The frequency of mediastinal lymph node involvement in our study was 14.3% and this was in agreement with the data reported in the literature. The 3-year survival rate was 46% in our patients; the published 5-year survival is 15-50%. A systematic mediastinal lymphadenectomy during lung metastasectomy for metastatic sarcoma has been recommended, but also argued against because of a low incidence of mediastinal lymph node involvement in sarcomatous metastases reported by some authors. We showed that mediastinal lymph node involvement was a negative prognostic factor. Systematic mediastinal lymphadenectomy as a routine procedure provides for a better staging. This is important in association with the development of adjuvant modalities, such as monoclonal antibodies, at present or a gene therapy in the future.

CONCLUSIONS

Even in a carefully selected group of patients, incidence of mediastinal lymph node metastases is high. Since no relevant data based on large patient groups are available, we recommend routine nodal dissection for all patients indicated for lung metastasectomy. Drawing a definite conclusion will require analyses of large numbers of data from multi-institutional studies and cooperation with the international database, if possible.

[History of thoracic surgery: from the beginnings to the end of the 19th century]

The authors give an outline of the history of chest surgery from ancient times to the end of the 19th century. They point out the individual milestones of human knowledge which opened the pathway for successful surgical treatment of intrathoracic diseases after solving the many physiologic and pathophysiologic problems that had made these procedures impossible.

[Biomarkers in the detection of minimal systemic dissemination in lung cancer patients]

INTRODUCTION

Minimal systemic disease (MSD) means the presence of circulating or disseminated tumour cells in mesenchymal compartments of a patientts' body (lymphatic nodes, blood or bone marrow). The aim of our pilot study was to identify sensitive and specific markers for MSD detection in 50 lung cancer patients, who underwent curative surgery in the I. Department of Surgery, Faculty of Medicine and Dentistry, Palacky University and Faculty Hospital Olomouc in 2009 and 2010.

MATERIAL AND METHODS

Absolute gene expression of carcinoembryonic antigen (CEA), epidermal growth factor receptor (EGFR1), lung-specific X protein (LUNX) and hepatocyte growth factor receptor (c-met) was determined in peripheral blood, bone marrow and pulmonary blood of 50 lung cancer patients using real-time reverse transcriptase-polymerase chain reaction (real-time RT-PCR).

RESULTS

(1) The LUNX marker is specific and sensitive for MSD detection in lung cancer patients. (2) The CEA positivity for MSD in the bone marrow correlated significantly with histopathological grading (GI-GIII). (3) Higher expression of CEA and c-met was found in pulmonary blood of patients with hilar or mediastinal lymphadenopathy. (4) Higher expression of MSD markers (CEA in bone marrow, c-met in peripheral blood and LUNX in pulmonary blood) correlated with higher pTNM classification.

CONCLUSION

Minimal systemic disease detection in lung cancer patients is technically feasible using sufficiently sensitive and specific markers for RT-PCR. Minimal systemic disease detection can be used to guide further systemic treatment. This theory must be validated in a larger group of patients and correlated with clinical data, especially with survival data.

[Rates of metastatic affections of mediastinal nodes during pulmonary metastasectomy]

OBJECT

The aim is the evaluation of lymph node metastasis rate during pulmonary metastasectomy harvested by technique of systematic mediastinal lymphadenectomy in year 2009-2010.

METHODS

We performed systematic mediastinal lymphadenectomy (the same technique as in non-small cell lung cancer) during pulmonary metastasectomy.

RESULTS

There was found lymph node metastasis in four cases from 70 patients. The rate of metastatic involved mediastinal lymph node 5.7% harvested during lung metastasectomy is on lower limit of published interval. We expected higher lymph node involvement in lung metastasis of colorectal origin.

