Lung carcinomas infiltrate the aorta mostly on the left side and are altogether rare. As an initial step, complete staging is performed and the results are evaluated in an interdisciplinary tumor ...board. If the patient’s general condition including cardiopulmonary reserves is sufficient, and if there is neither distant metastasis nor an N2 situation, surgical resection may be indicated. The option for neoadjuvant chemotherapy should always be taken into consideration. Depending on the anatomic tumor location, partial lung resection and resection of the affected aortic wall are performed employing a cardiopulmonary bypass. The resected aortic wall is replaced by a vascular prosthesis. In recent years, this proven procedure has partly been replaced by an alternative one, avoiding extracorporeal circulation. An endoaortic stent is implanted in the affected area followed by partial lung resection and resection of the diseased aortic wall. This new procedure has significantly reduced perioperative mortality and morbidity. With proper patient selection, long-term survival can be improved even in this complex malignoma.
Background: Lateral heat propagation has been an unavoidable effect of bipolar sealing with the risk of damage to surrounding structures. It is presently unknown whether leaving the perivascular ...tissue in situ may be advantageous in the sense of an isolation effect. Material and methods: Two groups were formed from ex vivo carotid specimens. Group A (n = 10) consisted of carotid artery with the perivascular connective tissue in place (mean preparation diameter: 10.57 ± 0.16 mm) and group B (n = 10) of skeletonized carotids (mean vessel diameter: 5.21 ± 0.12 mm). All specimens were fixed on a plastic plate and mounted vertically in a holder. Sealing was performed perpendicular to the axis of the specimens. The temperature during the sealing process was recorded by a thermal camera. Group comparison was performed by a nonparametric test and significance was set at p < 0.05. Results: Mean sealing time in group A was 3.71 ± 0.37 s compared to 3.42 ± 0.37 s (p = 0.009) in group B. The maximum temperature in the middle of the jaws was significantly different. Group A had a temperature of 71.4 ± 3.9 °C and group B had a temperature of 91.4 ± 7.4 °C (p < 0.0001). RILATE risk scores (percent of necrotic zone in relation to potential area of necrosis) at both upper and lower sides of instrumental jaws were significantly different. For group A, it was 14.9 ± 1.6 at the upper side of jaws, 20.4 ± 2.63 at the lower side of jaws and for group B, it was 21.9 ± 3.5 at the upper side of jaws, 30.2 ± 6.2 at the lower side of jaws. Conclusion: Perivascular connective tissue acts as an insulator with respect to lateral heat propagation. Peak temperature between instrument jaws is significantly reduced with perivascular tissue in situ. This may result in a negative impact on sealing quality.
Abstract
Lower respiratory tract infections caused by
Streptococcus pneumoniae
(
Spn
) are a leading cause of death globally. Here we investigate the bronchial epithelial cellular response to
Spn
...infection on a transcriptomic, proteomic and metabolic level. We found the NAD
+
salvage pathway to be dysregulated upon infection in a cell line model, primary human lung tissue and in vivo in rodents, leading to a reduced production of NAD
+
. Knockdown of NAD
+
salvage enzymes (NAMPT, NMNAT1) increased bacterial replication. NAD
+
treatment of
Spn
inhibited its growth while growth of other respiratory pathogens improved. Boosting NAD
+
production increased NAD
+
levels in immortalized and primary cells and decreased bacterial replication upon infection. NAD
+
treatment of
Spn
dysregulated the bacterial metabolism and reduced intrabacterial ATP. Enhancing the bacterial ATP metabolism abolished the antibacterial effect of NAD
+
. Thus, we identified the NAD
+
salvage pathway as an antibacterial pathway in
Spn
infections, predicting an antibacterial mechanism of NAD
+
.
Abstract Background The COVID-19 pandemic has had negative drawbacks on the healthcare system worldwide and on individuals other than those directly affected by the virus. Delays in cancer therapy ...and diagnosis have been reported in the literature. We hypothesized similar effects on patients with lung cancer at our center. Methods We retrospectively analyzed data of patients referred to our center with newly diagnosed lung cancer from 2018 to 2022. We considered distribution of UICC Stages and time from case presentation in our multidisciplinary tumor board or from therapeutic indication from treating physician to therapy initiation (surgery, systemic therapies and radiation) to define delays in diagnosis and treatment. Results 1020 patients with newly diagnosed lung cancer were referred to our center from 2018 to 2022, with a median of 206 cases yearly (range: 200–208). Cases with Stage IV in 2020–2022 were significantly higher than in 2018–2019 (57% vs. 46%, p = 0,001). 228 operative resections took place between 2018 and 2022, 100 from January 2018 to February 2020 and 128 from March 2020 to December 2022. Median time from presentation in our tumor board to resection was also significantly longer after the beginning of the pandemic than before (22 days vs. 15,5 days, p = 0,013). No significant delays were observed for administration of systemic treatment and initiation of radiation. Conclusions During the pandemic higher disease stages were reported for patients with lung cancer, yet there were no clinically relevant delays in treatment. In the context of the post-covid era new diagnostic strategies are necessary to facilitate early diagnosis of lung cancer. Despite the pandemic, for patients with suspicious symptoms prompt access to healthcare facilities is essential for early diagnosis.