[Neoadjuvant chemotherapy and surgical treatment in advanced stages of non-small cell lung cancer]

INTRODUCTION

Lung cancer takes first place in both incidence and mortality in the Czech Republic. This is associated with the disease being diagnosed in late stages, which limits the possibility of radical therapy. Five-year survival of patients operated on with stage IIIA is low and doesn't even reach 20%. These poor results and the development of systemic chemotherapy in the 1990's led to an effort to treat locally advanced disease by administering chemotherapy before the surgical procedure- induction chemotherapy. Its benefit, however, unlike that of adjuvant chemotherapy, remains unclear.

AIM

To analyze and compare the results between a set of patients with non-small cell lung cancer (NSCLC) with stage III A-B, operated on at the I. Department of Surgery at the University Hospital and Palacky Medical Faculty in Olomouc between the years 2000-2008, who underwent preoperative chemotherapy with the results of patients with stage III A-B diagnosed after the operation based on histological findings. Three- and five-year survivals, as well as survival median, were evaluated in both groups.

RESULTS

A statistically significant difference in survival between the two groups was not observed.

CONCLUSION

Neoadjuvant chemotherapy remains controversial in the treatment of NSCLC. The initially promising results have not been unequivocally confirmed in later studies and its role remains a question to be answered in future extensive randomized studies.

[Solitary fibrous tumor of pleural cavity]

INTRODUCTION

Solitary fibrous pleural tumor (SFT) is, in most cases, a benign tumor arising from mesenchymal cells. A malignant version of the tumor is rare and its histopathological evaluation is quite difficult. Usually, SFT affects visceral, as well as parietal pleura, most commonly in a form of a pedunculated tumor. The treatment is primarily surgical, with the aim to perform radical resection even in case of infiltrative growth. Adjuvant therapy is indicated in malignant varieties of the tumor, however, its outcome is uncertain. SFTs have fairly high relaps rates and their prognosis and the risk of relaps can be estimated based on morphological indicators and assessment of their biological characteristics.

AIM

Retrospective analysis of SFT group of patients, who were operated from 2006 to 2009.

SUBJECTS AND METHODS

The authors present a group of 11 patients with solitary fibrous pleural tumors, who were operated at the Ist Faculty Hospital Surgical Clinic of the LF UP (Medical Faculty of the Palacky University) in Olomouc from 2006 to 2009. The authors assessed the patient's age, size of the tumors, types of the procedures, biological characteristics of the tumors, duration of hospitalization and complication rates.

CONCLUSION

Solitary pleural tumors are fairly rare tumors arising from fibroblastic cells, Its biological characteristics is uncertain and, in some cases, is difficult to assess based on immunohistochemical, as well as morphological indicators. The treatment is surgical--removal of the tumor as far as the healthy tissue. Adjuvant therapy is indicated in malignant varieties of the tumor. SFT relaps rate is fairly high, depending on the tumor biological characteristics and its morphological features.

[Mediastinal lymphadenectomy in surgery of pulmonary metastasis]

The effect of lymphadenectomy in pulmonary metastasectomy is unceratain. Good indication and right radicality of resection are to-days surgery possibilities to manage the best patient survival. Next possibility is performance of systematic mediastinal lymphdenecomy for currative effect and increasing of staging quality for indication of adjuvant therapy by metatatic lymphnode involvement. The answer about performance of mediastinal lyphadenectomy and its kind was seeked by authors in retrospective study in years 1999-2008. Hundred and six patient underwent pulmonary metastasectomy, 34% patients were of sarcomatous origin. Mediastinal lymhadenectomy was made in 31% patients. There were found the lyphnode involvement in five cases. The group of own patiens is non homogenous for exact conclusion of impact mediastinal lymphadenectomy on survival after pulmonary metastasectomy. The comparison of patient survival with diferent kind of lymphadenectomy isn't acceptable because sampling of lymphonodes may be false negative. For exact comparison of mediastinal lymphadenectomy importance is necessary to do systematic mediastinal lymphadenectomy in prospective multicentric study.