Objective: Sublobar resections spare pulmonary function and offer a method of increasing resection rates in patients with lung cancer and limited functional operability. Previous studies demonstrated ...an increased local recurrence rate following wedge resections compared to segmentectomies in stage IA non-small cell lung cancer (NSCLC). However, a prognostic impact of this observation has never been shown and is still under debate. Therefore, this study has been performed to analyse the cancer-related survival of sublobar resections in stage IA patients. Methods: Over a 17-year period 87 patients underwent sublobar complete resection (R0) of stage IA NSCLC via thoracotomy. Sublobar resection was reserved for patients with cardiopulmonary impairment. Wedge resections with selective lymphadenectomy were performed in 31 patients (36%) and segmentectomies with systematic lymphadenectomy in 56 patients (64%). Patient characteristics, functional parameters, tumour specifics and follow-up duration were analysed concerning their distribution between the two groups. Kaplan–Meier curves were compared and possible joint effects between prognostic parameters were analysed by multivariate Cox regression analysis. Results: The median follow-up duration was 45 months. There was no significant difference between the two groups in gender (p = 0.11), age (p = 0.08), American Society of Anesthesiology physical performance status (ASA)-score (p = 0.32), forced expiratory volume in 1 s FEV1 (p = 0.08), tumour size (p = 0.30), histology (p = 0.17), grading (p = 0.12), complication rate (p = 0.15) and follow-up duration (p = 0.29). The mean number of dissected lymph nodes in segmentectomies (12 ± 6) was higher than in wedge resections (6 ± 3) (p = 0.0001). The 5-year survival rate was 63%. There were significantly less locoregional recurrences (p = 0.001), an equal distribution of distant metastases (p = 0.53) and a better cancer-related survival (p = 0.016) following segmentectomies compared to wedge resections. Cox regression analysis showed that the prognostic effect of the resection type was independent from gender, age, ASA-score, respiratory function, tumour size, tumour histology, grading and number of dissected lymph nodes (p = 0.04, relative risk 1.16). Conclusions: Studies investigating survival after sublobar resection of stage IA NSCLC should always distinguish between anatomical segmentectomies and wedge resections. If limited functional operability requires a sublobar resection of stage IA NSCLC, segmentectomy with systematic lymphadenectomy should be preferred.
Abstract
Introduction
Pulmonary segmentectomy, when combined with hilar and mediastinal lymphadenectomy, is currently considered the gold standard treatment for early-stage lung tumors (NSCLC) ...smaller than 2 cm in diameter. The preoperative planning for segmentectomies usually includes a contrast-enhanced CT with 2D reconstructions (axial, coronary, and sagittal). Recent technological advances allow 3D (volume rendering) reconstructions of preoperative CT scans, intended to improve the surgeon’s understanding of the segmental anatomy.
The study aims to investigate the added value of 3D reconstruction in enhancing the surgeon’s understanding of anatomical structures, thus facilitating surgical planning and improving oncological outcomes.
Methods and analysis
This is a prospective, randomized, controlled study.
Patients will be randomized into two groups:
1. Group 2D: the preoperative workup for these patients will consist of a contrast-enhanced chest CT with two-dimensional (2D) reconstructions (axial, coronary, and sagittal);
2. Group 3D: the preoperative workup for these patients will consist of a contrast-enhanced chest CT with two-dimensional (2D) reconstructions (axial, coronary, and sagittal) and a 3D reconstruction (volume rendering) of the same chest CT employing dedicated software.
The primary endpoints will be negative margin (R0) resection rate, resection margin (staple line-to-tumor distance), and thoracotomy conversions.
We will use Fisher’s exact test for binary outcomes and Mann–Whitney
U
test for continuous outcomes. For subgroup analyses, we will use regression. Multivariable analyses will be based on logistic regression for binary outcomes and linear regression for continuous outcomes.
Ethics and dissemination
The protocol and the model informed consent forms have been reviewed and approved by the ethics committee (N.: 1–2023) concerning scientific content and compliance with applicable research and human subject regulations.
A Subcommittee on Publications was established to review all publications and report its recommendations to the steering committee. The anonymized participant-level dataset and statistical code for generating the results will not be publicly available.
Trial registration
The protocol was registered at ClinicalTrials.gov (ID: NCT05716815; Prospective rAndomized sTudy efficaCy tHree-dimensional rEconstructions Segmentectomy - Full-Text View - ClinicalTrials.gov). Jan 19, 2023.
Paraneoplastic autoimmune multi-organ syndrome (PAMS) is a rare clinical condition characterized by variable and heterogeneous clinical phenotypes in the presence of neoplasias which largely depend ...on the activation of humoral and cellular immune responses. Clinically, these patients present with a spectrum of antibody-driven pemphigus-like lesions to graft-vs.-host-disease-like exanthemas with a lichenoid inflammatory infiltrate in the skin. PAMS is occasionally associated with thymoma, in which altered immune surveillance eventually leads to multiorgan autoimmunity which often includes variable cutaneous symptoms. This disorder is associated with a profound disturbance of peripheral immune tolerance against human autoantigens.
We here present a patient with relapsing thymoma who developed PAMS with several cutaneous and extracutaneous autoimmune disorders.
Peripheral blood mononuclear cells (PBMC), sera, and lesional skin biopsies were obtained at different clinical disease stages. Peripheral T cell subsets were characterized phenotypically and the cytokine profile of the peripheral blood T cellular response against distinct epidermal and dermal autoantigens of the skin was analyzed by ELISpot assay. Serological screening was performed by ELISA and immunoblot analysis. Skin biopsies were subjected to immunohistochemical analysis of distinct T cell subsets. Thymoma tissue was analyzed for the presence of T regulatory cells and compared with adult thymus and indolent thymoma.
In the present case, thymoma was the cause of the observed multi-organ autoimmune syndromes as its recurrence and surgical removal was associated with the relapse and regression of the cutaneous symptoms, respectively. Initially, the patient presented with two autoimmune disorders with Th2/Th1 imbalance, myasthenia gravis (MG) and pemphigus foliaceus (PF), which regressed upon immunosuppressive treatment. Months later, the patient developed a lichenoid exanthema with a Th1-dominated skin infiltrate. Further clinical evaluation revealed the recurrence of the thymoma and the lichenoid exanthema gradually regressed upon thymectomy. Our contention that T cell recognition against distinct cutaneous autoantigens, such as desmoglein 1 (Dsg1), shifted from a Th2 to a Th1-dominated immune response could not be fully substantiated as the patient was on a stringent immunosuppressive treatment regimen. We could only observe a decrease of the initially present serum IgG autoantibodies against Dsg1. Phenotypic analysis of the associated thymoma showed a lower number of T regulatory cells compared to adult thymus and indolent thymoma, suggesting that impaired thymus-derived immune surveillance had a direct impact on the outcome of the observed cutaneous autoimmune disorders.
Background. Lateral approaches to the spine have gained increased popularity due to enabling minimally invasive access to the spine, less blood loss, decreased operative time, and less postoperative ...pain. The objective of the study was to analyze the use of intraoperative computed tomography with navigation and the implementation of augmented reality in facilitating a lateral approach to the spine. Methods. We prospectively analyzed all patients who underwent surgery with a lateral approach to the spine from September 2016 to January 2021 using intraoperative CT applying a 32-slice movable CT scanner, which was used for automatic navigation registration. Sixteen patients, with a median age of 64.3 years, were operated on using a lateral approach to the thoracic and lumbar spine and using intraoperative CT with navigation. Indications included a herniated disc (six patients), tumors (seven), instability following the fracture of the thoracic or lumbar vertebra (two), and spondylodiscitis (one). Results. Automatic registration, applying intraoperative CT, resulted in high accuracy (target registration error: 0.84 ± 0.10 mm). The effective radiation dose of the registration CT scans was 6.16 ± 3.91 mSv. In seven patients, a control iCT scan was performed for resection and implant control, with an ED of 4.51 ± 2.48 mSv. Augmented reality (AR) was used to support surgery in 11 cases, by visualizing the tumor outline, pedicle screws, herniated discs, and surrounding structures. Of the 16 patients, corpectomy was performed in six patients with the implantation of an expandable cage, and one patient underwent discectomy using the XLIF technique. One patient experienced perioperative complications. One patient died in the early postoperative course due to severe cardiorespiratory failure. Ten patients had improved and five had unchanged neurological status at the 3-month follow up. Conclusions. Intraoperative computed tomography with navigation facilitates the application of lateral approaches to the spine for a variety of indications, including fusion procedures, tumor resection, and herniated disc surgery.
Background The left atrial (LA) appendage (LAA) is the main source of thromboembolism in atrial fibrillation. This study addressed initial pressure resistance of surgical LAA closures. Methods In an ...experimental model, pneumatic pressure resistances of different surgical closure techniques were examined, and variations in technique and access were studied. In preparations of the LA from freshly slaughtered pigs, pneumatic pressure was applied to the LAA. Burst pressures (mbar) of various closure techniques (n = 12 specimens per group) were measured: (1) epicardial double-layer suture, (2) epicardial stapler closure (staple height 2 mm), (3) epicardial stapler closure (staple height 4, 4.5, and 5 mm), (4) endocardial inverse double-layer suture, (5) endocardial inverse stapler seam (staple height 2 mm), and (6) endocardial inverse stapler seam (staple height 4, 4.5, and 5 mm). Results The mean burst pressure in group 1 was 175.5 ± 19.35 mbar. There was no significant difference compared with group 2 (174.5 ± 28.45 mbar) or group 3 (176 ± 27.69 mbar). Group 4 scored significantly higher than all other groups (198.9 ± 18.35 mbar). Burst pressures in group 5 (136.2 ± 16.68 mbar) were significantly lower than in group 4 and in group 6 (165.1 ± 21.94 mbar), but the differences between groups 5 and 6 were also significant. Conclusions In an ex vivo model, double-layer suturing of the inverted LAA from an internal LA access led to higher burst pressures compared with epicardial suturing and with both endocardial and epicardial stapled closures.
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