[Analysis of regressive changes in the lung carcinoma lymphatic metastases following induction chemotherapy]

BACKGROUND

Prognosis of higher stages of non-small cell lung cancer (NSCLC) is very poor. Only 13% of patients in stage IIIA survive 5 years after the diagnosis determination. The purpose of neoadjuvant (inductive) therapy is to eliminate haematogenous and lymphogenous metastases and to cause a cytoreduction in the primary tumor before the resection. Especially detection of lymphogenous metastases is the main factor in the indication of the pre-operative chemotherapy, but this therapy is frequently indicated according to CT without any bioptic verification. The authors suppose such a discrepancy in radiological and histo-pathological staging to influence in a positive sense rather optimistic results of therapeutic protocols, which include the pre-operative chemotherapy.

METHODS

A biopsy of the lymph nodes was performed as a part of the staging. If the metastasis was proved, the lymph node was labeled and the patient was treated by 3 cycles of the pre-operative chemotherapy. The 57 labeled lymph nodes were removed during the subsequent lung resection and lymphadenectomy. An analysis of regressive alterations in the lymphatic metastases of lung cancer after an inductive chemotherapy and comparison with the pre-operative bioptic findings have quantificated the chance of the inductive therapy to eliminate lymphatic metastases.

RESULTS

The clinical down-staging was stated in 21 cases (36.8%), but the viable malignant cells rested in the majority 50 (87.7%) of the taken labeled lymph nodes 57 (100%) even after the neoadjuvant therapy. On the other hand, the satisfactory tumor regression changes was proven in 49 (86%) lymphatic metastases. CONCLUSIN: The results of the study may modify an indicating judgment in the therapy of locally advanced stages of lung cancer because it has brought a new view to the results of neoadjuvant therapy.

[Duplication of the terminal ileum--a case review]

Duplications of the gastorintestinal tract are fairly rare developmental anomalies. They may occur throughout the gastrointestinal tract, however, most commonly, they occur in the small intestine. They are usually diagnosed in early childhood, however, they may be asymptomatic first and cause symptoms as late as in adulthood. Symptoms of,,urgent abdominal conditions", ranging from symptoms of intestinal obstruction, perforation to symptoms of bleeding from the GIT, prevail. A rare finding of a carcinoma in the duplication has been recorded. The etiopathogenesis has not been fully understood. The treatment is surgical. The authors present a case-review of the terminal ileum duplication in a child with symptoms of intestinal obstruction, resp. invagination.

[Extent of lymphadenectomy in lung resection for carcinoma]

Dissemination of the bronchogenic carcinoma into the lung and mediastinal lymphonodes is considered one of the basic prognostic factors. Correct evaluation of the lymphonodes involvement remains the principal pre-requisite for the choice of the most appropriate procedure and makes a forecast of a particular patient's perspective possible. The preoperative diagnostics of malignant lymphadenopathy is based on a CT examination. Once enlarged lymphonodes are detected, invasive exploration is indicated--either via mediastinoscopy, eventually via thoracoscopy. The final picture of the extent of the tumor dissemination via lymphatics is provided by the final histopathological examination of the lymphonodes removed during the surgical procedure. The minimal extent of lymphadenectomy is still being discussed. Some clinics do not conduct it at all. On the other hand, there are some clinics, where the en-bloc mediastinal lymphonodes dissection remains a common procedure during all lung carcinoma surgical procedures. On the group of 226 patients operated between 1996-1999, the authors assess surgical aspects and complications of the lymphadenectomic procedure within the radical lung resection for the non-spinocellular lung carcinoma. In the subgroup of 73 patients with a confirmed malignancy of the lung lymphonodes, the authors have found no statistical difference in the five-year survival rate which would be connected to lymphadenectomy. Mediastinal lymphadenectomy, with respect to its sound diagnostic and prognostic benefits, remains a necessary part of any curative resection. It proved to improve local control of the tumor, however, it has no clear influence on the survival rate. In small peripheral tumors (T1, T2), its extent may be restricted to systematic sampling of the interlobium, lung hilus and medistinum lymphonodes. On the other hand, in case of advanced tumors after the induction therapy, no other than en-block resection procedures are suitable or even possible.